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WINDOW WORLD
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DEPARTMENT OF LtUILDWG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S CONLPENSATION INSURANCE ATITIDAVIT
(licenser/perm�ttcc} ---
with a principal place ofbusiness/residence at:
_(phone,',') � � ,-�•�
(strevtici ty/sta�a p)
do hereby certify, under the pains and penalties of perjury, that.
O I am an employer providing the following worker`s compensation coverage for my
employees working on this job:
(Insurance 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 workeCs compensation policies:
(Name of Contractor) (Insuranc Company/Policy Number) (Expiration Date)
f
(Name of Coil tractoC (Insur<nace Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance ComT2ny/Policy Numb,--r) (Expiration Date)
(Name of Contractor) (Insurance Compa--y/Policy Number) (Expiration Date)
(attach additiccal s}uc(ifnecsur:to i_x}udc infoccnitioe pxtaiaing;o all c« ractors)
am it sole proprietor and have no one working for me.
( ) I am a hoone owner performing all the work myself.
NOTE:please be aware that w'iilc homcoµ-ixn who arploy pcz-;oaz to d)mAintrnancS corijctioc a trra r work on a d«cll rig of
not wore than thrco units in NvEch the rcaidca cr oa the U,�Uz�d3 appurtenant tlwdo arc not generally eoasickrcd to be
cmploycrs under the svorka's«.,-Cz=tion Act(GL152,-s 1(5)},apVLcz6on by a homcowncr for a licctnc a permit may cviScnee the
legal etatus of an omployor under tin Wotkc '&Compmiiiion Act_
I undasttnd that a copy of this rintcmcar may be forwnrded to tbo Dcpartum of Induitrid Ao6e=&Offioo of[sriusnco for the
coverage va-ificatioc and that failtn-e to!-Cure covcrago under section.25A of MOL 152 can(cad to tha imposition of criminal Penslt:n
consisting of a f nc of up to S 1,500.00 mrWor imprisossnxt t of up to one:year and civil penalties in dx form of a stop Work Ord--and a
fitto 0(:3 100.00 a day against[or-
_.. For c'—y^.rNum es oa[y
•, � f.,�-t---^-} ) Permit Number
Signature of LiccnsecNermittee e
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : __
License Number
Address Expiration Date
Signature Telephone
. � u' Not Applicable ❑
9"Registeretl Ho"m"�e Impronwement Contractor, fi.. . , _
Company Name Registration Number
l r .tGG IC- —
Address Expi(atio Date
5, 1,4414 CIO 5 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...... ❑
f�::&n,, eRA",
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 nets
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 buildint;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 fe-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 ndows Alteration(s) ❑ Roofing El Or Doors l
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: c�5�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet❑
sa:,"IfINdW'house and JI,or,'addition I to existing C ousinq,=cor iP]bte�tlie:fbflowin�:
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
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
�-� as Own Authorized Agent.-'
hereby declare that the statements and information on the foregoing application are true and accurate, the bes —o Fm
knowledge and belief.
Signed under the pains and penalties of perjury.
�otr --
Print Name ;
Signature of Owne /A
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
IFrYES, describe size, type and location:
.. <,
.City of Northampton S at Sid R ��
Building Department curb
212 Main Street Se erT e r
Room 100 Wa erlJf `
Northampton, MA 01060 aetsoy
phone 413.587-12140 Fax 413-587-1272
t 3 =
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section,ito be'�completed by-office
1.1 Property Address: �'
Map L`ot unit
Zone Overlay DistrIt1
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
J -r�uA
Name(Print) Current Mail ng Address:
_ S-011 f —
Telephone
Signature ----
2.2 Authorized Agent:
C Vj t�l �t– I( Qr Y1�O�CC S 1 t� r�S ly1.Q
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. Elecirical (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,
l
BP-2003-0894
GIs#: COMMONWEALTH OF MASSACHUSETTS
' CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2003-0894
Protect# JS-2003-1439
Est. Cost: $1113.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group; John Corbett 104000
Lot Size(sq. ft.): 10759.32 Owner: SZAWLOWSKI JEROME J&SUSAN M
Zoning: SR Applicant: John Corbett
AT. 56 WESTWOOD TERR
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:4122103 0:00:00
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 Occupangy Occupancy Si nature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 4/22/03 0:00:00 1546 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo