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25C-212 (2) i i J I a '0 . -PRoPOsPD DFcI<, 2 t,0 \ / PROPOSED [SULK HCAD PRO IPO S E D A P D.1 TZON 14) ar_ 4u��T uF *EMOUE W i N 00 t` \\ ltd � _SbNA TUB, ADD DOOR -XISTING HOUSE s �. 33,' i o FRONT PO RC N i Q W ! — ( LAWN -LA W N LAW N I t S DE WAS K i GRASS 13ELT N - FI) S CALF---_i a4%a ffis a s r RfL T Ba<saucEittactta' 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.