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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(licellsee/permi8ee)
with a principal place of business/residence at:
(phone#}
(streeuci ty/staDzi p)
do hereby certify, under the pains and penalties of pequ-y, that.
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Ins-=ce Company) (Policy Number) (Expiration Date)
O 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 Nutnbcr) (Expiration Date)
,,
(Name of Contra(:tor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Hxpimtion Dale)
(Name of Contractor) (Insurance Compaay/Policy Number) (Expiration Date)
(atiadt additioail thcct ifncocsury to inc}ude informatioa pcttaiuing to aU oca.7adots)
O I am a sole proprietor and have no one working for me.
Y) I am a home owner performing all the work myself
NOTE:ptcasc be awarc that whilc homcowtxta who employ pczsom to do m3iritcruncr,a��7ud on cr rrpair woc� oo a dwelling of
not moee than throe units in w�clt the homeowncr r=dcs oc oa the grounds zppurtcnant therdn arc no(Gcr cr-l y ooandcrcd to be
rniploym under the work x ccaq m4oa Act(GL152,"1(5)),application by n homeowner far a Lc=lc a permit may cvi&noc the
legal rtstbm of an omployoc under tho Woriuls C.ompemaLion Act-
I understand that a copy of this ztatcmmi may be forwarded to tho Dcpatmmt of Kiel Acci&xl&015oo of In5urxnoa for the
coverage vc6ficatioa and that failure to s==coverago under sccuoa 25A of MOL 152 can lead to tba impas ioa of c iasl petta12c'
oomisting of a f nc'of up to S1,500.00 and/or im{ttiso�of up to om year and civil pcaaitics in the form of a Stop Work Ord--and a
fim of 5100.00 a day sgniwl utc.
For depatm W use only
permit Number
tia. P{ Lot#
r ., Si 01 ermitlee Mate
SECTION 8"—CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
12eg(stgred Homim�rnvementContractorr; f ,�: „ .1 Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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....... ❑ No...... ❑
1'1:- Hom �Owne�rE�empt><ori
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 e id Loc o a nd State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5 DESCRIPTION OF:PROPOSED
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
a
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:
V it orthampton ,S
i i Department
ain Street
JUN 2 1 2002 om 100 a vre
Nort am ton, MA 01060e�. t« a
DEPT OF B q
7-1 40 Fax 413-587-1272 Pi'a 151te la
N
NnRTH�'APTON,MA 0!060 Q ?r SP,eC!fy ,3
�
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
This section to be�completed by offtce ,
1.1 Property Address: 5,
p 4
Lots
T� p p p� Map t
Zone Overlay,,District
r 3,?
Elm st. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: f ,
Name( t) Current ilin,�Address:
Telephone
Signat re -
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION'3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building / �r� .Cy (a) Building Permit Fee
2. Electrical C�.�.ra..`{` ri.i (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) Cc ow Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings, Date
•
File#BP-2002-1153
APPLICANT/CONTACT PERSON SMOLENSKI JOHN A&ELLA L
ADDRESS/PHONE 41 ALAMO CT (413)584-7796 O
PROPERTY LOCATION 41 ALAMO CT
MAP 29 PARCEL 130 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid ,�D 3 376 —
Typeof Construction: RE-FRAME EXISTING MUDROOM
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 FOL LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INTF,O,RMATION 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 Commission
Signature of Buildi Official iq 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.
BP-2002-1153
GIS#: COMMONWEALTH OF MASSACHUSETTS
1
a CITY OF NORTHAMPTON
Lot: -001
Permit: B u i[di i ng
Category: BUILDING PERMIT
Permit# BP-2002-1153
Project# JS-2002-1849
Est. Cost: $9000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. Q: 12283.92 Owner: SMOLENSKI JOHN A&ELLA L
Zoning:URA Applicant: SMOLENSKI JOHN A & ELLA L
AT: 41 ALAMO CT
Applicant Address: Phone: Insurance:
41 ALAMO CT (413) 584-7796 O
FLORENCEMA01062 ISSUED ON.6124102 0:00:00
TO PERFORM THE FOLLOWING WORK.-RE-FRAME EXISTING MUDROOM
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 6/24/02 0:00:00 1032 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo