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CD �Wdv f g/V l atv 0 b AM-O o i 1 III 4�n�P7p a 6 �lxssxc[lstsrtts' DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building ' Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT 1. 2t #1 Y HAzae'H- (licensed'Pertnittee) with a principaj,place of business/residence at: N 1Y11 &)y6T ,4 /Y F"T&1v Ro FL d f(A (phone#) (st=t/city/staw2ip) do hereby certify, under the pains and penalties of pedury, 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 Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (attach additioml thee ifnoDc=.ry to in,h- iafoemation pertaining ton ooatsadors) i 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 homoovnxra who employ pazom to do mxic�oonsuuctioa or repair work on a dwelling of not more than three units in Which tim homeowner resides or on the grounds appurtenant thereto are not gc oe aky coasidercd to be employers under tbo worker's oorapensatim Act(GL152,a 1(5))�application by a homoownir fora license or permit may evideaoe the legal status of an employee under the Workoea Compemation Act I undastsnd that a copy of this su temew may be forwarded to tho Department of I.od whial Amin&ofoo of Itnu�for the coverage verification and tbat failure to aoatre coverage under section 25A of MGL 152 can lead to the imposition of a•iminal.pemW- 000sLemg of a&ne of up to S1,500.0-0 and/or kVrisonmefld of up to one year and civil penaltia in the form of it Stop Work Order and a fine of 5100.00 a day against me. For dgMtn=W use only /f f Permit Number 4'it OQ { Lot# signahrre of Li rmiuze Late qc 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:I(�(. �� HAZUdzY _C 'S D/C ucl License Number I Al 11 44-sTgAtIPTOX) My 4 0 9 EW a,�F-- - — 'Ol Address 0106,P Expiration Date Signature Telephone in Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone ATIdN 52,1RKEF ENS i �. . .:.... , 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. igned 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 �'Homeowner Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Signature r. Ito New House ❑ Addition E§F�% Replacement Windows Alterations)❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other$4 Brief Description of Proposed Work: FCEP.A N)a E d- EX (.T PA Me ^ f2F R8 ©AI.4 4- Alteration of existing bedroom Yes No Adding new bedroom Yes *04--No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ • Sheet❑ a. Use of building: One Family��r Two Family Other b. Number of rooms in each family unit: 'V� Number of Bathrooms i c. Is there a garage attached?A d. Proposed Square footage of new construction. � Dimensions e. Number of stories? f. Method of heating?_rA6S-- de-r J/, Tigi'Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? Type of construction 1,00e P 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 ,SE N 7a Q�l R AUT#16RIZAT11ON,•TO 1RE COMp1ETED WHEN W1+ 5 AG> C)RCt3RTACtR ArsPL1E5 IRUILDIMVG PERMIT I, (� A R L E S 6o 1 —ry s as Owner of the subject property hereby authorize to act on my beha in lrnatters r�_ work authorized by this building permit application. Signature of Owner Date I, [(L111 ! k ff-Az U611 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. ,ALSigned under the pains and penalties of perjury. d Print Name Signature of Owner/Agent 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 K 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 X 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: City,of Northampton a Building Department �p�1 3 0 2000 212 Main Street 4 Room 100 _..z w. t�toampton, MA 01060 6 41.-!W- , -k240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SKMN I,-517 INFORMATION 1.1 Property Address: N 5, 7 ,'� i .�,• �vr,r��r �'t fi � � r,z' ssa /j/''�� L //�) L /yyy//e//• /rte *r'�■y{ 3m�a'i yz &�n�� '� ? �vc;'s `` z :,; MIMIV IV IV V ii Mxb •' 4 k"YV' ;YJ ��,i :. SEGT1> 2 P OPERTY'1`31,iVER f 1 -,-ZA 1t l~ti Et AGENT 2.1 Owner of Record: 41#A 9� LTY5 LAkE A FLO Name(Print) Current Mailing Address: Telephone 6-D -l —s- ?1?/tl i Signature l 0 2.2 Authorized Agent: 11{/f 14)j5 S 7-R,�9-HF710 t4 JeD Name(Print) Current Mailing Address: Signature Telephone SE( fSN 3.E�ESTIt4iA` D ccilvsTRUC�ricll }, Item Estimated Cost(Dollars)to be Cffcal L1e drily ; completed by ermit applicant 1. Building (a)Bitrng P�rn1� Fie;: 2. Electrical (b) Estimated T6tel Cast of "® Cod struction,,tt0rn •. 3. Plumbing 13uitding.PermIt-Fee 4. Mechanical (HVAC) _ 5. Fire Protection 6. Total =(1 + 2 +3 +4+ 5) Check,Nmtier, 11111s.,Sedl6n or,O fidal Use001 :$uI>c ' mtthrrer a '" gate Issued. �!ppture: Billdiiig Comrnissfonrli'lispctor of Buildings Date File#BP-2001-0539 APPLICANT/CONTACT PERSON William Mazuch ADDRESS/PHONE 1411 Westhampton Rd (413)586-8749 PROPERTY LOCATION 67 LAKE ST MAP 17A PARCEL 238 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out Fee Paid Typeof Construction: CTNRAUCT ENTRANCE/EXIT RAMP FOR PERSONAL USE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 010936 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 Conservatio ission Permit from CB Architecture Co ittee cod 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. i 67 LAKE ST BP-2001-0539 G1S#: COMMONWEALTH OF MASSACHUSETTS MV.-Block: 17A-238 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2001-0539 Project# JS-2001-0935 Est.Cost: $800.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: William Mazuch 010936 Lot Size(sg.ft.): 10236.60 Owner., SOLTYS CHARLES JOSEPH&MARGAR Zoning:URB Applicant. William Mazuch AT. 67 LAKE ST Applicant Address: Phone: Insurance: 1411 Westhampton Rd (413) 586-8749 FLORENCEMA01062-9751 ISSUED ON.1211100 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT ENTRANCE/EXIT RAMP FOR PERSONAL USE 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 12/1/00 0:00:00 137 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo