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DEPARTMENT OF BUILDITNG INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFFIDAVIT
oicenser./pernl ttee)
with a principal place of business/residence at:
(phone#)
(street/city/sta&2h p)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Expiration Date) sM: ;<•
( ) 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 Comparry/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiocW shoot ifnaceuary to kwJude information pertaining to all cootrn,dots)
( ) I 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 homcowocrs who employ pawns to do mxiatena corsstructioa or repair work on a dwelling of
not more than throe units in which the homeowner resides oc on the grounds appurtenant thereto are not generally coandered to be
employes under the vmd e's compensation Act(GL 152,ss 1(5)),application by a homeowner for a license or permit may evideaee the
legal slatus of an employer under the Woricota Compensation Act
I understand that a copy of thin zu t—it maybe forwarded to tho Depattaxa2 of Indus4ial A=dm&Offioe of Iesuranco for the
coverage verification and that fail=to secure coverngo under scctioa 25A of MGL 152 can lead to the imposition of criminal penalties
consisting of a fine'of up to S1,500.00 and/or imp iso of up to one year and civil pc=Wcs in the form of it Stop Wort Order and a
find of 5100.00 a day agMnst me.
For depzrw r'= l use only
ptrmit Number
Map# Lot#
Signature of Licensee/permittce e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
ws% m
Address Expiration Date
Sign fu Telephone
Applicable ❑
Not
Company me Registration Number
\Clc-, i�hly;;� 5
Address a 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...... ❑
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
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SECTION - E C O .O oP S EQ WOK I(ghepk All applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes N0 /
Attached Narrative❑ Renovating unfinished basement Yes \/ No
Plans Attached Roll ❑ - Sheet❑
I rN W,.
Ing
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 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, C_�1� r1� 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.
Signed under the pains and penalties of perjury.
Pri N e
—f>11 - Y_�� \A(� I
Sign wner/Agent Date
A
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 Sp ial 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 #'V—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. k there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
City of Northampton
Building Department
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
f This se tiort toom" e ed �f#icy
1.1 Property Address: r 1
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'IE1 'wit: M0 rlCt�
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
a e Pri ) Current Mailing Address:
Sig Telephone
SECTION 3.-E,TIMATED CON, 4UCTION COS I
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 Commissionerflnspector of Buildings Date
PROPOSAL
PROPOSAL NO.
SHEET NO.
y W DATE
PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT
NAME ADDRESS
ADDRE-SS__
DATE OF PLANS
PHONE NO. ARCHITECT
We hereby propose to furnish the materials and perform the labor necessary for the completion of
_.-- --
All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and spec
cations submitted for above work and completed in a substantial workmanlike manner for the sum of _
- - - Dollars (
with payments to be made as follows.,,-,, -
Respectfully submitted l`
Any alteration or deviation from above specifications involving extra costs
w'II be executed only upon written order, and will become an extra charge Per ___-
over and above the estimate. All agreements contingent upon strikes, ac-
cidents.or delays beyond our control.
y y Note Th is proposal may be withdrav
by us if not accepted within da
ACCEPTANCE OF PROPOSAL /
The above prices, specifications and conditions are satisfactory and ark hereby accepted.,Nou are authorized to do the
as specified. Payments will be made as outlined above.
Signature' ' - — --
Date Sianature _
Adams NC 3818 50 PROPOSAL
MADE IN USA
File#BP-2001-0434
APPLICANT/CONTACT PERSON JASINSKI MITCHELL&HELEN C
ADDRESS/PHONE 808 RYAN RD
PROPERTY LOCATION 24 POWELL ST
MAP 17A PARCEL 194 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: STRIP ASPHALT SHINGLES&REPLACE
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 LLOWWG 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 Comm' i Permit from CB Architecture Committee
is 2G 2 and
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.
T� - _._ -_--_ �. �. _ _. . w, ---- -- - .�-...,�...
24 POWELL ST BP-2001-0434
GIS# COMMONWEALTH OF MASSACHUSETTS
MM.Block: 17A- 194 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-.2001-0454
Project# JS-2901-073$
Est.Cost:$0.00
Fee:$25.00 ' PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
vie Gaup: CDT CONSTRUCTION 130152 E
-lit` sq.ft.k 7f�s $ gutter: .JASINS,X1 N9TCIED,L&FMVN C'
Zoning:URB AgpHcant. CDT CONSTRUCTION
AT 24 POW,ELL ST
ApplicantAddress: Phone: Insurance:
158 NORTH MAPLE ST (413) 585-8677 Workers
Compensation
FLORENCEMAO 1062 ' ISSUED ON.-10126/f1O 0:00:00
TO PERFOM THE FOLLOWING WORK:STRIP ASPHALT SHINGLES & REPLACE
POST THIS CARD SO IT IS'VISIBLE FROM THE STREET
Inspector of plumbing Inspector of Wiring D,P.W. Inspector of Buildings''
Underground: Sirvice: Meter:
Footings:
Rough: Rough:; House# Foundation:
Final: Final:
Rough Frame
i
Gas Fug D.vim ent Fireplace/Chimney:
Rough: Insulation:
Final: Smoke: Final: 0 k 3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Qccuoangy si' a re:
Fee Doe: ,, Rec„ Xt No Date Paid: Check No: Amount:
Building 10126/00 0:00:00 3285 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo