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25C-212 (3) IDIE C EE V FEB 5 20M DEPT OF BUILDING INSPECTIONS NORTHAMnON,MA 01060 . cr Al Br; I( (�/ � scin�r► NXi rn f Ivd� nC �ICN t- fie,., 46 i �Jcir_�t Bros.:.(( oT .J Tort C \ �1atI.,,or j I.>gl4"t/ P i In r 1''Ic�,• -tom t%� �'�/ O�.�ttAMp�O 6 Grxt� x1f Nart4aiitptot z � � �1i55 AChtt8rliff' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (l1 censee/perml ttee) with a principal place of business/residence at: 3 /�} P�� sr /�•��,, �?t (phone#) 6-Y9- s9C/ (str=UCity/statrlrip) 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 Compaay/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml sheet ifnecessary to include information pertaining to an contractors) (VI am a sole proprietor and have no one working for me. ( ) I am a home owner performing all the work myself. NOTE:please be aware that while homcowncra who employ pc=m to do makd nance,construction or repair work on a dwelling of not more than three units in which the homeowner resides cc ou the grounds appueteaant thetdo art no(generally oonsickred to be employers under the wro rice`s compensation Act•(GLI52,Ts 1(5))�application by a homeowner for a Gernse a pumit may evidence the legal status of an employee under the Wodcoes Compamatkn Act I unde sued that a copy of this statemcat may be forwar W to tho Dgmrwj nt of Industrial Accidaats'Offioc of lmn"'°e0 for the coverage verificd1on and that failure to secure coverage uadcx section 25A of MGL 152 can lead to the imposition of criminal pea cs consisting of a fine of up to$1,500.00 and/or imlxisomnerit of up to one year and civil pcn Wes in the form of a Stop Work Orda and a fino of$100.00 a day against me. Fct use only Permit Number Wpb_---Lot# Signahrre of Li a tree e CTIDN$ :CONSTR"UCTION SERVICES Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �(cy=� Gw /t 40(a 000 z© License Number Address � Expiration Date / SY9 -S9S� Signature Telephone 14M EF Not Applicable ❑ _._, ,' .., PP Company Name /� Registration Number 3%9 P Fi►t 5' Address ,� Expiration Date A,% "�t`S �, 1414. Telephone 1-0,�"�h J'! SECTION 10, VItORX RS'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. ' ned 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 D c !;a lI New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[✓f Brief Description of Proposed Work: D"s "I &jeo en 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 ✓ 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 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 . I. Septic Tank City Sewer Private well City water Supply SECTION'7a*OWNER AUTHORIZATION -TO BE COMPLETED WHEN CiWN I S�AGI=NT OIL Ci ON't SAC 0111 'I 61I*" F1�iI ° UIIrI3ING PERMIT An as Owner of the subject property hereby authorize leeVA L?q le to act on my behalf, in all matters relaQive to wo uthorized by this building permit application. f. Siggrature of ner Date /64W a. C?,. �� as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. wed under the pains and penalties of perjury. Print Name Zia F` s Signature of Owner/Ag7nt 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 d 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 V 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 i 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: sE r r City of t mpton 3 SBIi ng rtment 212 ain treet n""'�'"F P 101NG INSPECTI m 1 0 r . l�dfpton, A 01060 phone 413.587-12 ax 413-587.1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SfTE INFORMAT-1Of4 x 1.1 Property Address: /� y J Tipp /� fr � k �l �Od��KM4�01r J a� SECTION " PROPERTY OWNERSHIP/AI�THORIZED AGENT 2.1 Owner of Record: �c�4t4 c ®r4�✓ me(P t) Current Mailing Address: f � 58�. 3f'sc:3 Telephone Sign ure 2.2 Authorized Agent: P Name(Print) Current Mailing Address: sy9- s9 s� Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Buil i (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 =G + 2 + 3 +4 + 5) Check Number This Section For Official Use Only uilding,Permit`Number:. Date Issued: S►��ture k3uilding CoMmisslonerflnspect ar of Buildings Date File#BP-2001-0670 APPLICANT/CONTACT PERSON Gale Home Improvement ADDRESS/PHONE 319 Pine St (413)549-5951 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 Buildina Permit Filled out Fee Paid Typeof Construction: REPAIR FOUNDATION W/FOOTINGS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 060020 3 sets of Plans/Plot Plan THE LLOWING 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 C ission Permit from CB Architecture Committee L� Signature of Building Of icial Dat 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-2001-0670 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-212 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0670 Project# JS-2001-1215 Est.Cost: $3000.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Gale Home Improvement 060020 Lot Size(sq. ft.): 10802.88 Owner: BOROWSKI EUGENE J SR&SHIRLEY Zoning.URC Applicant. Gale Home Improvement AT. 5 LINDEN ST Applicant Address: Phone: Insurance: 319 Pine St (413) 549-5951 AMHERSTMA01002 ISSUED ON:216101 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR FOUNDATION W/FOOTINGS 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 2/6/010:00:00 1174 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 5 LINDEN ST BP-2001-0670 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-212 CITY OF NORTHAMPTON Lot: -001 Permit: Buildinq Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0670 Project# JS-2001-1215 Est.Cost: $3000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Gale Home Improvement 060020 Lot Size(scft.): 10802.88 Owner: BOROWSKI EUGENE J SR&SHIRLEY Zoninp-: URC Applicant: Gale Home improvement AT. 5 LINDEN ST Applicant Address: Phone: Insurance: 319 Pine St (413) 549-5951 AMHERSTMA01002 ISSUED ON:216101 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR FOUNDATION W/FOOTINGS 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: ' D T t 44 O Rough: Rough: House# Foundation: Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:m k 3'39 o- I THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc Si nature: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 2/6/010:00:00 1174 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo