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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street a Municipal Building
Northampton, Mass. 01060 �y
WORICER'S COMPENSATION INSURANCE Ar, ' AVIT
(IicenserJpermitiee}
with a principal place of business/residence at:
(phone#)
(street/city/sta zip)
do hereby certify, under the pains and penalties of pequry, that.
O I am an employer providing the following workers compensation coverage for my
employees working on this job:
(lnsurance 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/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) Gmsurancc Company/Policy Number) (Hxpimdon Date)
(Name of Contractor) (Lnsuiance Company/Policy Number) (Expiration Date)
(attach additional sheet ifn6Dc I ry to incKsde infoanutioa pertaining to all ooati ors)
I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:plcasc be awarr that whilo homcowvaa who cmpioy pa-tom to do tna nlcaanc4 COi dClO cr repair Mode on a dwclling Of
not more than throe unite in which the homoow% c residcs of oa the grounds appurtenaof tbudo arc oat gcncrzity coandcmd to be
cmployas under the worker's cempcazsa as Act(GL152,xs 1(5)�application by n homcowaa for a licrrzsc of 1?11 R may evidence tho
Iegal starua of an omployef under tho Woa$oes Compomation Act
I undavund that a copy of this rt tcmccd may be forwarded to the Dcpnrmmt of Indatstrial Accidm&Offioo of Iawrwoo for the
covcz- g vcrireslioa and that fad=to&carte covetngo under Scetion 25A cf MGL 152 can Itad to tho imposition of criminal pea Ill
ooasisi of a fine'of trp to S1,500-00 and/of imprisoanxat of up to one ytar and civil pemitia in the foam of a Stop Work OrdG and a
faro of:S t OO.00 a day s gninst ma
For dT-W'Cda]uao only
permit Number
Lot#
4 f of LiccnseelPermittce e
SECTION 8'-CONSTRUCTION SERVICES
8.1 Licensed Construction supervisor: Not Applicable ❑
Name of License Holder
U v� l a `-', d
License umber
Ad rresss Expir tion Date
Signature Telephone
S- S /.� /
Not Applicable ❑
rsr� ltd
Company Name Registration ,Number
eli g�7 aq/
Acfdress -j Expiration Date
1171 is Telephone S �C
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...... ❑
11
WPM it,,
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 Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs/ [ ] Decks [ ] SidingfC] Other [ ]
Brief Description of Proposed Work: i <
Alteration of existing bedroom__Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a, If New'}iouse and or addi.t�onYto exi"sting- housing,=corr pl6 Ah'616116winir:
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
SECTION 7a'-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, U as Owner of the subject property
hereby authorize l -_— _ _ _ to act on
my behalf, in all matters relative to work authorized by this building permit application.
gnature of Owner 17 Date `
I, 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.
Print Name
Signature of Owner/Agent Date
r
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:
D. Are there any proposed changes to or additions of signs intended for the property ?YES —
No
IF YES, describe size, type and location:
Y
of Northampton of
i ing Department C I x
2 Main Street =5„. e I: ► .
�� t JUN 2 7 2002 Room 100 a r e
N rtha pton, MA 01060 efts: a
rT or Fill”Q11dG INSP CTI
.58 -1240 Fax 413-587-1 272 o <Slte�
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section by office
eN s
r7�oe / S Map Lot Unr
Zone O'verlay bistnct�
Elm!St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Addres
Telephone
ature
n
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 (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 Only
Building Permit Number: Date Issued:
Signature:
Building'Commissioner/Inspector of Buildings Date
A 901111111111"M BP-2002-1184
GIS#: COMMONWEALTH OF MASSACHUSETTS
,:.. CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2002-1184
Project# JS-2002-1896
Est. Cost: $15000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Ronald Mistarka 118693
Lot Size(sq. ft.): 38594.16 Owner: SZAWLOWSKI REALTY INC
Zoning.URC Applicant: Ronald Mistarka
AT. 5 HENRY ST
Applicant Address: Phone: Insurance:
P O Box 205 (413) 575-1271
NORTHAMPTON MAO 1061 ISSUED ON.6/27/02 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE PORCH DECKING & INSTALL SIDING
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 6/27/02 0:00:00 1119 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo