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36-043 (4) 2 G) I CD 4 EPT OF BUILOW IhIr kl%TOV r cr r. OD .4y CL ,�d INSPEcrin- ms VC O 4L f" 4�twNP�. o o � B �assaciinsctls DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT L deT 8 rile) with a principal place of business/residence at: _(phone#) 1.113 -7.71i' (streed/city/stalrJap) t3 t 3 do hereby certify, under the pains and penalties of penury, that: (� I am an employer providing the following worker's compensation coverage for my employees working on this job: cc 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) (Insurance Comparry/Policy Number) (Expiration Date) +r (Name of Contractor) (lnsurance Compary/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioaal shed ifnearsary to include infocazrion pertaining to all ooatran ) ( ) 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 whUo homcownan who employ pc zom to do m iatc „�a zr! us ioa or repair wort;on a dwelling of not more than three units in which the bomeowncr resides or on the grounds appurtenant thereto arc not gully,ooasidered to be employes under the worker's aoaTcas4oa Act(GLt52,s 1(5)),application by a homeowner for a license cc permit may evidence the legal swu of an employer under the Workde Compomation Ace. 1 undatitand that a copy of this ru t-s may be forwarded to the Departarnt of lMLvbial Aoa OfSoo of Insurance for tho ooveragc verification mad that failure to soc;=coverugo under suction 25A of MOL 152 can lead to the imposition of criminal penalties comisting of a fine of up to$1,500.00 and/or impriso of up to one year and civil pemltics in the form of a Stop Work order and a firm of 5100.00 a day ag&inst me. LPermit t=6Ll use only 12 G` ,;;� _ - - Number Lot# tgnallm of LicenseeRcmduce Date ` . ~ SECTION$-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : 0!76 as—n License Number Add Expiration Date !�Ignature Telephone Not Applicable 0 Company Name Registration Number Address Expiration 13ate Telephone SECTION 10-WORKERS' COrM PENSATION 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. The current exemption for~homeonmem^was extended toinclude one(1) ortwo(2)families and m allow such homeowner»u engage uu individual for hire who does not possess ulicense, provided that the owner acts Homeowner:as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. Derinition of Person(s)who own u parcel of land on which he/she resides mintends 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 aUooUncm. . Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official, responsible for all such work performed under the building permit. As acting Construction Superviso your presence oo the job site will be required from time 0o time,during and upon completion of the work for which this pen-nit ioissued. Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapter |53 (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be liable foopexoon(e) you hire k`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 PROPQSEQ WORK(check all applicable) New House ❑ Addition ❑ ReplaceqeV Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks Siding VN Other[ ] Brief Description of Proposed Work: /° Cs+-O X S! Alteration of existing bedroom Yes X No �dding new bedroom Yes X No Attached Narrative❑ Renovating unfinished basement _ Yes Y No Plans Attached Roll ❑ - Sheet❑ a "'24 �, f o 1 I ow... 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 AOPLIES''FOR BUILDING PERMIT I, _, 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 I, , 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. s� eA- R d.J c Print Name Signature of Owner/Agent Date V . Section 4. VE 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 /°°X /J.v Frontage f x�-a a c� 10/Uv Setbacks Front Side 3e- L: R: L: -A Z R: Rear 3 Q Building Height f ' � Bldg. Square Footage % 154f N Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has aCS�pecial Permit/Variance/Finding ever been issued for/on the site? NO J� 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: �/. �e�.f j�rr j,�r rr'A �r: ity of Northampton � F ilding Department 12 Main Street k ; SONS Room 100 orthampton, MA 01060 one 413-587.1240 Fax 413.587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION'1-SITE INFORMATION 1.1 Property Address: This sectiro to a completely office Zone Oirrla�Disttc# Elm�,�tfstrlc# `. CB°Dfstrct` SECTION'2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record:yy bi �ml k,Name(Print) Current Mailing Address: .S-S(Q -10 i-7.. -AJ,— Telephone Signature 2.2 Authorized Agent: !GL(� ii/��a..\... . .. 13L Z ��75 i��..a-.��j�c..r.C+, 1 \ 'r �-��T',•_ (.�s n Name(Print) Current Mailing Ad ress: c:!,1 c, �ri 761, 8 ignature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 60 O©ca (a) Building Permit Fee 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) / ©oa Check Number Thls Section For Official Use Only'' Building Permit Number: Date Issued: Signature'; Building Commissioner/Inspector of Buildings Date File#BP-2001-0621 APPLICANT/CONTACT PERSON PETER BURAKIEWICZ ADDRESS/PHONE 545 LAMPBLACK RD (413)774-7648 PROPERTY LOCATION 27 WINCHESTER TERR MAP 36 PARCEL 043 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out _ Fee Paid Tyl2eof Construction: INSTALL SLIDER,CONSTRUCT 12 X 12 DECK,AWNING WINDOWS ON SCREEN PORCH VINYL SIDING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building-Plans Included: Owner/Statement or License 056350 3 sets of Plans/Plot Plan THELLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § _w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § _w/ZONING BOARD OF APPEALS 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 r - o j Signature of Building icial 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. a 27 WINCHESTER TERR BP-2001-0621 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36-043 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Deck Addition BUILDING PERMIT Permit# BP-2001-0621 Project# JS-2001-1105 Est.Cost: $10000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: PETER BURAKIEWICZ 056350 Lot Size(sq.ft.): 1001 8.80 Owner: DION CAROL A Zoning.URA Applicant. PETER BURAKIEWICZ AT. 27 WINCHESTER TERR Applicant Address: Phone: Insurance: 545 LAMPBLACK RD (413) 774-7648 Workers Compensation GREENFIELDMA01301 ISSUED ON.•1/11/01 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL SLIDER, CONSTRUCT 12 X 12 DECK, AWNING WINDOWS ON SCREEN PORCH, VINYL SIDING 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 Sienature• Fee Type: Receipt No: Date Paid: Check No: Amount: Building 1/11/010:00:00 2101 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo