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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AF+ AVIT
(liPeT��)
with a principal place of business/residence at:
(phone#)
(shr_et/city/stairJrip) ���b'� (�-
do hereby certify, under the pains and penalties of pequry, 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 homeowncf (ci cle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Compauy/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attarb additio"slice if ne<--m y to ix}u infocauti on pertaining to all contra rs)
�I am a sole proprietor and have no one working for me.
( ) I a n a home owner performing all the work myself.
NOTE:please be aware that Abile homcowvcta wibo employ pccso=to do mxiat +•acr,ccrr—�uctioa cr repair work on a dwelling of
not more than thrco unite in which the hom owner rides or oa the vvaads app ales r t tbttcto art no(gcnazlly coaiidcrrd to be
anploycra under the woeK&s canipc s4oa Act(GL152 fs 1(5)),application by a homcovma for a Eca-M cc per r may cvidcnoe the
legal etatu of an omployoc under tho Workers Compoaaatioa A.ce_
I unacnttad th:t a copy of this uatcmcat mey bo forwurdad to tho DcparCncai of I.&,za6 al Ar6d &OfE-of L0 ruanco for t1-
coverage verification and aiat failure to s==oovengo under section 25A of MOL 152 can lead to tbs imposition of cr miner pcnalfics
comistiag of a fine of up to S1,500.00 and/or inTriso of tip to ow-ycsr and civil pcnnttics in de,foan of a Stop Work Ord--and a
fir of:S 100.00 a day against me
For only
permit Number
Lot 4
Signature of LtccnSecipermittce e .:
SECTION 8 CONSTRUCTION SERVICES.
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
c
y
Signature Telephone
.r " Not Applicable ❑
'1 L 5 (�U br"fir' s s j yx, ✓t� t' �g �� 2
Company Name Registration Number
Address Expiration to iv- Telephone �2, 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 affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... X No...... ❑ _
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinlls 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 strictures 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 pen-nit 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 CTI'ON}� f)ES�CRIPTION OF,�PROPOSED WORK(check alhapulicable)
�_ _-a.3a ...�k""'"➢- '�.i'.�i3. 2�.,n 74:«,a,,m�..v. .�': 2. ,r.n'w� , r. ...... .-_. ,} }.�..9. n , . _.�:�3a.-,.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. O Demolition❑ New Signs [ ] / Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: C GT p `, t
Alteration of existing bedroom Yes No Adding new bedroom Yes No /o n
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
��,�IfNew �io se�a�ido��cld'itionto existing.'hou"s`ing�°`complete"Ythexf�llowin :
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? a A--
f. Method of heating? 0, ! 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 7i OWNER AUTHORIZATION'-TO BE COMPLETED; WHEN
OWNERS AGENT OR -,CONTRACTOR APPLIES FOR BUILDING PERMIT
LI v'��` �A � �_ >� ` /C'�� , as Owner of the subject property
v U i-��Ir / —4-- �`'�- c--..&--...j � /� to act on
_hereby authorize -- — AI-
behalf, in all matters relative to work authorized by this building permit application.
gnature 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 i fer �
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 �s 0
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:
• r
City of Northampton
Building Department
212 Main Street x .
Room 100 a
Northampton, MA 01060 _
phone 413-587.1240 Fax 413-587-1 272
APPLICATION TO CONSTRUCT, A VATE O LISH A ONE OR TWO FAMILY DWELLING
t l SEP 2 7 2002
SECTION 1 -SITE INFORMATION i, 1NGl'SPECTIONS
NpRYti�.,q (GN is sectlott to be completed by o free
1.1 Property Address:
7- Overlay Distr)ct � .��`��'�
Elms t.District CB.Distrtct"
SECTION 2 - PROPERTY,OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: f
Name(Print) Current Mailing Address:, / )
Telephone _
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address: j, - ��(� ~L 4c c�C,:y: -, Cpl C"" (v
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by,permit applicant _
1. Building u
(7("; (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
Building Permit'Number: D --, 3 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0336
APPLICANT/CONTACT PERSON NORMAN ZALESKY
ADDRESS/PHONE P O BOX 53 (413)268-3553
PROPERTY LOCATION 128 NORTH ST
MAP 25C PARCEL 005 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid !Z94of ASV--
Tyneof Construction: REBUILD PORCH POST RAILS/FLR JOIST(10 X 40)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 034841
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I FORMATION 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 Commission
Signature of Building 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-2003-0336
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0336
Project# JS-2003-0564
Est. Cost: $4500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin NORMAN ZALESKY 034841
Lot Size(ss . ft.)31058.28 Owner: MCCLELLAN ELAINE F
Zoning:URB Applicant: NORMAN ZALESKY
AT. 128 NORTH ST
Applicant Address: Phone: Insurance:
P O BOX 53 (413) 268-3553
WILLIAMSBURGMA01096-0535 ISSUED ON.10 110102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD PORCH, POST RAILS/FLR JOIST (10
X 40)
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 10/10/02 0:00:00 794 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo