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R�:0.C7 ALI�YIC,C+oat Yea�alTe OIOr 11QHE tOLL RIEF ia�ibt'HO ti 0 –� - aB �asaariJnsttts DEPARTMENT OF BUILDrNG INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE A r'MAVIT 1-, (Ii ceusee/permi tree) with a principal place of business/residence at: (phone#) (streeticity/statrlap) do hereby certify, under the pains and penalties of perjury, that. ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance 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 Company/Policy Number) (E) irntioa Date) f. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date) (attach additional shod tf nrCssary to include informsiion pertaining to all oCt&r o ) ( ) I am a sole proprietor and have no one working for me. I am a home owner performing all the work myself. NOTE:ptea&e be aware that while homeowners who employ persom to do ma;atcn,n t,comtructioc or repair work on a dwelling of not more than throe units is which the honseowner resides or on the grounds app irtenard thereto ate oo(gen=ily coandercd to be cmploycn under the worker's ration Act(GL152,s3 1(5)),application by a homeowner for a License or permit may evidence the les2l status of an employer under the Wockees Compemaiioa Art I unders nd that a copy of this etatemmi may be forwarded to the Depertmco2 of Ia&L�bisl Acci&af Ofhoo of Imursne'for the coverage vaificxtioa and that failure to&==coverage trader section 25A of MGL 152 an lad to the invosition of criminal penalties oomistxu of a fine'of up to S 1,500.00 and/or' i of up to one year and civil pa altie,in the form of a stop Work Ocda and a find of 5100.00 a day agaimt tno- For dcparw—w—only permit Number c � Map;{ Lot# .. .Simature r){T t. SECt7Ot8 CNSTRL1CT10N 5EFt1/ICES 3 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone v: me n ra r Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SEC,TI0Ngl`04fVORKERS 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....... ❑ 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, Sta and Loc 1 oning La n=tts General Laws Annotated. Homeowner Signature 4 z�AN »l:.iu PO WOR x` SECTION 6ESCR�IPTIONtOtPRO ED3K check II licablet t k4i New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other Brief Description of Proposed Work: avo D8 r Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative D Renovating unfinished basement Yes No Plans Attached Roll ❑- Sheet D IfNew o see n�do ddit'iontoecist'ingho�s�ngcomple"e hdffolla"w�ng: 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 within 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 5ECTlON 7a OWNER AUTIORIZATION TO BE COMPLETED !WHEN QWN RS AG NT OR CONTRACTOR APPLIES FOR`s ILDING.PERMIT I, as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date i &,I—� L C C!SK / , 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 u erJthe ins and penalti of per'ury. / j �J I ��l 1�ILL.- / ,j !�/'� Print N e Al 4hJAi1i_,, 50�0 , 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 Building Department Lot Size / ��! / 0-a %� Frontage Id d— � '�- Setbacks Front _ 30 1� Side L:_ R: L: R: f 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: a a. Cit Af rthampton '1,;` MAY Z3 20T p € uildi Department C r 2 2 M in Street Se Roo 100 a v i-NDRTHA P �' dam t n, MA 01060 N17RTHANiF,vi�,`: . �.,.�� P p one 0 Fax 413-587-1272 P►otlS.e APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION Thinsection to,be comple#ed y ff�ce 1.1 Property Address: Zon .. a t SECTION 2- PRO PERTY OWNERSHIP%AUTHORIZED°AGENT 2.1 Owner of Record: AK- 65 Natri Current M 1 in$Address , Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECT10'N 3 - ESTIMATEDiCONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Off icial Us,e:Only cojVpIeted by ermit applicant 1. Building D 00 (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) Check Number " This Section For Official Use.Onl Buildi.Rg°Permit Number: Date Issued: Signature: L. Building Commissioner,�lnspec#or of Buildings Date.., Joe t File#BP-2002-1046 APPLICANT/CONTACT PERSON GOLASKI KATHLEEN L&WILLIAM J ADDRESS/PHONE 68 GOLDEN DR (413)585-9503 () PROPERTY LOCATION 68 GOLDEN DR MAP 29 PARCEL 429 001 ZONE URA/WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out Fee Paid Typeof Construction: INSTALL 24 FT ABOVE GROUND POOL / S New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9MATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Co ssion Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. File#BP-2002-1046 APPLICANT/CONTACT PERSON GOLASKI KATHLEEN L&WILLIAM J ADDRESS/PHONE 68 GOLDEN DR (413)585-9503 () PROPERTY LOCATION 68 GOLDEN DR MAP 29 PARCEL 429 001 ZONE URA/WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL 24 FT ABOVE GROUND POOL W/10 X 12 DECK&REBUILD&MOVE 16 X 12 DECK New Construction Non Structural interior renovations Addition to Existing. - Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission _Permit from CB Architecture Committee Permit from Elm Street Comr i n 6 Z O0 �-- Signature of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. � `' 1st In M A .� wi s ' ar � R �a Mr. z Y= as ^" � x , NJ, f 68 GOLDEN DR BP-2002.1046 GIS#: COMMONWEALTH OF MASSACHUSETTS MapBlock:29-429 CITY OF NORTHAMPTON Lot:-001 Permit: Buildin- Category: BUILDING PERMIT Permit# BP-2002.1046 Project# JS-2002-1681 Est.Cost:$500.00 Fee:$25.0 0 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: LJse Group: Homeowner as Contractor_ Lot SizAsq.ft.): 11412.72 Owner: GOLASKI KATHLEEN L&WILLIAM J Zoning,:URA/WSP Applicant: GOLASKI KATHLEEN L & WILLIAM JJ AT: 6$ GOLDEN DR Applicant Address: Phone: Insurance: 68 GOLDEN DR (413) 585-9503 FLORENCEMA01062 ISSUED ON.615102 0.00.00 TO PERFORM THE FOLLOWING WORK.-INSTALL 24 FT ABOVE GROUND POOL W/10 X 12 DECK & REBUILD & MOVE 16 X 12 DECK 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:He L r S ©,F Driveway Final: Final: Final: Rough Frame: ` Gas: Fire Department Fireplace/Chimney: Rough: nil: _ Tnsulatiog: --_ Final: Smoke: Final: K' j"a i'43 -cw THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT10q OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu arlC Si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 6/5/02 0:00:00 1289 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo