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m DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION MSURA-NCE ATTLDAVIT
Olcensec/permlttee)
with a principal place of business/residence at-.
v X12
, ro�t.< ✓lA l -(phone#) %3 5_�5' /S Z
-- (strect/ci ty/stately p)
do Hereby certify, under the pains and penalties of perjury, that.
( ) X am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Kato-&rice 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 workers compensation policies:
(Name of Contractor) (Insurance Compan-y/Poliq Number) (Expiration Date)
r
(Name of Contractor) (lasurance Company/Policy Number) (Expiration Date)
(Name of Contractor) jnntran� Compan y/Policy Nuinlxr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(&Hach abditionil v1x ifnoc.i to include infonuiIIoc pertaining to all coatn�rs)
(v�l am a sole proprietor and have no one"working for me.
( ) T am a home owner performing all the work myself.
NOTE:please be a-A-u that while homco-rt)cca who crnplay pGZom to 63 caizicaaac,_m G Q Cr rcpaa work oo a dwtiling of
not mock th n thmo units is Airch the homoowv rezidcs oc oa the grounds zppurtmant thereto a c rKc gaxrally comidacd to be
eatployrrs under the wort es ca cas-Mica Act(GL152,n1(5)�application by a homeowner for a Lc nx or p--ma may evidmoe the
legal et�ua of en employer under the Worker's Compcmation Axc
I unacra=d that a copy of thin stat.emcct any be forwnrded to tho Departm of Indruaid Aaidcrr&Off oo of 1—"'°O°foe the
coveax vcrif cation and that failtrro to azure eovcrago under s t ei oa 25A of MOL 152 can lead to tbo imposition of criminal pcnalt:t s
oomisting of a fine of up to S1,500.00 and/oe imprisoauxat of up to one year and civil pcmttia in the focm Of,,stop Work Ord--and a
fin&of S 100.00 a day ags_inst me
_ EMap4__oaly
-71,Z Lot
Signa of LicenscdPermittce e
SECTION8'-:CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : JotI-gr'S °SOLI �`" 1� D n 9
License Number
'3 �" D �'h-
Address c: rn a �n S 1 Expiration Da e
4Signare Telephone
J&,9—e rya
stered Not Applicable ❑
i .
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...... ❑
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 DESCRIPTIONtOF PROPOSED WORK-'(check all applicable)'
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ )
Brief Description of Proposed Work: UV W ' �' 45 ��"�'"� �' �``'`f t 14,sr,'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet❑
sa. If�New�hou`°'se 'a�'hd�or�adiiition`-to``exi sting=tiousintr.comp a"te"`�thefoll°owin' :
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-w OWNER,AUTHORIZATION -'TO BE COMPLETED WHEN
OWNERS AGENT OR.CONTRACTOE?APPLIES FOR BUILDING;PERMIT
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
c Z 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.I
Print Nam
Date
Signature of Owner/Agent
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 S
- �ing Department urbG t!
Main StreetSe
Room 100 Wafier�IWel .v
C"CN n pton, MA 01060 TSets`ofS 'r
bhone 413 X87 1240 Fax 413-587-1272 Pl6QSite Ptan'„z>
Other Speclfy� ���,°-
-
�rst
A'PPL�I6ATtO�J-'f b� ' ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
L_
SECTION 1 SITE INFORMATION
1.1 Property Address:
This section to be completed by office
t Ma ,Lot Unit
' iPte�J��.1 p
0 P, �, k f-cam Zone Overlay District
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
e K. -. _ �f5�� �V. I¢ytk 5 f . 3 j ' ,' __�7,�S_010
Name(Print) � Cu ent M ding Address: — ---
Te ephone
Signature
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
fBuilding �Pd (a) Building Permit Fee
2. Elecirical c) 0 ��d (b) Estimated Total Cost of
_ �� C V Construction from 6
3. Plumbing 0r Building Permit Fee
4. Mechanical (HVAC) t�
5. Fire Protection
6. Total = (I + 2 + 3 + 4 + 5) 6 . -Ono_ Check Number
This Section For Official Use Only
Building Permit Number: 77 [Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0397
APPLICANT/CONTACT PERSON JIM MAILLOUX
ADDRESS/PHONE 3 CORTICELLI ST (413)585-1592
PROPERTY LOCATION 2 KINGSLEY AVE
MAP 32C PARCEL 339 001 ZONE URC/GB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: UPDATE KITCHEN&BATHS INCLUDING SHEETROCK&PLASTER REPAIR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building,Plans Included:
Owner/Statement or License 081694
3 sets of Plans/Plot Plan
THE FLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO CATION 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 Co on
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
, cSii �r Avlr BP-2003.0397
GIs#: COMMONWEALTH OF MASSACHUSETTS
Block:32C-339 CITY OF NORTHAMPTON
tvt p:
Lot: -001
Permit: Building"
Category:Nonstructural interior renovations BUILDING PERMIT
Permit# BP-2003.0397
Project# JS-2003-0396
Est.Cost: $40000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group JIM MAILLOUX 081694
Lot Size(sq. ft.): 8886.24 Owner: SIENKIEWICZ CHARLENE
Zoning:URC/GB Applicant: JIM MAI LLOUX
AT. 2 KINGSLEY AVE
Applicant Address: Phone: Insurance:
3 CORTICELLI ST (413) 585-1592
FLORENCEMA01062 ISSUED ON:10122102 0:00:00
TO PERFORM THE FOLLOWING WORK.-UPDATE KITCHEN & BATHS INCLUDING
SHEETROCK & PLASTER REPAIR
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 10/22/02 0:00:00 323 $100.00
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
IN