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32C-308 (7) 4 4 LttANPT0 S'O � s 8 Grxt-� ((f wart 4a11tp#111 ^ 9 Blxsaarhttsrtla' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 ' WORKER'S COMPENSATION INSURANCE AFFIDAVIT (li censeelpermi ttee> with a principal place of business/residence at: (streeUcity/stalr/ap) do hereby certify, under the pains and penalties of pegury, that ( ) I am an employer providing the following worker's compensation coverage for my employees working on this job: (mince 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) amsurance Compary/Policy Numer) (Expiration Date) (Name of Contractor) (Insurance Compairy/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (atl=h additiocal ri-. if neccuiry to inerude iafonnstioa pertaining to all ooatradora) ( I am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:pfcasa be aware that whilo homcowuen who employ periom to do mxint rr c�,eoas;ry oa or repair work on a dvvetliag of not moee than thrco unit+in vdnch the homrwtwcr residn a oa the grounds app artenaai thereto arc oo(gcner7 ly ooandcrcd to be employers 11 the worktt's compcns4oa Act application by a homcovma for a 11—or pernuf may evidcoce the (e-gal ctahrs of an employer under the Worlcods Compeal&ion Ad I undcrtsand that a copy of this ctatcmrst may be forwarded to the Dqx t owd of Indauh i d Acci&-&Offioo of lmx r for rho corsage verification and that failure to scarce covetngo under soetion 25A of MGL 152 can lead to the imposition of criminsl pcualCts oomisting of a fine'of up to 51,500.00 tmdlor imprison scat of tip to one year and civil pcnsltia in the form of a Stop Work Order and a fum of:S 100.00 a day against mc. For dcp:rw'-w use O ly Pcrrnit Number Y v of i rmittee i SECTION 8CONSTI]CTION SERVICES" 8.1 Licensed Construction u ervisor: Not Appliicca^ble ❑ Name of License Holder: © Gi e��J License Number A dress Expira i Date P ; n Telephone Not Applica 3 Company Name Registration Number Address Expira ion Date Telephone S ` SECTION 10-WORKERS' COMPENSATION INSURANCE"AFFIDAVIT(MG.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...... ❑ a A 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-mar 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 r , ST ON >DSCP _ (� PROPOSED WOR c iA'a11 a licable .av m -_ ..� .. ...... .. .. e::�a mh.- _,�,_ �.9,a._s ..a ,. • .aN.�a. ,•era„�re�aRat•>..uvm�sv�"vx New House ❑ Addition ❑ Replacement Windows Alteration(s)❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other [ ] Brief Description of Proposed Work: n ptp,- -t tn l Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ ' a N - h a"d `�cltlitr�foexistng�Fiousing.�coim'pl�e�e... �'ie�#ol":la�i'in'>7: 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 7 k,OWNER AUTHORIZATION -TO BE'COMPLETED .:WHEN OWN� S�`AC��N'7F�,0R�'�0N"� ACT0R APPLIES FOR t3U1Lb1NG.PERMIT 1 wt !s✓a (�'Lrjr as Owner of the subject property r hereby authorize - to act on my behalf, in all t rs relative to rk authorized by this building permit application. Signature of Owner Date 1 , 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 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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587.1240 Fax 413.587-1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING i SECTION 1 SITE INFORMATION ts° n Fh�s sec o ff e 1.1 Property Address: �u � � � �r � ---- Map p z14klar' Ag EIm"St. District CB D s rr ct . SECTION 2- PROPERTY OWNERSHIP/AUTHORIZ,ED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Autho zed 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 Cast c•s 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 Buildi,n,g Permit Number: Date issued: 3i Signature Building CQmm1s o►eOn5pec$or of Bw..-I gs Dade•, • " HENRY ST BP-2003-0333 GIS#: COMMONWEALTH OF MASSACHUSETTS :Block: 32c-308` CITY OF NORTHAMPTON Lot: -001 Permit: B u i l d i g Category: windows replaced BUILDING PERMIT Permit# BP-2003-0333 Project# JS-2002-1896 Est. Cost: $16500.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grout Ronald Mistarka 069836 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:9127102 0:00:00 TO PERFORM THE FOLLOWING WORK:N EW WINDOWS & 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 Occupant Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 9/27/02 0:00:00 1197 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo