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35-045 (3) d, �,, ,, ��. ... ,y .. � ��,. . _„� ,.,_., `� t �, F .� _....�„ ..1,.. ^( i + 4 { _.__ �e } s. � 3t( �� `�6�;N t d � i �. f _ ,� ,, °,�... ,„, ,, 3 _, g q a .- _�__., .--> �. n ,•� . - _..,�. F ._..�M.a,.. _.�_.0 _ _�._.... .... ......_.__.._ .._�........_ r k 4ttiAAlp�0 Boo °fl Crx 710[ 'Xart4a11Y}1foil B 6 JRxsaRChnsrtts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 " WORKER'S COMPENSATION INSURANCE AFFAMAVIT (li ceusec/permi tree) with a principal place of business/residence at: (phone#) {stmet/ci tylstaie/a p) do hereby certify, under the pains and penalties of pegw-Y, that ( ) I am an employer providing the following workers compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration Dale) ( ) 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/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml sheet if necess_uy to include information p"uinins to a cvojrndnta) ( ) I am a sole proprietor and have no one working for me. �<I am a home owner performing all the work myself. NOTE:please be aware that whilo homco Amcor who employ persons to do maintc�comtuction or repair work on a dwelling of not more than throo units is which the homeowner resides oc oa the grounds appurten thereto arc not 6coa-aliy ooandctcd to be employrrs under the work oempca&4oa Act(GL152,ss 1(5)�application by a homoovrna for a Gccnse or permit may evidcaoe the legal stsdau of an employee under the Workeez Compensation Acct I undcataad that a Copy of thin ctatemcat may be forwarded to the Dqm w..,2 of l-&Le id A,-i&- 'Oiboe of Insruanco for the coverage vaifictuoa and that fad=to&=uc coverago under so=oa 25A of MGL 152 can lead w the imposition of aiminal penalties oomistmg oft fine of up to S1,500.00 anNoc imprison of up to one year and civil peaaltics in the form of a Stop Work Order aad a firm 0(5100.00 a day against me. For l u oaly Permit Number NfaO Lot# -r x Signahtre of LicenseelPermi e 5ECTJOCONSTRUCTION SERVICES 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone pp e�g1S 'e e `i�ome 1ih`p' rpvement•C�n�,ractor, k� = �; ,�,�;,y�: Not Applicable ❑ 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 affica will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... ❑ No...... ❑ ±�meO���ie� .•��em��� �ri The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)familie 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( 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 l A, ae er .'T ,r SECTION 5 DESCRIK O PROPOSED K check all a livable .,,..,...air.�;,n't; ' = .'�'��s,`xP,>�l�'r,3,..`��§,#.. "!.�..,p,.,i,•r'��. .`a:=�aa# �.rd+ ",u."`-':l;�f��4n�.�',a�.'. .K..xn" �'.�v�, .PN,'3. -N: ..>_?k�'. -`''-,.d:���3°,.,��eu.L?3�.E .`�"y-„:,*�2ctsx,,:�.:.;. ,� : •i t> ..h+'-w.:"sw9Ln'L 'ax,a,'„r,.,�...J ,.,.K.., ��F*'t";;�„�_; New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Q Siding[ ] Other [ ] Brief Description of Proposed Work: &57c�-7 i/y;' LYi Iga Alteration of existing bedroom Yes �o Adding new bedroom Yes ._kt!!'No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑- Sheet❑ !f N'ew�houe'”a°rdo” addit"ionto�risting.Fiousinr-,-corri'pletetW6followin : 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 f 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 7a01NNERAUTHOtIZATION TO BE COMPLETED ;WHEN O:YYNERS,A�GEN OR CONTRACTOR APPLIES�OR.BUILDING PERMIT I, �OIU � FZ as Owner of the subject proper hereby authorize to act my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 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 �Q 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 A" 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 y 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: r Cit of Northampton U n,� d epartment Tzi in Street "fie 0 rn 100 aer1N V i. SEP - o "tha n, MA 01060 phone 413-58 -12 0 Fax 413-587-1272 PIotlSie DFPT OF BUILDING IMPECTIONS Ot�h�er�Speoify � . T 1 N ER, REPAIR, RENOVATE OR EMO`LISH A ONE OR TWO FAMILY DWELLING SECTION"1-SITE INFORMATION This section to be,' ompleted by office 1.1 Property Address: �� yA/✓ �O/�D Map Q1, 'plot :Zone Overlay D�stnct� -L ,E�rc€, f li9 O a Elm St:"District CB Di"stnct ` SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: -,-, ,. Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION`S - ESTIMATED CONSTRUCTION""C05TS" Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building M nom' (a) Building Permit Fee WrW 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) 0OP©0 1 Check Number Wo Q This Section For r'Official,Use On 7-7777777-77-= 77: guilding'Perinit Number ."� ". - Date Issued." z Signature " _ Builmg Co""mmissionerJlnspector ofB,uildChg „ = Date s File#BP-2002-0263 APPLICANT/CONTACT PERSON SLEZEK EDWARD M ADDRESS/PHONE 967 RYAN RD (413)586-2677 Q PROPERTY LOCATION 967 RYAN RD MAP 35 PARCEL 045 001 ZONE RR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid m5v t — Tyueof Construction: SCREEN IN EXISTING DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure _ Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved Denied PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan OR Special Permit and Site Plan Major Project: Site Plan OR Special Permit and 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 Commission -,ZJ.4u� 1 .d-7 iv Signa a of Buildi 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. BP-2002-0263 GIs#: COMMONWEALTH OF MASSACHUSETTS > Ic:35-lass CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2002-0263 Project# JS-2002-0398 Est.Cost: $2200.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin: Lot Size(sq. ft.): 31842.36 Owner. SLEZEK EDWARD M Zoning:RR Applicant. SLEZEK EDWARD M AT. 967 RYAN RD Applicant Address: Phone: Insurance: 967 RYAN RD (413) 586-2677 (� FLORENCEMA01062 ISSUED ON.91111010:00:00 TO PERFORM THE FOLLOWING WORK.SCREEN IN EXISTING DECK 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 Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 9/11/010:00:00 960 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo f tg s S v mow vek Low I oil own 967 RYA V .4 RD BP-2002-0263 COMMONWEALTH OF MASSACHUSETTS MV.-Block: 35-045 CITY OF NORTHAMPTON x Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2002-0263 Project# JS-2002-0398 Est.Cost:$2200.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: Lot Size(sq.ft.): 31842.36 Owner: SLEZEK EDWARD M Zoning:RR Applicant. SLEZEK EDWARD M AT. 967 RYAN RD Applicant Address: Phone: Insurance: 967 RYAN RD (413) 586-2677 0 FLORENCEMA01062 ISSUED ON:9111 1010:00:00 TO PERFORM THE FOLLOWING WORK.-SCREEN IN EXISTING DECK 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:6k Gas Fire Deuartment Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Finale- o_ THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF . ANY OF ITS RULES AND REGULATIONS. w C6rtificate of Occupancy si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 9/11/010:00:00 960 $25.00 212 Main one;(413)581-1240,Fax:(413)587-1272 � inissioner-Anthony Patillo 4 f ��' __ ;j 1 f i �.,�f �� �� ! 'tom J.; .... .......... _ ...._.... ... 1 M.� �.. { f� pj� Y ��._,� i i �(�...� �( '� yam, �� �...,} !" P .�� T -.. ,., � .._,, 'yr a .....t r -.e...71,.. ;... j ..-. *,.••.� �'�/ jig ,. /�''�-' ] _�.o.e d ,�"�, ti i, u l I i tt. 3 k t 1 _ i� i f i 1 `, m»..,..„n .n.-,..r.,:... ....o-i.w+..:...zvn.,em.v+nn.roaanw...new.v✓wwnw.. _ - � G f r