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m DEPARTMENT OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORNER'S COMPENSA ON INSURANCE Ar, I AVIT
hem 11
(licensez'Jpermittee) — -
,with a principal place of business/residence at: h�p '�Sa Se Ya O,cfl,,h
/f � �.+ I(street/ci ty/state/2i p)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following wor'ker's compensation coverage for my
employees working on this job:
(Insusaace Company) (Polio Number) (Expiration Date)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurance Coiupany/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/Poticy Number) (Expiration Date)
(Name of Contractor) (Inatrance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiooal sheet ifnoc=xry to include iafcxmarioa pertaining to ell cc�ra)
( ) I am a sole proprietor and have no one wonting for me.
I am a home owner performing all the work myself.
NOTE:please be aware that whilo homcowvcra who employ paaQm to rio rn.i*.fcain,e,oom n: ca cr rtpair work on a dwelling of
Mot nxra than thrn units in which the homeowner r mdc3 or on the Vvja s appurtenant tbtrdo arc not&axrzlly eomidcrcd to be
cmploY—under the worker's o=*=saticn Act(GL152,sa 1(5)),application by n homcow ncr for a liocwc or permd may evidence the
legal ctatuc of an amployor under thn Workcer,Compomation Ace_
I ua8aTtand flat a copy of thv cfatcmcat may ba forwarded to tbo Dtpartmm of Indr> jd Accid,=&Offioo of 1---000 for thn
coverage va ificalion and failure to aeatre coverago under section 25A of MGL 152 can lead to the imposition of criminal penalties
oomisti t of a fine up 1,500.00 Mwor' of up to one ytar and civil penalties in the form of a stop Work Order and a
fumorstoo.00 me
For dcp:rt�use ooly
permit Number
Map I Lot 4
SECTION 8—CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
n E vm ro E ti, a �xm � € pia
.Re . 1 red:--Nom Y v-amen n r c r ,Gsf ,.�,�ud; ,�,. R_ ... .. 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....... ❑ 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"certifi and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State an `cal Zoning L s an State f Massachusetts General Laws Annotated.
Homeowner Signature
. a
SECTION 5= DESCRIPTION-OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [
Brief Description of Proposed Work:
1) arc reel ,
Alteration of existing bedroom C--Yes No Adding new bedroom Yes _No
Attached Narrative❑ e�nova ing unfinished basement Yes xNo
Plans Attached Roll ❑ - Sheet❑ f F I S
64 IfiNew Youse'and 'r addition:ao exi"stun housin com' lete°the follovcrrn"
a. Use of building : One Family Two Family Other
b. Number of rooms in each family u it:_ 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?? (t Fireplaces or Woodstoves A/ 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 F� Private well City water Supply
SECTION 7a' OWNER AUTHORIZATION TO BE COMPLETED WHEN
01NNERS Ai�ENti:06R 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.
O wner 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
Date
Signature of Owner/Agent
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 S-G(,k✓ L
Frontage f a
Setbacks Front (GW &
Side L: R: L: J R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved S
parking)
#of Parking Spaces r Y/
Fill:
volume&Location)
s 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 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:
c +!
orthampton
( *1 Department u
I
in Street
m 100 e
Wirt p4o t n, MA 01060
L. phone 413.58 -12 0 Fax 413-587.1272
l (coZ(c u, ,i �;G iNSPECiION$ Q et SpeGt =i
APP14CATi0N t, CT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
11 Property Address: , / sa
��� Map' — Lott ' Unit
Zon' Overlay b,istr�ct - ='
Elm St. District cb District '
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
w
�6Ll�� s k� D
Name(Print) Current Mailing Address:
Telephone
Signature _
2.2 Authorized Agent:
ye ,o J �, l (r
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 2 v d (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
0 Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5)T L000 Check Number A)
This Section For Official Use Only
Building Permit Number le2 Date Issued:
Signature: ':
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0013
APPLICANT/CONTACT PERSON PAULINSKI DAWN
ADDRESS/PHONE P O BOX 3809918
PROPERTY LOCATION 142 NORTH ST
MAP 25C PARCEL 007 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: ADD 4 CLOSETS&COVER PORCH CEILING
New Construction
Non Structural interior renovations
Addition to Existiniz
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 ssion
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 0013
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0013
Project# JS-2003-0019
Est.Cost: $2000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor_
Lot Size(sa.ft.): 44431.20 Owner: PAULINSKI DAWN
Zoning.URB Applicant: PAULINSKI DAWN
AT: 142 NORTH ST
Applicant Address: Phone: Insurance:
P O BOX 3809918
CAMBRIDGEMA02238 ISSUED ON:712102 0:00:00
TO PERFORM THE FOLLOWING WORK:A D 4 LQSETS A COVER PORCH CEILING
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 7/2/02 0:00:00 Mo $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo