17A-250 Ctw1PJ.
9 6 �ssaxcflasrtta'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKER'S COMPENSATTON INSURANCE AFFIDAM
(licensee/permittee)
with a principal place of business/residence at:
(phone#)
(st:r=Uci ty/sta&zi p)
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/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Compauy/Poky Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(attach additional shect ifnecev_►ry to inch)d&information pertaining to all voasatigta)
( ) 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 homeowners who cmplay persom to do m.;,,m ncr ccastruc:ion cr rtpait work on a dwelling of
not mote than three tarts is which the hoamwna resides or on the grounds appurtenant thereto arc not gcna-Zy oowidcrcd to be
employers under the wmkces.c0mpcns4cn Act(GL152,ss 1(5)x,application by a homeowner for a uccwc or permit may cvidcnoe the
legal status of an employs under the Workees Compematioa Act
I undersund dul a copy of this stztemcnt may be foawwde,d to the Departo c of rnausU i al Aecideats()Moo of Iuzxunnce for the
coverage vaificaiioa and that&darn to&earn coverage under section 25A of MGL 152 can lead to tba imposition of criminal penalties
oomistiag of a fine of up to 51500.00 andlor rapt iso of tip to one year and dvia pc=16 in the form oCa Stop Work 01&r and a
fine of 5100.00&.&Y against me.
E�11fO Only
umber
Lot#
y Signature ofLicenswipermittee e
�Do S,TT�UCTIONSIERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
6 .,
.e m. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTrION 10 WORKERS' COMPENSATION INSURANCE,AFFIDAVIT(M.G.L. c. 152, § 25,C(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
SE VOR c ckalla ficable�,t
t
' '% -'';:2,4 ,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
i
Brief Description of Proposed Work: W GAD / L°C AJ °vt�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑- Sheet❑
�aliNe o �a ,"�i a iddit"iontoeXisti��housing�com°ple�e` thfol1owi
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 CONTRgCTOR APPLIIli$FOR;BUILDING PERMIT
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
6 Yj�V k0 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.
Print Name
0 1'l�
Signature of Owner/Agent Date
t
I4
I `
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 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:
Campton
Buildi artment
OCT 2 ' 2'1'1 12 Street
oom 100
�- pton MA 01060
(?FpT OF Ff.III.DING,
v. 1vtfhw4m -1240 Fax 413-587-1272
Ot e.--Sp
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section tobrc"ortipfetedb-offrcew
1.1 Property Address:
ryjap �
.c Ar
Zone
EI�w vvistrict s CB DtstrFcf ��
SECTION`,2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
0 FU5 2 ST-19IMrws11 I
ame(Print) Current Mailing Address:
✓p�. Q,af � 1J1'1 Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - 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.Onl
Building,Permrt;Number Date Issued: "
z:
Signature
: Date,, '
Building Commissjoner/Inspector of Buildings n �."
f
t. 1C � ' BP-2002-0458
GIS#: COMMONWEALTH OF MASSACHUSETTS
s1I of k: 17A-250 CITY OF NORTHAMPTON
Lot: —001
Permit: Building
Category_roofing BUILDING PERMIT
Permit# BP-2002-0458
Project# JS-2002-0692
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot Size(ss . ft.): 16683.48 Owner: STANKOWSKI TADEUSZ& KRYSTYNA
Zoning URB Applicant: STANKOWSKI TADEUSZ & KRYSTYNA
AT. 108 LAKE ST
Applicant Address: Phone: Insurance:
108 LAKE ST
FLORENCEMA01062 ISSUED ON:10126101 0:00:00
TO PERFORM THE FOLL O WING WORK.-STRIP & 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 10/26/010:00:00 602 $25.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Building Commissioner-Anthony Patillo