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25C-212 • r cue � P �t F, �ttAMpT O �tasaarilnsc:la DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street a Municipal Building ' Northampton, Mass. 01060 C WORKER'S COMPENSATION INSURANCE AFFIDAVIT -- L (Iicense&permittee) with a principal place of business/residence at: l L! k [- �zVdZ (phone#) (streedci#y/statrlu � do hereby certify, under the pains and penalties of perjury, that: ( ) 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 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 Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Attu,additiom(shed ifneocn=y to include inf«,nshon pertaining to all oordredon) O I am a sole proprietor and have no one working for me. (ki am a home owner performing all the work myself. NOTE:please be aware taut wbilo homeowners who employ persons to do n ;rdMa me oomtruetioa or repair work on a dweUing of not more than three units is whichthe homeowner reaida err on the grouads sppucteannt thereto art not gmeralty oo=dered to be employers under the worker's co-pensatton Ad(01,152,ss 1(5)1 application by a homeowner for a license or permit may evidence the legal status of an employer underthe Wakees C.aapem dim AcL I understand that a copy of this wtemeat¢uy be forwarded to the 1)eparwwad of In&=triel Axi ca&Office of kwMenee for the coverage verification dad that failure to soatre coverago radar suction 25A of MAIL 152 can lead to the imposition of criminal peaattioa cocusting of a fine ofup to$1,500.00 andfar imptisonmeni of up to one year and civil pcn&Wes is the form of a stop Work order and a fim of$100.00 a day against tree For depctmeeral use only ��� Permit Number Lot# S' ofLi =rmittce SECTION 8.CONSTRUCTION SERVICES .1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION,i0-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. igned 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"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 �tG' "�T�Z�rw�l1-rte v` z.. o . '` IP ION OF EBOtOSED.1NO .ch c applicable) New House ❑ Addition L� Replacement Windows Alterations) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New S'gns ] Daks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: A:W ✓ t ��k Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ Sheet❑ a. Use of building : One Family V Two Family Other b. Number of rooms in each family unit: 7 Number of Bathrooms / c. Is there a garage attached? N d. Proposed Square footage of new construction. /09 Dimensions e. Number of stories? � f. Method of heating? Fy !it"a Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? Type of construction u/ij i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes i/ No j. Depth of basement or cellar floor below finished grade ,Me Feh e'r-1,.3 it Co k. Will building conform to the Building and Zoning regulations? ✓ Yes No . I. Septic Tank City Sewer i/ Private well City water Supply SCTIbN 7a,-OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR_BUILDIN.G PERMIT I, 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. Signature of Owner Date as Owner/Authorized Agent hereby d fare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. igned under the pains and penalties of perjury. Print Nar�ye Signature of ner/Agen 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 %t3� aUv- S'. f i—p F � Frontage r75'- Front ' 1� 02c) Side L: / R: a l. L:—X—R: l� Rear J o I t 8`� / jO's Building Height r i Bldg. Square Footage 1 % ICS % 6,1. �b Open Space Footage % � � (Lot area minus bldg&paved , -7(e 7 W 3 c) parking) #of Parking Spaces 3 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: - ...-_.osoic vr>e'NO1dIr�vEllaoN sN01.03dsNIDNInn9 a f No thampton r� Build ng epartment lvJ� Z HV N21 n Street 100 MA 01060 > I pho je Al$50- Fax 413.587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE 1NFORMATION 1.1 Property Address: Map 4 s j �o�e � rlay Distr '� Y a� `E#rig St: $ CT(0N 2- PROPERTY 6WkRSHIP/AUTHORIZ9D AGENT 2.1 Owner of Record: Name(Prirl ) Current Mailing Address: $ 394"3 Cv J/6 Telephone Signatu 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone S CT10N 3- ESfiIMATED CONSTRUCTION COST 5' Item Estimated Cost(Dollars)to be Official Use Only, completed by ermit applicant 1. Building /,© 1 (a) Building Permit Fee 2. Electrical c, �L� (b) Estimated Total:Cost of Construction from 6) 3. Plumbing Building Permit I:ee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Sectionz For Official Use On,l Building!Permh Number: / Date Issued: Signature: Building Commissioner/inspector of Buildings -Date File#BP-2001-0760 APPLICANT/CONTACT PERSON BOROWSKI EUGENE J SR&SHIRLEY ADDRESS/PHONE 14 LINDEN ST (413)586-3863 Q PROPERTY LOCATION 5 LINDEN ST MAP 25C PARCEL 212 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid lypeof Construction: CONSTRUCT 9 X 12 BATHROOM ADDITION 12 X ECK &BULKHEAD New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building,Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § _w/ZONING BOARD OF APPEALS 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 Crfiission Permit from CB Architecture mmitte v 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. 5 LINDEN ST BP-2001-0760 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-212 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: alteration-addition BUILDING PERMIT Permit# BP-2001-0760 Project# JS-2001-1426 Est.Cost: $10500.00 Fee: $93.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Lot Size(scLB.): 10802.88 Owner: BOROWSKI EUGENE J SR&SHIRLEY Zoning.URC Applicant: BOROWSKI EUGENE J SR & SHIRLEY AT: 5 LINDEN ST Applicant Address: Phone: Insurance: 14 LINDEN ST (413) 586-3863 () NORTHAMPTONMA01060 ISSUED ON:4151010:00:00 TO PERFORM THE FOLLOWING WORK.CONSTRUCT 9 X 12 BATHROOM ADDITION, 12 X15 DECK & BULKHEAD 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 4/5/010:00:00 1124 $93.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo