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DEPARTMENT OF BUILDITIG INSPECTIONS
212 Main Street a Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
(liomsee/permittee)
with a principal place of business/residence at:
' (street/city/sta.W2i0
{;r
do hereby certify, under the pains and penalties of perjury, that:
�� :l. I am an employer providing the followin worker's compensation coverage for my
employees working on this job:
5 '
(Insurance Company) (Policy Number) (Expiration Dale)
( ) 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 Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Comparry/Policy Number) (Expiration Date)
(ntfu+ad&doml sheet ifaerocsmary to include information p=taiaing wall 000tmdon)
( ) 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 that while homeowner who employ pasoos to do makdc aaoS caastr d oa or repair work ou a dwelling of
not mon than three units in which the homeowner reside=oc on the grounds appurteaaot ibwdo arc not geaaally,coondered to be
employers under the worker,ration Act(GL152-s 1(5)),appiication by a homeowner for a Bosse or permit may evideaoo tho
legal ctatua of an employer under the Workers C.ompomation Act.
I understand that a copy ofthia rw—ecd may be forwarded to the Department of Industrial A,oadmt>'Offioc of Imur-0 for the
cove me verification sad that failure to secure coverago mxkr sectioa 25A of MGL 152 can kid to the imposition of aiminal Peaaitflm
oomisting of a fine of up to$1,500.00 and/or impris�of up to one year and civil pcn&Wes in the firm of a Stop Work Order and a
firm of S 100.00 a day against ma
For dq=W=c al use onty
Permit Number
Lot#
i Signature of Li erndttce Date
• SECTION-8:-CONSTRUCTION SERVICES
1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder-:
License Number
Address Expiration Date
Signature Telephone
OTo. ' Im m nCon.rac rs: 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...... ❑
l� olleAIOneenaUOri
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
'EGTIpN 5 DESCRrPT10N OF PROPOSED WORK(check all applicable)
New House ❑ Addition V Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: AJJ Qsllcu^ e-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D - Sheet D
Ifi Ne h` m e # e o o n.d-d " ez
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? Ne-
d. Proposed Square footage of new construction. %Q Dimensions %� X
e. Number of stories?
f. Method of heating? F,r Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
Type of construction LA/.;o)
i. Is construction within 100 ft. of wetlands? Yes y/No. Is construction within 100 yr. floodplain Yes VIN o
j. Depth of basement or cellar floor below finished grade .'nc Fcli et 1.3 C:- -1't S f`•
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 TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING 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 der'tare 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.
r C/a 4A-, r T 'o
Print Name
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 %01 (8 _ S". {t j U �G,v !Zi
Frontage
Setbacks Front
Side L: / R: j.J L: I R: %8. /5—
Rear j 0 1 � g Y / lob
Building Height r
Bldg. Square Footage 1 ` %
Open Space Footage %
(Lot area minus bldg&paved (� ) (� t?? 7,3.�0 � (�
parking)
#of Parking Spaces 3 �t
Fill:
(volume&Location)I�c,`C IJr �r
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:
09010 VW'N01dWVH180N
SN0In3dSN19Nla11n9 @1 a f No thampton
Build ng epartment
J Z w21 n Street
( (I 100
MA 01060
phone 1.050- Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 P Address:
Thts section tole com�letedsy
Property N
Map Ipt Unit
.y�� Zone Oarerlay D�strrc
i `1 er 4 Yl 11 d�'L {" 1
SECThON - PROPERTY OWNE
2 RSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pr r Current Mailing Address:
✓ �, Telephone
Signatur
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3= E'S'TIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be � 'OfficIf Wse Only
completed by ermit applicant
1. Building �, �� (a) Building Permit Fee
2. Electrical c, (b) Estimated Total Cost of
Construction from(6j.
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) `J<<3 Check Number 3
This,,Section Por Official Use 0, l
.
Buirding Permit Number /--7 Date lssued:
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 772 cf'
Tvpeof Construction: C014STRUCT 9 X 12 BATHROOM ADDITION, 555 SQ FT DECK &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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
/De
Lnied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
(,,O Finding Required under: ,,2-9-3/—/)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 Comm' n Permit from CB Architecture Co ittee
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.