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36-111 (4)
A 2 � o k R, t� a � ,a c a i _ 1 C, N C,7 A 4 � 2XIo Pi � t3' Q " SPnrv� F 1 k --� N m cu d � ' i I , S ( HED19 r, I : : I (.�rT,�PAUk 4t,E- (7 ^ u 3 - IY : : 0 9 .8 L1.x�7 1a� �O:t"�(�F�l1I�T�IIII - � B j�asaacflttsrtts DEPARTMENT OF BUILDWG INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORICER'S COMPENSATION INSURANCE AFFIDAVIT 1,2 r7 ,�S (� - �l E"t l,s5 K( (li censerJpermi tt ee} with a principal place of business/residence at: (phone#) (street/ci ty/staiela p) do hereby certify, under the pains and penalties of pegury, that O I am an employer providing the following viorher's compensation coverage for my employees worldng on this job: CL�� 0z_ ::r� <S—, �,, F -Le' It r3 '785 >e / `iY— Z (Iasumnce Company) (Polio 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 Comparfy/Policy Number) (Expiration Date) ,f (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (E,\-piration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Aaach a6ditioa2l s}xct ifnocc=Ary to inc}ude infttmifion pertaining to all ooclt d rs) O 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 homcowtxrs who employ persorA to CJO na �7uCion cr r-pair WUVk oo a dwelling of not atone than throo units in which the honxowvcrresida or oa the poua,;3 appurtennjjjthordo arc cot Ccoa-ally comidcmd to be employva under the wor}c l 0=PC=fim Act(GL152,sa1(5)),appl tttion by a homcoww for a 6o==cc permit may cvidcaac the 4921 etatua of an employer under the Wodcor's Con*oosLtion Act. I unders d that a copy of this ciatcmmt nvy be forwcudad to tho Dcpartmced of Indtuhid Amidw&Office of lnx ADD*for the oovera verif'cstion and that failure to s==coverage under section 25A of MGL 152 can lead to the kVositim of criminal pcnall:es ooasiuin of a fine of up to 51,500.00 and/or imprisom=rd of up to one yt:ar and civil pcasltics in the form of a Stop Word Ord-and a fine 0(5100.00 a day sgaiast mc_ //z Foe dcpsrtrrl—only Ct c)2, permit Number p�{ Lot# Si of Liccnsec/p tree e SECTION 8-=CbNSTRUCTION SERVICES' 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder (4 - 1 -�'� 1 ^rs(C License Number �'?- r - IELD /`'�/�Y G ia3 4f-)( ` 88, j Address ;7 Expiration Date U�►- 2 Signa re Telephone R M":��_� r ,v men _, : �� 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 affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... A 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 . s� 7 it ZlC W�S �a77Ehs 6)r� SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable) s; New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other Brief Description of Proposed Work: R i d (9 F '�' 12-'X 1V Wit win i(o 1C2,6 ' Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Shee* 6��IfNewlio�s a"mid='or�addt�on'.toexisting�h�using,comp"1'e�etlie�followin�: a. Use of building : One Family '� Two Family Other 2 b. Number of rooms in each family unit: is Number of Bathrooms c. Is there a garage attached? I d. Proposed Square footage of new construction. 0 PEN DELK Dimensions t(11 1< 2-6 e. Number of stories? A7 f7far- 6,00P, 04 E'K WN-i- 6,'&r f. Method of heating? ,_- Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction (.Jnvn 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 /'4'7 6.1,04 Lr k. Will building conform to the Building and Zoning regulations? K Yes No . I. Septic Tank City Sewer Private well City water Supply SECTIONIA=.OWNERAUTHORIZATION!-TO BE COMPLETED WHEN OWNERS(GENT"0,R CONTRACTOR APPLIES FOR BUILDING PERMIT S L t 5 (--E n as Owner of the subject property hereby authorize ::3P(.6-0 14 2— (i`� t.,jSt(-( to act on my behalf, in all matters relative to work authorized by this building permit application. L) �- Signature of Owner Date a,- per/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 t4 Print Na - e C F V Signature of wn ent 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 ( '2(�C> Sly F F- L&& 3 d F7 Frontage ©� r 6 Setbacks Front �jC> L3 C�> Side L:_L2 R: 3 f L: R: 5— Rear Building Height J Ig 18. Bldg. Square Footage t5 �.7 % d&ct 16).y o Open Space Footage % (Lot area minus bldg&paved 15- 174., '/o parking) #of Parking Spaces �� y 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: 4 of Northampton 11. gilding Department b2 Main Street APR 2 4 200 02 Room 100 e Mort ampton, MA 01060 ` phpne X13.5 7.1240 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 section fo becompleted by offf[ce 1 Map Ns}niti 121k,111111,1121'Arl, 0, "177 73,5 TqFng, Zone .,Overlay Dtstrict Elm St."District CB District SECTION°2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: lcS/Ibl-� L Name(Print Current Mail'!n Add res Telephone Signature 2.2 Authorized Agent: ,-7-1 0t&.� t`I Name(Print) Current Mailing Address: ig3l5; o Sign lure Telephone SECT 3 - ESTIMAT - CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by ermit applicant 1. Building .3 6za (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) 3, r>i� Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date I File#BP-2002-0929 APPLICANT/CONTACT PERSON LEBEAU SUSAN ADDRESS/PHONE 223 BROOKSIDE CIR (413)584-6045 Q PROPERTY LOCATION 223 BROOKSIDE CIR MAP 36 PARCEL 111 001 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 T_ypeof Construction: REPLACE EXISTING DECK W/20 X 16 New Construction Non Structural interior renovations Addition to Existing - Accessory Structure Building_Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan B FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ATION 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 ion ignature o uilding 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. cnt BP 2002 0929 G1S# COMMONWEALTH OF MASSACHUSETTS •I t CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2002.0929 Project# JS-2002-1507 Est.Cost: $3000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: John Zieminski 017889 Lot Size(sq. ft.): 18251.64 Owner: LEBEAU SUSAN Zoning:U Applicant: John Zieminski AT: 223 BROOKSIDE CIR Applicant Address: Phone: Insurance: 8 CIRCLE DR (413) 247-9014 Workers Compensation HATFIELDMA01038 ISSUED ON:4126102 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING DECK W/ 20 X 16 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 4/26/02 0:00:00 4428 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 223 BROOKSIDE CIR BP-2002.0929 CIS#: COMMONWEALTH OF MASSACHUSETTS MaVBlock: 36- 111 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category_ BUILDING PERMIT Permit# BP-2002-0929 Project# JS-2002.1507 Est. Cost: $3000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: John Zieminski 017889 Lot Size(sg.ft.): 18251.64 Owner: LEBEAU SUSAN ?nnin2:UP-,\ Applicant: John„ZiPminski AT. 223 BROOKSIDE CIR Applicant Address: Phone: Insurance: 8 CIRCLE DR (413) 247-9014 Workers Compensation HATFIELDMA01038 ISSUED ON:4126102 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING DECK W/ 20 X 16 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: 0 L L S o K `/ 9 a Driveway Final: r/ ^� Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:0 K -�--/ 3' a THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA'�ION OF ANY OF ITS RULES AND REGULATIONS. ,%I �,/ Certificate of Occu an Si nature: % Fee Type: Receipt No: Date Paid: Check No: Amount: Building 4/26/02 0:00:00 4428 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 223 BROOKSIDE CIR BP-2002-0929 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 111 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2002-0929 Protect# JS-2002-1507 Est. Cost: $3000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: John Zieminski 017889 Lot Size(sa.ft.): 18251.64 Owner: LEBEAU SUSAN Zoning:UIv4 Avphcant:_J_o h_n.:Z i e m i n s k i AT. 223 BROOKSIDE CIR Applicant Address: Phone: Insurance: 8 CIRCLE DR (413) 247-9014 Workers Comnpensation HATFIELDMA01038 ISSUED ON:4126102 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE EXISTI N DECK W/ 20 X 16 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: S 0 K /-� 9 •a a Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:0 K -/ 3- G 9 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. /I Certificate of Occu an Si nature Fee Type: Receipt No: Date Paid: _ Check No: Amount: Building 4/26/02 0:00:00 4428 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo