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17C-032 c"I 6 it Vie; t, cn woo C-D CD t j z/ ei'O k2-7 04��MpTO 9 � �x�7 lOr� �RZ���11Y�t�IIt1 - � B �lxssxrhnsrtta <L m DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street e Municipal Building ' Northampton, Mass. 01060 WORNER'S COMPENSATION INSURANCE AFFIDAVIT (litxnsee/permittce) with a principal place of business/residence at: A))o k T_ F/0 C 0 hone# (P ) ( city/stalrJ7ip) CIC?b do hereby certify, under the pains and penalties of perjury, that: O I am an employer providing the following worker's compensation coverage for my employees working on this job: (Insurance Company) (Policy Number) (Expiration Daze) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers compensation policies: (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) f. (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Lanlrance Company/Policy Number) (Expiration Date) (attach additioml shed ifnecenuy to include information pertaining to all 000trndom) ( ) I am a sole proprietor and have no one working for me. /, am a home owner performing all the work myself. NOTE:please be aware that whilo hoamwncta who eraploy persons to do mainienr=e constriction or repair work on a dwelling of not more than throe units in which the Iwmoowncr resides or on the ground:appurtenant therew arc not Ccn=lly ooasidaed to be employ=Under the tvorkce%compcatsatioa Ad(GL152,-3 1(5)�application by a homeowner for a lice=or pertnit may evidence the legs!status of an employer under the Workeet Comparnation Ace. I understand that a copy of thin rutement may be forwarded to tbo Dgmrw:oc of Industrial Acci&a&Offioo of Imurxnoe for the covaxgo verification aid that failure to aectrre oowmv under section 25A of MGL 152 can Iced to tba imposition of criminal peaaltiea consisting of a fmc of up to$1,500.00 and/or of up to one ytar and civil peaaltia is the form of a Stop Work Order and a fine o(3100.00 a day against me. For dqM nnootal trap only t Permit Number x•sc - 2 � Map#_______Lot# Signature of icenseeJPermittee Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone I T, .� ...., a Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152,§2SC(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...... ❑ 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 buildine 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 Northam ton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. nq Homeowner gnature SECTION 5-DESCRIPTION OF PROPOSED WWQRK{check'all applicabie) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: J e 2� 1 Q 4-- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ & :1 1F N e a e; _ . 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? h. 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'COMPL>TED 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 I, as Owner/Authorized Agent hereby cleclard 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. p Print Name SIgnattj.A of Owner/Agent Date R 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 ii 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 V 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: OCT pil 3 2 `a° City of Northampton a 0� Building Department f 212 Main Street Room 100 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: section# be rmpi�ted�y office . y f i� V�Q Map Zone ueriay I�istr ©6 IElmt,ostlt C�,Qt�rllct SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: SarnP Name(Printj Current Mailing Address: Telephone Signat re`" �2, -�j 0�G' �J ) <�C✓ 2.2 Authorize Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION'S ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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 = (1 + 2 + 3 +4 + 5) Check.Number This'Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings bate File#BP-2001-0461 APPLICANT/CONTACT PERSON KUBOSIAK HENRY PETER JR&MARY ADDRESS/PHONE 89 NORTH MAPLE ST (413)586-1512 Q PROPERTY LOCATION 89 NORTH MAPLE ST MAP 17C PARCEL 032 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REPLACE ROTTED WOOD&ENCLOSE EXISTING PORCH New Construction Non Structural interior renovations Addition to Existin¢ 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 Co ssion Permit from CB Architecture Committee G�, J L Loop 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. r c 89 NORTH MAPLE ST BP-2001-0461 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma :B1ock: 17C-032 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0461 Project# JS-2001-0785 Est.Cost:$600.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor: License: Use Group: Lot Size(sq.ft.): 14461 .92 Owner. KUBOSIAK HENRY PETER JR&MARY Zoning:URB Applicant: KUBOSIAK HENRY PETER JR & MARY AT. 89 NORTH MAPLE ST Applicant Address: Phone: Insurance: 89 NORTH MAPLE ST (413) 586-1512 O . FLORENCEMA01062 ISSUED ON.11 13100 0.00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE ROTTED WOOD & ENCLOSE EXISTING PORCH 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 11/3/00 0:00:00 740 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo