25A-083 (2) . ��tiA1•Ip�O ..
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DEPARTMENT OF BUILDWG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATTON INSURANCE AF MAVIT
I-,
(licenser�permittec}
with a principal place of business/residence at:
(phone#)
(stT=Ucity/staIdzip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees wonting 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 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 Compari/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (ExTiration Date)
(attach additional sod ifn6o=sary to include iafoemirioo patA;uing to all coatr.d n,)
O-Lam a sole proprietor and have no one worming for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homcownera who employ persom to do m&jnjc coffiuw:too or repair work on a dwelling of
not more than throo units in which the twmrowncr raidcs oc oa the pounds appurunud thereto art ooe gcncrany coasidcmd to be
cmploytra undo the worker's oompcus cn Act(GL152,ss 1(5)1,application by a homcowoa for a Gccux cc permit may cvidcnoc the
legal ctatua of an amployer undertho Worker's Coenpoosatioa AcL
I understand tisst a copy of thin r W=acai may bo forwarded to the Depa w3ccd of IMwtial Ac6&.>'Ofboo of Imsusnoo for ths
coverage ve ificalioa and that failure to towre covcrago under soctioa 25A of MGL 152 can lead to the invoS3ion of criminal penalties
oomuting of a fine of up to$1,SOO.t?0 and/or imgt isoamaat of up too year and evil peasltia in the focm oC a Step Work Ordtz and a
fum of S 100.00 a day agyiazt ma
For dcpsztm�t'aa Only
permit Number
Maps Lot
a f:s Signature of Licenseeptrmittee e
EC ON ONSTR UGT�ION$5ERVICES,
.,� ..
Rj
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
A dyes Expiration Date l
Sign ure Telephone
m« l
Not Applicable ❑
c �� /l4c ��r.-� f // `f,� 9 3
Company Name Registratio Numb r
te�r 7 c: p
Address Expiration Dat
Telephone � 7� /7
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 affida
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)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
a
SECTfONg DESCRIPTIONrOF�PROPOSED�VVORK checkall�a 'licabte s ,
�fl..,�' 1�::+? x�'a"�.k"�`mas:fi�r1_'-u�%i�,�aly.,.v'v.»:b Se -:�v�,:Q"?,. al�.,"""�4isdu?•",�§?a"59a'�#"i i(`�,� i ,..N HLC��.
,�,.at,' $ �,x.�aP,,�,�+? ...�..a+.�: .5,..,.....i -� :;3.;,:+.;,✓.° -.#k [S .�rl?. �..r..M��:.3„ zar..k .-"*." ;h;'i'�°^ 1�v:
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing -
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
ra l'fIN W house a "tl or
'A- -W
existin iµo S ng, compleiLe�the fol:low>Inix:
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 I
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
1. Septic Tank City Sewer Private well City water Supply
S'EG�lflN 7a OWNER=AUTHOItIZATiON TO BE COMPLE�7;ED ,WHEN
01NNERSAGENT OR=C,ONTRACTOR;APLIESiFOR'6UILDIN;G.PERMIT
( U as Owner of the subject proper-
hereby authorize _;((JP ti Cc /� r 5 TGL �" �°L to act
m ehalf, in all m tters relative to work authorized by this building permit application.
a (.
Signature of Owner C V 6ate
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
Signature of Owner/Agent Date
tf d
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:
a
City of Northampton at e-
Building Department curb e:
212 Main Street
Room 100 a r 1Ne1 va.'�
Northampton, MA 01060 o Setso r, :`
phone 413.587-1240 Fax 413-587-1272 Iot1�SePla
�t er�Specify -
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE'I NFORMATION
C This section to be'completed 6r offare
1.1 Property Address: "
n Map L'ot Unit
5-57,
RE
tf $}
A /
OA AA //�� y/�V�` �j� /`� / - Zone ' --.Ouerlay�Distr�ct ' _ k
Elm St'District CBkDistr
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�=L mac: t � �� 06 uf.
Na e(Print) Current Mailing Address:
v 7[fe—CIA�!crr�f (�'I O/l1(U
Telephone /
Signature— l3 ��--
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
�ECTl0N,3 - ESTIMATED C6N5-TRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use'Only
completed by ermit applicant
1. Building (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) Check Number
This Section For Official Use Only
Bullding Permit Number Date Issued:
3
y nature
Building Co„mm�ssiQ,tier%1'nspectoX of 6uiidinBs..� ,... Date.,
-...::'
0�COOLIDGE AvE BP-2002-0271
GIS#: COMMONWEALTH OF MASSACHUSETTS
os3 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinq
Category:roofing BUILDING PERMIT
Permit# BP-2002-0271
Project# JS-2002-0407
Est.Cost: $6500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Ronald Mistarka 118693
Lot Size(sq.ft.): 1 2501 .72 Owner: NETTO MICHAEL J&LINDA L
Zoning.URB Applicant: Ronald Mistarka
AT. 15 COOLIDGE AVE
Applicant Address: Phone: Insurance:
P 0 Box 205 (413) 575-1271
NORTHAM PTO NMA01061 ISSUED ON:916101 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 Tyne: Receipt No: Date Paid: Check No: Amount:
z
Building 9/6/010:00:00 863 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo