32C-198 (3) �11AMp2,
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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licenserJpermittee)
with a principal place of business/residence at:
o- � �tSS Sly /k-c-�e� ma., O/D �' (p hone#)
(stree city/scate/aPj
do hereby certify, under the pains and penalties of perjury, that:
(vf'I am an employer providing the following worker's compensation coverage for my
employees woriang on this job:
LC. __T h SU t1C e u-p W1 LU (!of 16�7 fn.it
Unsarance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Corupa ry/Policy Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Pobicy Number) (Expiration Date)
(attach additioaal sect ifmccvuy to iaOude information pertaining to all corlra ors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that whi]o homcownm who employ pcaom to do m jnt cons.7wxion or repair work on a dwelling of
not Moro than throe unit in WEuch the homoowncr resides or oa the grounds appurtenant jbe,t arc not geacrally oocaidcrrd to be
emPloyers under the wmikz s oompc=tion Act(GL152,ss 1(5)).application by a homcowocr for a license cc permit may evidence the
legal statue of an omployec under the Wor u z Compansatiou Act
I understand that a copy of this statcmcat may ba forwarded to tbo Dcpwt nm of Industrial Aca&a&Of$oa of Imurwoo for the
coverage verification and that failure to scatre covenrgo under suction 25A of MGL 152 can lead to the impos oa of criminal peaaWcs
oonsistixtg of a fine of up to S1,300.00 andloe imprisoamart of up to one year and civil Pcalwes in the form of a stop Work Order and a
find of S 100.00 a day against ttx
For dgnctm W use only
Permit Number
. � Lo
Map t#
Stah>M of Licensee/Permittee e 's
gn
SECTION.8'-.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :- Wi`I, m m L71�6L�✓
License Number
Address Expiration Date
/ cs`yv-cr
Ylgrmture Telephone
Not Applicable ❑
Company Name Registration Number
(• I ki-14 n
�Address Expiration Date
T.d cUG� [LGC�L°
1170-d&36— Tel ephon 7�/-, 1r40—
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... Ef eo No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws,Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner" certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5' DESCRIPTION'OF PROPOSED WORK(check all applicable)
, . _.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing P"
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work:sAp,D� f��yAjt"'� - t e-0 t�,i^ " F'yUo ic,t1 e '_OPT
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet o
ra If New�tioU aari or�acldUNTAo..eiristtn�gFi�u's`"ir g complete�ttie`fr�CCiivtin
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions_
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves_ Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction w thin 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes _No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a r OWNER AUTHORIZATION'-TO BE COMPLETED WHEN
OWN ERSAGENT OR CQNTRACT.OR°APPLIES FOR gUILDING:PERMIT
9Cl�GUals,�c� //7� as Owner of the subject property
hereby authorize W���1�1¢iYl (;r1a-t to act on
my behalf in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, w� �I }rn �►1C�- � as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
U)t LL ! Glyn e-e
Print Name
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
} Existing Proposed Required by Zoning
This column to be filled in by
/t Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO ! DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
w '
Northampton
BOl l rig Department
Main Street
Room 100
♦♦r t �tUb3tha pton, MA 01060
/
240 Fax 413587-1272 P
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -'SITE INFORMATION
1.1 Property Address: This section to w,r:bp-q Completed vy office
wip
-„ �
Map.-
Zone Overlay District
tT
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
k waa s;
Name(Print) Current Mailing Address: �—
Signature Telep one'
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from' 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) �< v�l Check Number
This Section For Official Use Only
Building Permit Number: - Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
ILLIAMS ST 0893
bTW
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C-198 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2002-0893
Project# JS-2002.1464
Est. Cost: $4200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: William Gnatek 100088
Lot Size(sa. ft.): 11194.92 Owner: KOWALSKI STANISLAW
Zoning.URC Applicant: William G n ate k
AT: 107 WILLIAMS ST
Applicant Address: Phone: Insurance:
P 0 Box 204 (413) 584-5682
HADLEYMA01035 ISSUED ON:4118102 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE HOUSE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 4/18/02 0:00:00 794 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo