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17D-048 (2) 4T t1 P�. L o a� Gxfi� of &Nart4aillpfon aB �i3ait{�tt8rtt3 DEPARTMENT OF BUIL)TNG INSPECTIONS 212 Main Street ' Municipal Building 'a Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFIDAVIT (l t censee/perrni ttlre} with a principal place of business/residence at: pox� (phone#) v 5 12 I (streWeity/sta&2ip) 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/Policy Number) (Expiration Date) *r. (Name of Contractor) (Insurance Company/PoUcy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (Expiration Date) (Name of Contractor) (Insurance Company/Policy Number) (E)piration Date) (attach additional shoot ifnecenxry to include infncrostion pertaining to all coatradors) '�"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 thst whilo bomeownera who employ person:to do mamtenaaoc,suction or repair work on a dwelling of not moce than throe units is wbich the homeowner resides or on the groin appurtenant lh=W aro not gcoerally comidered to be employ—under tba w-kces oompeas4on Act(GL152,ss 1(S)),application by a homeowner fora tioruse or permit may evidcaoe tho legal status of an employer under the Wockeet Compensation Act I undertimd that a copy of this rutemmt may be forwarded to tho Dcpactnxaa of Inds trial A=dm&0ffioo of lavxxooe for the covaage verification and that failure to sea=oovetago tinder section 25A of MOL 152 can lead to tba imposition of criminal penalties oonsisting of a fine of up to 11,500.00 and/or impsisowmcrd of up to one year and civil pmaltia in the form of a Stop Work Order and a fmo of 3100.00 a day again&tna. For deal use caly permit Number Map#____---Lot# Si 4gatt of LiccnseelPerinitkee e ECTION 8'. CQNST',�U�TION S>:12V1C�5 1 Licensed Construction S ervisor: Not Applicable ❑ Name of License Holder License qumber f� Ad ress Expira ion Date 11.1 "� Si in ature Telephone Not Applicable ❑ ,n..E.... €.... aEl.a.., ... ... Company Name Registration Number Address Expiration Date Telephone SECTION 1U Wt3121CRS'E COMPENSAI"ION INSURANCE AF F1biAViT{M.G,L ;:152;§2C(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. igned Affidavit Attached Yes....... ❑ No...... ❑ w 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 �! �_c �l',��—d ti y ' ii I i t G t N, i I F p` S D.WO c c livable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ l° .. 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, O. EK;AUTkft)RI?ATION !!,TQ BE COMPL TTED WH {+f QWNI=t Afi1E C flRON�"RAC S�,I AP,tI:tIS. <?1 :: UI>;DIG PERMIT I, 6 6 )z A )V A N S O N as Owner of the subject property hereby authorize to �T�? f" A to act on my behalf, in all matters_relalive to work authorized by this building permit application. Signature of Owner Date / d Q I, 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. igned under the pains and penalties of perjury. MANsOAJ Print L4arne v Signature of Owner/Agent Date ti M 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: City of Northamptonsf . Building Department �z 212 Main Street 'z •. Room 100 Northampton, MA 01060 . phone 413-587-1240 Fax 413-587-1272 Ott,.,J7 .pZ•0�.. :; � .,�,xgx3 ., ... ,,.;,$. G;: APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I- SITE INFORMATION 1.1 Property Address: This section tole completed �y:affice S�i'�r�i /��✓ Map Lot Unit I Zone Ouerlay District.• roc c d� L2 6 Elml,St. District CS District,"'' SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: z Ale rte;4 q sr � ��L✓ f�j� Dame(Print) Current Mailing Address: 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 = G + 2 + 3 +4.+ 5) Check Number This Section For Official Use Only, Building Permit Number: Date Issued: Signature: Building,Commissioner/Inspector of Buildings Date' e. 1 78 STRAW AVE BP-2001-0598 GIS#: COMMONWEALTH OF MASSACHUSETTS P'M MiBlock: 17D-048 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category:roofin g BUILDING PERMIT Permit# BP-2001-0598 Project# JS-2001-1077 Est. Cost:$4500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groun: Ronald Mistarka 118693 Lot Size(sq.ft.): 5183.64 Owner: ZUZGO THELMA M Zoning URB Applicant: Ronald Mistarka AT: 78 STRAW AVE Applicant Address: Phone: Insurance: P O Box 205 413 584-5140 NORTHAMPTONMA01061 ISSUED ON.12128100 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 Deuartment 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 12/28/00 0:00:00 691 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo �} 3 `"` �,,. � , ,4 : . ,R � �' R e f j + { 7 ,' 1 £ t'', t �i f .. � ... t � : p ..: f �} w M � r ,. ... �_ �, �� r } .. F .1 _ }}; � .. i �? 1 ,`�� ., �3^. ", ... ...._.._ ... _...... ... ,e.,._._, __.. _.... .. ._.... _ ..._ ne _ .._.......:....., 78 STRAW AVE BP-2001-0598 CIS#: COMMONWEALTH OF MASSACHUSETTS a : lock- 17D 048 CITY OF NORTHAMPTON Lot:-001 Permit: Building Cate.,gorv:roofing . BUILDING PERMIT Permit# BP-2001 # JS-2001-1 077 Est.Cost:$4500:00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Ronald Mistarka 118693 Lot Sig4sq.1):5183.64 Owner: ZUZGO THELMA r,, t Applicant: Ronald Mistarka AT. 78 STRAW AVE A, fffic r xtAddress: Phone: Insurance P'{)Iox 205 (413) 584-5140 NORTHAM PTO NMA01061 ISSUED ON.12128100 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: t Rough: Rough: House# Foundation: t Final: Final: Rough Frame: Gas Fire Department Fireplace/Chimney: Rough: Oil. . Insulation: Final: Smoke: Final: Ct 'J�� Z /� v l THIS PERMIT MAY BE REVOKED BY THE CITY O NORTHAMPTON UPON VIOLATION F ANY OF ITS RULES AND REGULATIONS. Certificate of Occuganc si nature: Fee Tune: Receipt No• ate Paid: Check No: Amount: Building 12/28/00 0:00:00 691 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo