25C-103 (2) CtpT
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE A.I+MAVTT
f, X11 Z/ - -
perinittec}
with a principal place of business/residence at:
(phone
(Etrrzi/ t f/ 71
do hereby certify, under the pains and penalties of per}ury, that
(V I am an employer providing the following worker's compensation coverage for my
employees working on this job:
Qnsurance Company) (Policy 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 worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Compary/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Policy Niunber) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(anach additional sl3ect ifntccssary to inc}tsde iafocrosIIon patniaing to all ooci:adon)
( ) I am a sole proprietor and have no one work;sng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while homeowners who cmplay person3 to do m irrfml,,,c =st'=oc or repair work ova dwelling of
not mom than tbroo units in which the homoowncr resides Of oa the gcound3 appurtenant thereto arc not generally ooandacd to be
employers under the worker`s.compensation Act application try a homcowncr for a license a permit may evidence the
legal rlatua of an employee under the Workeez Compomation Ad.
I understand that a copy of thin ctatemmi may be forwarded to the DqK t.m of lr>AL-Oimi Aaid-&OPlioo of rnzurwos forth*
coverage venficatioo and that failure to axuro coverage under Stciioa 25A of MOIL 152 can lead to the imposition of criminal penalties
000siztM9 of a fine of up to 51,500.00 and/or imprisoao>cni of up to one year and eiVi1 peasltia in the form of a Stop Work orda aid a
firm of S 100.00 a day against me
Foe dcprrtme —ooh'
Permit Number
/ ZJ� Magi Lot#
iVl ab=of Li Date
47111-77177-71711,
SECO�S 07,CNSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder: I2 /
Licensee Number
Address Expiration Date
-3H 3
nature Telephone
e en n Not Applicable ❑
`17/
Company Name Registration Number
Addre Expirati n Da
Telephone.._
SECTION=10 YVORKERS' 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...... ❑
empt b,
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
hasx
S GTfON ., DB RAP h. ROPOSE�W� `chMU'lla livable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing f
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❑
�a�` 1 1Vew o�sea'�cl °�dtlition�toe` cisting�h0�irs�`�n;>:�complefe�theftil'I:a�in�:
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 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 7a;-`OWNER AUTHORIZATION -T9 BE'COMPLETED WHEN
OWNERS AGENT 011-`60' TRACTOR.APPLIES FOR-.BUILDING PERMIT
as Owner of the subject property
her y authorize _ �� � to act on
my behalf, in all rs relative to work aut ized by this building permit application. _
nature of Owner Date
WW � as Owner/Authorized Agent
her declare that the statem is and information on the foregoing application are true and accurate, to the best of my
kn wledge and belief.
Signed under the pains and p naIt' s of perjury.
Print N Re
Date
nature of Owner/Agent
nat
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?X--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 x
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:
----- of Northampton
i ing Department
i1 t5 2 Main Street
�J Room 100
2 9 r002 N a pton, MA 01060
phone 41 58 -1240 Fax 413-587-1272
I
nFpq of Bl!{LO{NG INSPEGTIONS p:
AA
ONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I - SITE INFORMATION
This sectio #o becomple' #iyokm`3 K
1.1 Properly Ad s:
�;
Ma Lot
p
2 x
Zone
k �
Elm St: District: CB Disnct
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT '
2.1 Owner of Reco d:
N (Print Current M vAddr�s�
Telephone
ignature
2.2 Authorized Agent: -046(
ame Pri t) Current Mailing Address:
ignature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building 00 (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 Perinit,;Number:- Date Issued:
Signature Buildmg.Commission'er/Inspector of
Buildings ti,. DateE.
BP-2003-0107
G1S#: COMMONWEALTH OF MASSACHUSETTS
-1U3 CITY OF NORTHAMPTON
Lot:--001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0107
Project# JS-2003-0210
Est. Cost: $3950.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: S E Sulenski 101718
Lot Size(sq.ft.): 5270.76 Owner: GNATEK JOHN F
Zoning_URB Applicant: S E Sulenski
AT: 33 GRANT AVE
Applicant Address: Phone: Insurance:
103 South Street (413) 532-3630 Workers
Compensation
HOLYOKEMA01040 ISSUED ON.7/30/02 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. 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 7/30/02 0:00:00 11718 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo