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29-205 zp r , y Fro > ati� �4 Of "Nnu liallip1011 . - B Rlasenchnsclla d DEPARTMENT OP BUILDING INSPECTIONS � 212 Alain Street ' Municipal Buildinu Northampton, Mass. 01060 WORK'ER'S COMPENSATION INSURANCE AF < AVIT (li ccuscc/perrni ttcc) -- %vith a principal place o1-business i-esidencc at: (stmt/ci ty/stair-/zi p) do hereby certify, under the pains and penalties of perjury, 11t ( ) I am an employer providing the following worker's comocns Don cove:2ge ifor In)' eluplovees worUng on tills job. (Incur-;nc:� Comr=, (Polio;Nu_mirr) (r;xpirtion Dzlc) O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors Listed below who hive the follo%ving worker's co»oen`anon policies: (Name of Cout::3cror) (Iii-s-uranc'.; Company/Pchc-, NU-Min-) (XpII-w1on Date) (Name of Contracior)--- (Insurance Company/Policy (`LxpLmiion Date) (Name of Contnctor)-- (Insuranc: Company/PoUc} Number) -- (Expu-noo Date) (Name of Contractor) (Insurance Comrnny/Pohcy Number) (Expiration Date) (eaach additi ld cixc!ifno xiv to ii cku mfoRa n: pc�to ell c_o:�) O I am a sole proprietor and have no One working for me. I am a home owner performing all the work myself. NOTE:p(csc tx aware th al a,trJc bourn"" ra wbo ciaploy pczocu to 63 a. c=-,:-sc_ioo c�rcp air work on.d,,cIh--F of nrx aroec th_n Ltuoe uuitj in u1,iidr the kwmooaavcr midi -oa the fjout zppulteci zi thc�o a.c o-x,Ecxsa l y oec�id.-�cr1 to he cniploym undo ccnipc=sm-lion Acl(GL152-s:5 1(5)�nppliratioo by a homcoc,),:T for c c v or permit r�.y c«drnoc trx legal etxnic of an e,-rplovoc under dto Works ',Coaiponz..lioa A<t I undasL,nd dw a oopy of thiu etat—ai.y bo fora nvdod to rbo DeSxirtmait of Offioo of L--oo for tl o oovcn,gc vcrT1C:Uo0 and t11--t r=iltnt to saauc covcrasc under soction 2 5 A of MGL 152 can loiJ to tl>c i ,� ou of cnmia-d pco-lkia ooci it g of a floc cf up to S 1 500.00 andrex iu2frT3, lri of up W 0r---yrsr and aai]penal a n tic form of a Stop WO&Ord-end a fim oCS100.00&day tgziasl rD-- rOr(Sc;liStili_���UK«ily Permit Number _-- 1 Lot siBnaturc of I,iccn_ctll'6 nitice - TSCe *4 ' iI SECTION 8-CONSTRUCTION SERVICES i Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone E, � .... .«..' Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.O.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. ned 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, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature ��Z ::;�� Ai "'CT ION 5- DESCRIPTION OF PRO 'OSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s)0 Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes o Addin new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 6 ? M . a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: -S Number of Bathrooms c. Is there a garage attached?Pv f d. Proposed Square footage of new construction. Dimensions X e. Number of stories? /� I f. Method of heating? 42,.+s Fireplaces or Woodstoves Number of each ;41 Energy Conservation Compliance. Mascheck Energy Compliance form attached? 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 SECTION 7a -OWNER,AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , as Owner of the subject property IF I hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 7 pcJ 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. ned under the pains and penalties of perjury. 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 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: OPW- D. Are there any proposed changes to or additions of signs intended for the property ?YES _ No IF YES, describe size, type and location: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 ae APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This sec 110 to be completed txy office, Map l.ot_ � :. 0nrt Querayas#�� t x , fiY' c fl lGt GB 0ric f)tS SECTION 2"-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: C Gas T z. m ,4&4L- me(Print) -t o-ri, l>e`o� Current,/ailing Add ,A t/ otli� Telephone 7 Signat e 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 _ com feted 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) Cheek Number 0fu4 This Section For Official Use Only wilding Permit Number: (' TDatelssued: Signature: Building Commissioner/Inspector of Buildings Date 0 lb File#BP-2000-1038 APPLICANT/CONTACT PERSON NIEDZWIECKI CHARLES J&KATHLE ADDRESS/PHONE 19 BEATTIE DR (413)586-1624 Q PROPERTY LOCATION 19 BEATTIE DR MAP 29 PARCEL 205 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Oy — Typeof Construction: CONVERT EXISTING BASEMENT CLOSET INTO BATHROOM New Construction Non Structural interior renovations Addition to Existinp, Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presentedibased on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: §_ w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: §_ w/ZONING BOARD OF APPEALS 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 C fission Permit from CB Architecture Committee 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. 19 BEATTIE DR BP-2000-1038 GIs#: COMMONWEALTH OF MASSACHUSETTS + Mg.-Block:29-205 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2000-1038 Project# JS-2000-1869 Est.Cost:$3500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(sg. ft.): 1001 8.80 Owner: NIEDZWIECKI CHARLES J&KATHLE Zoning:URA Applicant. NIEDZWIECKI CHARLES J & KATHLE AT: 19 BEATTIE DR Applicant Address: Phone: Insurance: 19 BEATTIE DR (413) 586-1624 0 FLORENCEMA01062 ISSUED ON:5117100 0:00:00 TO PERFORM THE FOLLOWING WORK.CONVERT EXISTING BASEMENT CLOSET INTO BATHROOM POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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 Sijjnature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 5/17/00 0:00:00 4700 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo