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m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORT{ER'S COMPENSATION INSURANCE AFFIDAVIT
(IicenserJpermitiee)
with a principal place of business/residence at:
.`7
(phone#) 3: �P-n)R f
(stre`t/city/stalr/np)
do hereby certify, under the pains and penalties of penury, that
O I am an employer providing the following workerjs compensation coverage for my
employees worlang on this job:
(lasurance Company) (Policy Number) (Expiration Date)
(Iaam 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/Poky Number) (Expiration Date)
(Name of Contractor) (In_nlraace Company/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additioml shtct ifne,ec—uY to inetude infornutioo pertaining to all oodsaeors)
i
(� a sole proprietor and have no one"Workin g for me.
( ) X am a home owner performing all the work myself.
NOTE:please be await that whilo homcowDm who employ pcnom to do % ,�coastr i co or itpair work an a dwelling of
not nxva than throe unit in which the homoowncr rciidcs or oa the gonad,appurtenant thereto arc not generally coondcrrd to be
employers under tho vvor�oompcmaticu Act(GL152,ss 1(5)),application by a homeowva for a bc=c cc Permit may evidence tho
legal rtatua of an amployec under the Workeez Compensation AcL
I undenfand that a copy of this vWconcat may be forwarded to tho Dcparmxo2 of Indu b ial Aocidm&Of&oa of In wrxnoe foe the
covaxge verification and that failure to secure coverugo under suction 25A of MOL 152 can Iced to the imposition of criminal Pcaalti-
ooau3ting of a fine-of up to 51,500.00 andloe imprisoamrni of up to one year and civil pcnallia in the form of a Stop Work Order and a
firm of S 100.00 a day against me.
For caly
Permit Number
i of LicenseelPermiaze e
SECTO'N$ CONSTRUCTION SERVICES
81 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
` Skk�gc9/7
License Number zevziel
AddL"S "-,A, Expirat4 Date
Signat Telephone
Re 'a, n Not Applicable ❑
Company Name Registration Number
CV-
Address Expiratiwf Date
Telephone f
SEC 100'r10-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...... ❑
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
S CTIONS:`DES�C rliOFRR01?OSED YViORk Cxc'�aa ' licabie
N b#ai' U�#K4;'b3 3 -� dx�N3NV9 W� 9i b SdS'Y h'tdM NRWR �
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing X
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: od
Alteration of existing bedroom Yes No Adding new bedroom Yes ��N0
Attached Narrative 0 Renovating unfinished basement Yes fo� _No
Plans Attached Roll ❑ - Sheet 0
G�Ifi Ne ho affA addition t exigsfing hh using, complbl&lieloTlo
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 COMPLETED WHEN
OWNERS AGENT O t CONTRACTOR APPLIES.r R BUILDING PERMIT
r � �, ` PP as Owner of the subject property
hereby authorize /C=c'�•��' ��'�i� / '`""' l� i,� '� to act on
my behalf, in all ma relative to work authorized y this building permit application.
yJ� 12
Signature of Owners Date
' as Owner/Authorized Agent
her y declarelhat the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
SigRet9'Gnder the pains and penalties of perjury.
Pnn ame
rn `]
Signa Date o /!
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 i/' YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW i/ 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:
f Northampton
B ing Department I
Main Street S'
oom 100
0-T 1 7 "t 2No� °� pton, MA 01060
phone 41587- 240 Fax 413-587-1272
Q -e
l L>r;°T Ct B4Ji!C'?:G IhSr'ECT!�`�S �
ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1 -SITE INFORMATION
This section two be!completed
1.1 Property sby af�ftce
P Address: Y
Map Cot $ 1nit
Zone �O�erlayDistrict
Elm St:District CB Distract
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/h C,/'P-7 of !w^
Nam 'nt) - 1 Current Mailing Address:cor
64'�' dfz';P/` Telephone
Signature
2.2 Authorized Agent:
"z4zzl �
NPrin Current Mailing Address:
Sign Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building If,, Ci- (a) Building Permit Fee
d
2. Electrical X (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/).;-' r
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2003-0399
GIs#: COMMONWEALTH OF MASSACHUSETTS
7 � 4 CITY OF NORTHAMPTON
Lot:-00
Permit: Buildin#7
Category: BUILDING PERMIT
Permit# BP-2003-0399
Project# JS-2003-0675
Est.Cost: $11000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY SKROCKI 060967
Lot Size(sq.ft.): 22346.28 Owner: NORTHAMPTON CONGREGATION OF
Zoning:URB Applicant: TIMOTHY SKROCKI
AT. 165 BRIDGE RD
Applicant Address: Phone: Insurance:
6 MILL ST (413) 529-0527
EASTHAMPTONMA01027 ISSUED ON:10117102 0.00:00
TOPERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
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 10/17/02 0:00:00 1353 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo