32C-339 (8) 11wfP 0
....... DEPARTMENT OF BUILDP\IG 1N 1 E C'11 0 N S
212 Malli Street * Municipal 13ulldlllg
Northampton, Mas'. J1 C,G 0
vY()jZjCER'S COMITENISATTOIN INS U VA AFFIDAVIT
pillic"paj place of bus'MessJrcs1de-,, a,
451 t Y S1 t 71 P)
do hereby Cetlf),, under the pains and penalties of
a--i an employer providing the following ,,, j kc-js coverage for my
clnolovccs working on this '0b:
0 2-,
co 01
Company) ;Yeti1 (Ex-pir-ation Date)
T Fir11 u cote proprietor, general con Lj-ac,,c)F or one) in e
d Have hired
the (-Onm-Lctom listed below who have the poficles*.
(�Inme (L (Expiration Date)
(M-1111c of coutrnctor) (Insurance comt"aiivipohlcy Nulllb�r) (Expiration Date)
(NIallic of Contractor) (Taairancz Comp2iiyRol"(-'. (17-xpuaftri Date)
(Nanic of Contractor) (Insurance COT 111Kuly/Poli�-- (Expiration Date)
Y
to iafc�t1116&u pczl.Laing to e11—.tr.c""f5)
I tun a sole proprietor and have no one vorkino for
0
I am a home owner performing alt the work, -,nys,--1E
NOTE p[casz be a+r:c that w ulc ho ncowvcrz who cmp!cy on a d�+c[Ling of
u-"thin thmo uflif-3 LI tcl I -- A ocr rclicIC3 or Oc dlc gc'un-il Golly to be
'lid]the
cnjpjoycr3 undrr the wor,aes axr pc uticn Act(GL152,s3 1(5)�r.ppLicaficn by a for a Ec'flu oc permit may ni&r�the
lepi etatnr of an cru-Ployoc under d Wozkct'z COMPenvfica A (-
I underhand th-t a copy of this ctatcrzxnt may bo forwarded to thw D-VarLZ d of1,dL,,tn,1 (XE Of[>�u&o�for tho
covalf,c Vcrificitioc and that failure to&cu=covcmgo ink scc6ou 25A ofMOL 152 can lead to the i1211>051fi0il Of
OOQIututg of fine ofl-'P to S 1,500.00 ardor imprLsonmeaS of up to one year&nj c:-'jj PeJ'ajticl in fcxm of stop Work Ov&c and a
fine of 5100.00 it day tg�ni: m--
F
I Y
�� ap" L
ot"
Signature of Liccnsc-[Pc
tt=
SECTION$ -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ,, yr� Not Applicable ❑
Name of License Holder : �'�"� L � ------
License Number
Address Expiration Date
Si g nature Telephone
2�-
�� ' Not Applicable El 9 Registered`Nomez rnproue�ment Contractor
y G- Lev C—
Company Name Registration f�1,imber
g ess/ Expiration Date
rGl r^ 7� 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....... L5' No...... ❑
1�: 3H.o° neOwn°er Exemption
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 Budding 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 Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other
Llay+�
Brief Description of Proposed Work:
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 house""arfd or addition to existing housing, compl'ete.th°e following_
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? `
n. 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
I ;OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/GILD 11C«" C'Z-
as Owner of the subject property
L go �, ;Ze4c� to act on
hereby authorize easy.
my behal al matters relative to work authorize,611 by this building permit application.
Signature of Owner Date
6x-v,tj L. ���� ate+/Authorized Agent
hereby declare that the statements and inforKiation 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 Owns+-/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 °6
(Lot area minus bldg&paved
parking)
# of Parkin�,, 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 -sgoer
Building Department Curb-at/a
212 Main Street SewerlSeptic R a►i
Room 100 WaterlWe I�Ava�t1 R. .
Northampton, MA 01060 TWO Sets of Struc tlra an
phone 413-587-1240 Fax 413.587-1272
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION 1
1.1 Proper Address:
This section to be completed by office
i
Map Lot Unit
f fj i U
Zone Overlay District
`Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
sr
Name(Pr ) Current Mailing Adcress:
_ Telephone
Signature
POO^ 89 j— 19.3 j
2.2 Authorized Agent, J�
Name(Print) f Current Mailing Addr s:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building S-10 6 OL�— (a) Building Permit Fee
2. Electrical � (b) Estimated Total Cost of
Construction from 6
3. Plumbing rte, Building Permit Fee
I
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
BP-2002.0545
GIs#: COMMONWEALTH OF MASSACHUSETTS
1 3�,#339 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: windows replaced BUILDING PERMIT
Permit# BP-2002-0545
Project# JS-2002-0835
Est.Cost: $5100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 8886.24 Owner: SIENKIEWICZ CHARLENE
Zoning:URC/GB Applicant: B & R Siding
AT: 2 KINGSLEY AVE
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:111271010:00:00
TO PERFORM THE FOLLOWING WORK INSTALL REPLACEMENT WINDOWS
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 11/27/01 0:00:00 17975 $25.00
212 Main Street, Phone(413) 587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo