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10B-108 (3) k 't et 3 1 � � I i f 1 i 1 I I 6� a J,. i [T + f 1v ar d J -� ............... p. it PF t t ti ey i !", 'D C%Ci,<°„<, - L.�i7r"/ "ago? f2Aa.y 9 E 2 A,-Z-1 fir,,;.,, 11 I e Y4;!" rot�r"i a c f u — --—-- --� I ' r w i r. u: i a i P k s t y i c � f S d j d 3 u � 1 71- i r tt A�—T e 3 t s ` t s Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. e Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage, Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. r,. r City or Towns .Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 -- The Commonwealth of Massachusetts Department of Industrial Accidents _— Office efinyestfgatfew _= 600 Washington Street y Boston) Mass. 02111 '�li-Z1.S'yam Workers' Compensation Insurance Affidavit name: location: E �' �/� city phone# .1 V -7 I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. address. city phone# ,�' porgy# , affeas BEEN= El I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address: city: phone.#• insurance co. policy# company name: address: cites phone#: insurance co. policy Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of fine up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature �I j� Date Print name v b�f t [t=�YZ/�=' �/ Phone# `/ �e"� official use only do nol write in this area to be completed by city or town official �: `4 city or town: permit license# rlBuilding Department E]Licensing Board F-1 check if immediate response is required E]Selectmen's Office Ejllealth Department contact person: phone#; f 10ther (rmscd 3195 PIA) 'SECTION'8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: ����`� Z yi /� © -7 License Number Gr/_'c t %fi9 �EZr 41-03S- Address Address Expiration Date �.� -f 13 ;-2 iq 3>9 t Signature Telephone - .pr � .,w NotApplicable ❑ 9.12egister0—ff melmo/vement`Contractor PP Company Name Registration Num er - -- -" J/) -/4" � n-? / O o /3 3 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....... ,Bt No...... ❑ Hom&Owner Exemption 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 i.y 1:.,L.In f r r�orcnn(cl Employees for injuries not resulting in Death)of the Massachusetts General Laws A;u;otated,v;,::...�v., • r_..._--,-, 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 r SECTION 5-DESCRIPTION OF PROPOSED WORK{check all applicable) New House Addition �:;. Replacement Windows Alteration(s) Roofing Or Doors CI Accessory Bldg. Demolition New Signs [ED] Decks ([] Siding[[-1) Other[O) 2 z Brief Description of Proposed °� �'E T»•.! Work: y•,4 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes Jk' No Plans Attached Roll (�--Shh eel +n!rf"'" �tY•"iI•!*4�xC`?.'�, .".A-� Y tKti..kT`�r"i..:r*....a ,.....,""!�"" ."M""•�!"^ ..q;,r-.. a:�.. ..•��wu.—...rc.!�'•'r#�t' sa_'If•Nevir-house�and'.br.addi ton.fo_extsttng-houstng;hcomplete•4he,followtng: a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: 7 Number of Bathrooms c. Is there a garage attached? A/V d. Proposed Square footage of new construction. 6 Dimensions e. Number of stories? f. Method of heating?lab• Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction G✓"Don Fi44w i. Is construction within 100 ft.of wetlands? Yes X_ 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. 1. Septic Tank City Sewer x Private well City water Supply SECTION 7aI-OWNER AUTHORIZATION-;TO BECOMPLETED`WHEN OWNERS.AGENT.OR CONTRACTOR APPG.I ES FOR BUILDING'PERMIT 1, as Owner of the subject property 'l hereby auth r ✓Oh�N %�"�rinrS/�I to act on m b alf,in all atte re tive to work authorized by this building permit application. Signat a of ner 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 3 / 7 ' �y Signature of 00t/Agent Date ` , Section 4. ZONING All Informati6h Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size V Frontage Setbacks Front )-;7,r 1 Rear Building Height Open Space Footage % (Lot area minus bldg&paved ' #of Parking Spaces (volume,&Location) A. Ho�uSpada| Permit/Varance/F issued/��y_� /~/� . No \~� DON'T VV KN0 YES \_ ' IF YES, data issued: . IF YES: Was the permit recorded at the Registry ofDeeds? NO �� DON'T um / mvuvv 0 ,co IF YES: enter Book Page! and/or Document# B. Does the site contain u brook, body of water urwetlands? NO 0 DON TKNUV 0 YE5 0 IF YES, has permit been or need to be obtained from the Conservation Commission? ' Needs tobeubtained Dbtained /—\ Da�* |ssued' | \~� \.�' ' ' L_______-_--1 C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there an proposed YES /~� NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orixd part ofa common plan that will disturb over 1acre? YES [ ) r NO L�^ IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ` '� City of Nort taampton Status of Permlt i4tM .r".' * . %,� Building Department Curb CutlDtveway PermttF 'Y x � r � k24tf �� � > Wy SAY, O vatabtli212 Main Street aAty ' 5� 6 Room 100 Water/VVell Availability yi an \'a �oN rthampton; MA 01060 Two Sets of Structural Plans isc ' �r Na r , S d++1 N •c» r x w iS� v �.t^xr 'a rtir; 413-587-1240 Fax 413-587-1272 Plot/Ste Plans �`t 't"ifs rl�xT a a r r u�1tr+b �� ; Qther Cl Sbe �e fy LICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1'-SITE INFORMATION..'' This ection to be completed by office ' ,� r , 1.1 Property Address: Ave Map '' LOt41 Unit I Etm St.District k '' CB.Distnctt _ SECTION 2 PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: - Telephone Signature 2.2 Authorized Agent: ✓���/�. `�%E�'yi^'S,C� �v �IVO,ai�f�,"fCi:� �y�i-vi0 3� Name(Print) Current Mailing Address: c<& V13 Signat e Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building ,(a)Building Permit Fee 2. Electrical .(b)Estimated r Total Cost of y 00 O Construction from 6 3. Plumbing Building Permit Fee 4. mecnanicai triviAC) 5. Fire Protection O 6. Total =0 +2+3+4+5) .7 3 -5-dl O Check Number This Section For Official Use Only Date Building Permit Number Issued: Signature: i Building Commissioner/Inspector of Buildings Date . � ��✓ I N l�R File#BP-2014-1222 C APPLICANT/CONTACT PERSON JOHN ZIEMINSKI ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413)247-9014 PROPERTY LOCATION 20 GROVE AVE MAP IOB PARCEL 108 001 ZONE URA000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out '14 C7 Fee Paid Typeof Construction: CONSTRUCT 14 X 16 MUSIC ROOM ADDITION&24 X 24 DET GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory_Structure Building Plans Included: Owner/Statement or License 017889 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Permit DPW Storm Water Management D olition Delay Si o ui din ficia 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. 20 GROVE AVE BP-2014-1222 GIS#: COMMONWEALTH OF MASSACHUSETTS MW:Block: IOB- 108 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:ADDITION BUILDING PERMIT Permit# BP-2014-1222 Project# JS-2014-002062 Est.Cost: $73500.00 Fee: $227.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN ZIEMINSKI 017889 Lot Size(sg.ft.): 21170.16 Owner: CHERULNIK PAUL D&BEVERLY E Zoning: URA(100)/ Applicant: JOHN ZIEMINSKI AT. 20 GROVE AVE Applicant Address: Phone: Insurance: 8 WOODRIDGE CIRC (413) 247-9014 Workers Compensation HATFIELDMA01038 ISSUED ON:512912014 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 14 X 16 MUSIC ROOM ADDITION & 24 X 24 DET GARAGE 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 Sienature: FeeType• Date Paid: Amount: Building 5/29/2014 0:00:00 $227.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner