17C-175 04� t PT0 I L
A � ��111�1II1t
'' $ 6 �lasaacE(nsrtts'
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060
WORKEWS COMPENSATION INSURANCE AFFMAVTT
(li txnsee/permi flee)
with a principal place of business/residence at:
(phone#) 5__YZ-s0-1d
(streWcity/staid2ip)
do hereby certify, under the pains and penalties of per3ury, 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/Policy Number) (Expiration Dale)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aaach additional shoot ifnecenuy to include informauoa pertaining to all oontmetors)
I am a sole proprietor and have no one working for me.
( ) T am a home owner performing all the work myself.
NOTE:please be aware that whilo homeowners who employ persons to do m adcn ce c=&uctioa or repair work on a dwcUiag of
not more than throe wait+in which the homeowner resides or on the grounds apprutenut thereto are not generally considered to be
employers under the worlre compeasstion Art(GL152,ss 1(5)),application by a homeowner for a license or permit may evidence the
legal statue of an employer under the Workeet Compensation Act,.
I undavamd that a copy of this statement may be forwarded to the Dep utmen2 of Industrial Atcideate Offloo of Iaseusnoe for the
coverage verification and that failure to secure coverage under sectioa 25A of MGL 152 can lead to the imposition of crimiaat penalties
coaiLtmg of a fine of up to S1,500.00 and/or imprisonment of up to one year and civil penalties in the form of a stop Work Order and a
fine of 5100.00 a day agaiaA me.
For dal use only
Permit Number
/ •.�' d Map#_______Lot#
ems._
Si of Lt ermit#ex
e;CE�CTION 8-CONSTRUCTION SERVICES
Name of License Holder 05'71 S 7
.41,4qf
Addres Expiration Date
Signatu/ Telephone
Not Applicable El
Company arne Registration Number
Address Expiratio'n Date
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?f the building permit.
The current exemption for^bonzuovnuem''was extended toinclude one(1) or upn(2)bzo,Uies
and 0o allow such homeowner to engage au individual for hire who does not possess ulicense, 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 forrn acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Superviso your presence on the job site will hu required from time to time,during and upon
completion
/\|xhoudvbedOhat*vdbreferunuetoChupt rl52( Vorkexa' Compouaa1ion) and Chapter l53 (Liability of Employers to
Employees for injuries not resulting iu Death)ofthe Massachusetts General Laws Annotated,you may be liable fo«peraon(a)
you hire to perform work for you under this permit.
The undersigned^'honoeovmner`uortifium 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
ACTION 5- DESCRIPTION OF'PROPOSED WORK(check afl applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: �N �� q C° Px' '��j'l� ^
Alteration of existin bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll ❑ - Sheet❑
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?
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
l �G/ as Owner of the subject property
hereby authorize G '¢1,er A/A o'lWf to act on
my b h f, in all matters rlative to work authorized by this building permit application.
r r_,
Sig ature of Owner Date D
0_ ed A• , as Owner/Authorized Agent
hereby declare th the state nts and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
igned and the pains and penalties perjury.
Print Name
0 .9 zv
Date
Signature of Own /Agent
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 Spe 'al Permit/Variance/Finding ever been issued for/on the site?
NO
DON'T KNOW 40� 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:
T E c E � U E
City of Northampto APR 3
Building Departmen �
.s:
212 Main Street
Room 100 DEPT Of8UILDI
Northampton, MA 01 NORTHAMPTF ,
phone 413-587-1240 Fax 413-587.1272 i
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed i;y yoffic
Map Lot'.t1ni
Zone +4xerla .Dlstrict
Y.
Et', Dist'rlct CB;Dlstr➢ct
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Tom',7P xyer
Name(Print) A Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
&I-01", j''W
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 Cast of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5) xe, ou Check Number A79
This Section For Official Use Only
Building Permit Numler:_-Wi - Date Issued:
Signature:
Building Commissioner/]nspector of Buildings Date
to*
26 FAIRFIELD AVE BP-2001-0777
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 175 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2001-0777
Project# JS-2001-1456
Est.Cost: $8000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Craig Marney 102112
Lot Size(sq.ft.): 5314.32 Owner: SIENKIEWICZ CONSTANCE L&
Zoning.URB Applicant. Craig Marney
AT. 26 FAIRFIELD AVE
Applicant Address: Phone: Insurance:
P O Box 128 (413) 586-5512
LEEDSMA01053 ISSUED ON:414101 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 4/4/010:00:00 2749 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo