25C-170 (li,ifl,� of �\301✓11jullipfoil
f3tasencfincr(la _
DEPARTMENT 01' I3U1(1�f>\G lNSPICT1O11S -
212 Alain Strcct Municipal DmIdin,, =� '
Northampton, ofass- 01060
WOIZI' EWS COtUENSATTON INSURAN(--F', AI?FJDAVIT
l
\>rrlth a principal place of busIL)eSSJFCSideI]CC 21.
37 Cff�� r�L�
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do hereby certify, under the pains and penalties ofperjury, dial
( 1 an3 an employe: prOVtdlll", tlli_. I0llowlM Woi c;Crzs Colnnnsc;.'o:l cove:-',C icl Illy
c mplcyccs wor:'dng on tills job
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(lnnlr-.,�.
( l aln G sole prODllCtoi "elIcral GO)IIaCtOr Or holllc-ov uce (Cli h1teC]
t11e CO11:-Ic O:'s C:'.Iov"' -'" 'o ,` Pv." the
g fl"c. C. ( , .-'GO"1 (�I �,-..I1C (-Oal7._. 7/!fit. �t1l,l__:) { JL�!' D?.lc�
(l\u1111'.
Of ConiPCOt) (Ills lid1]CC CD1➢D3;]vi��0�1�,' �'l1L-lCri) - (L'XT?lt il0n Daft!)
(Name of Coanactor) - (lnsuranc Comhan��PoLc Namb ) (1.xpir e❑ Datc)
----------- ------ ------
(i��c Of Coat1<ctor) (Insllran Cora[ Nay I'ohc; Numbs)- (Iu�ltion D.a1c)
1 all a sole proprietor and have no one worl�- jjo for me
iD
( ) 7 a>st a florae owner performilig all the work myself.
11071.:plcx be c'-z-rc tti`i't:.lc tzoc:rcna-r_n"to<nrtloy V_moo. to 6; rc;3'au.. fk of
n x a—<t ti LL-m in ul ch xix t r»r:`x rc :d d o t a I _
�zralayc-z u�..:. t!�-.aa�i;c'�c�• ��c:ioo Act(GL1S2�a1(S)),rppti^.ticn vy a ho:ncoQa-r tm c Lc a Ik-rmn rL:y ca.d7»c tl.�c
I eS"j a'-".of c� loyrr under dio Wor{:..ora coc.{'c Ljon Act_
I undo-stand thn a copy of tbi.a �m.y lx foa-z -d-d t.o tbo Dcp_tn>rsz!of l,wiuz'.ricl Arad�OfSoo of trs�for d-
covcnsc vcr1t7C1ioo aM that Lilac to scauc co
alrtt�un<Sc1 10ct7o(1 2 S A a!.{GL 152 an Iczd to the v�-3,�sIIioa of c;i.-nitul prv-+ltics
000su.mg of a pint of up to 51,500.00 and/c< of up to rnr- i m I-da Cx form of n Slop W-k 016-n.3d e
fits o f 5100.00.day t gA n:1 rn-
/`% For dc�uun 111 a r_on1 Y
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P cnnj 11�I um bcr
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' 00 Lot -
Signalurt
C,NSTRUCTION SERVICE
.1 Licensed Construction Supervisor: L� Not Applicable ❑
Name of License Holder: IUOAAM I
License Number
3-7 c M lts 7�D&F I CCD CS O
Address Expiration Date
Signature Telephone
WW
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone D 4 r! ol
N5AI T{M:G.L.c.152,§25C(6))SECT10 A CtRKERS'COMP VJ i
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.
' ned Affidavit Attached Yes....... ❑ No...... l�'
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
b
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 4
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: _)1 _7 D'K R FP+'A-(__11A fv- F' W it AI N w S
Alteration of existing bedroom Yes4 No Adding new bedroom Yes n No
Attached Narrative❑ Renovating unfinished basement Yes _ No
Plans Attached Roll ❑ - Sheet❑
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?
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 .
L Septic Tank City Sewer Private well City water Supply
'SECT 7tt r OWNER AUTHORIZATION-TO BE COMP,LE 'ED WHEN
OWNERS, OR CONTRACTOR Af.PLIES IFOR dUII:DING I�ERIVII"I
l , as Owner of the subject property
hereby authorize O to act on
my behalf, in all matters rela 'vet wor authorized by this building per it application.
Signature caner Date
as Owner/Authorized Agent
hereby declare that the statements and in o ation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Logigned under the pains and penalties of perjury.
Print Name
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
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
Room 1'00
Northampton, MA 01060
phone 413.587.1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION':1-SITE INFORMATION
1.1 Property Address:
,. i5^eCtiQiA�y ornpl `,
3 op, c T 'RP J� a l
1 m c 5% a �vjjiy ry icy' °,
r
SECTION 2=PROPER7"Y OWNERSHIP/AUTHORIZE6 AGENT
2.1 Owner of Record: —731 A/w—)Lenriw, M d) b k—
me( rint) Current Mailing Address:
Telephon
Signature
2.2 Authori d Agent:
Name(Print) Current Mailing Address: 144G) 01-00fb
3
Signature Telephone
SEOTIdN'3 ES7IM�TEO`CON5TRUCTION COSTS
Item Estimated Cost(Dollars)to be Official use Ori :
completed by ermit applicant
1. Building (a) Bwfafng Permit f,
2. Electrical (b) Estimated Total Cost.of
0ib"6kruction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4+5) Check Number JO If
This Sedloin For Off lal ll�et�nl
Tiding Permit Nur�tber. Date Issued:
Signature.
E#tifdingpr�#rnissicxr',�x/lnspctot of Su�l..ut Dam _
'i I
38 ORCHARD ST BP-2001-0120
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block:25C- 170 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:windows replaced BUILDING PERMIT
Permit# BP-2001-0120
Project# JS-2001-0172
Est.Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NORMAN ZALESKY 128482
Lot Size(sq.1): 7710.1 2 Owner: SHEEHAN EUGENE M&WILLIAM C
Zoning.URB Applicant. NORMAN ZALESKY
AT: 38 ORCHARD ST
Applicant Address: Phone: Insurance:
37 CHESTERFIELD RD (413) 268-3553
WILLIAMSBURGMA01096-0535 ISSUED ON.811100 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 Type: Receipt No: Date Paid: Check No: Amount:
Building 8/1/00 0:00:00 304 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo