24A-078 24 RIDGEWOOD TER BP-2017-1243
GIS is COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-078 CITY OF NORTHAMPTON
Lot: -001 PERSONS CON IRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit ft BP-2017-1243
Project# JS-2017-002082
Est.Cost:$6000.00
Fee: 540.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Croup: DAVID JAGODZINSKI 106068
Lot Size(sq. ft.): 7492.32 Owner: DEAN MARK S &ELLEN CADY
Zoning: URA(1001/ Applicant: DAVID JAGODZINSKI
AT: 24 RIDGEWOOD TER
Applicant Address: Phone: Insurance:
P O BOX 204 (413) 230-9160 WC
NORTH HATFI ELDMA01066 ISSUED ON:5/1/2017 0:00:00
TO PERFORM THE FOLLOWING WORK REPLACEMENT WINDOWS FOR ENTIRE
HOUSE
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:
FeeType: Date Paid: Amount:
Building 5/1/2017 0:00:00 S40.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
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/ City of Northampton tlIt
Building Department r .-rl7 ra�r .Zy
> 212 Main Street y,t, ttA� /4 iatlitiPE-R .3f
ry1 % Room 100 1�rr"fll,-(x/.11 �i:4jIG. �. i4 p<
Northam',ton, MA 01060 itf�±°sxuf+ld y,,,) , nr "''— '""
- phone 413-587-1240 Fax 413-587-1272 i't l! "'s ,�k � ""a"
L
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_APP KATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISHaaA ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION b®— 17 - L.1-
1.1 Property Address
This section to be completed7by office
9H ?I4GC/n:� Te(r0.Ce Map dli , Lot 07y Unit
Ndrfkomitn 1 -GSS 0100 Zone Overlay District
Elm St.District - CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
3W3 Vcnan Sf- Aid r4 „Pbn. A
MAIk Tenn c rd filen Pule �w‘
Name(Print Current Mailing Address: 0(060
_. % Telephone
Signature /0)77a j./;
2.2 Authorized Agent: ('� 1 r1
1 A nick . A wok_ -e. 0. i-3,,„, (}0''"1 f.}, t{4CCteg -FtL.SS.
Name(Print Current Mailing AddressAe :
a' 1- ill 3—.230 - 9/c040
Signal a Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building lila Ore()
(a)Building Permit Fee
2. Electrical f�'LW (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection Sei cid
6. Total=(1 +2+3+4+5) Check Number Y'
This Section For Official Use Only
Date
Building Permit Number: Azde,
Issued: //Signature: C —,277
Building Commissioner/Inspector of BuildingsDate
Da�
rY2
/ `� Livehrif/ /ampCeO
/1/6)V—&/ f �PJ� �UIe
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To incomplete Information
Existing , Proposed Required by Zoning
This column to be filled in by
Building Depanment
Lot Size I _ 1_. .__. .. ........._
Frontage r _ L ... I [_ _ __
._....a_1
Setbacks Front -'-
Side LL._..._� R:I....- L:_ . .J R:L.___J.. I1....'i I J
Rear 1 -=7
_
Building Height I L I L111
Bldg. Square Footage I_..I E- I °/ 11±-1
,,, F-
I {'^ }
Open Space Footage _ °o
(Lot areaL minus bldg&paved _._I I -......I I-- 1 �._�
parking) _
of Parking Spaces 11-17,11 L TI L---11 v _._. _.. .
r
Fill:
( __. J I .___ ._.._ I
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW O YES Q
IF YES, date issued: l
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book I Pagel and/or Document #r
B. Does the site contain a brook, body of water or wetlands? NO 2 DONT KNOW b YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained , Date issued: L
C. Do any signs exist on the property? YES O NO (�
IF YES, describe size, type and location: // ^^
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location: _—� — S
E. Will the construction activity disturb(clearing, grading,ex ovation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors ® _
Accessory Bldg. ❑ Demolition ❑ New Signs [CH Docks [[] Siding [O] Other[CD
Brief Description of Proposed A--/'�/u 7m/v/ ` , dote" �/. en✓h /_ten i.n
Work: (if/ dote" /% /�/��/d'�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
5a If.New house ardtor addition to existing housing,.+complete the following:
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. Masscheck 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, `&r^' Dear , as Owner of the subject
property 11
hereby authorize 4tU . cm CLI n,Sk 1
to act on my behalf, in�i We to -rk authorized by this building permit ap licatio .
Y. i?
Signature of Owner V• I Date
C\
I, •NI I a c„ t^'$I< f ,as Owner/Authorized
Agent hereby declare that the st I7aments 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.
cJzi.t51c I
Print Name r
G�f/iC / ?0 /7
Signa !e of Owne ••ent Da
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Cs-
0
Name of License Notder: �tt(( .. r iti3GC, _ Cs- [ 0 la 0` 6
JJ License N meet
_ , t \ A LG4 /J. lfaf€ QWt.11as, e1Oroc, _ _.1 t
Addre.- Expiratl,n Da-
'� f13d3U `I/60 ..
Si•nature Telephone
EmRfl' Jullad
cavri
S.Registered Home'lmpreyement Contractor-2.. i$.q, Not Applicable G
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 18-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
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 buil 'ng permit.
Signed Affidavit Attached Yes No D
11.l•'11ome Owner emotion
The current exemption for"homeowners"was extended to include Owner-gccupied Dweoines of one(I) 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 acs
as supervisor.CMR 780, Sixth Edition Section 1083.5.1.
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 he,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,duringand upon
completion of the work for which thispermit 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 fir State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: c`/ Rgrad Trrc c
The debris will be transported by: f)a,vd jettieficc47
The debris will be received by: Alley i ecye/ivl
Building permit number:
Name of Permit Applicant AcetZ'vtsct.
y 97f �Al - ,
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
V _ ` 1 Congress Street,Suite 100
Boston,ASA 02114-2017
wwwmass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �k p J Please Print Legibly
Name (Business/Organization/Individual): AI- O �f ai A.
Address:_„ ?/ 0. 1(joc )0`.1
City/State/Zip: t e r zutLi$5 Phone 0: (3 -0)3e -VW
Are you an employer?Check the appropriate box:
Type of project(required):
L I am a employer with 3 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-tune)." have hired the sub-contractors g�
2.n I am a sole proprietor or partner- listed on the attached sheet. 7. i�Remodeling
ship and have no employees These sub-contractors have 8. E l Demolition
working for me in any capacity. employees and have workers'
.insurance! 9. ❑Building addition
nom
[No workers' comp. insurance p
required] 5. ❑ We are a corporation and its I0.❑Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself,[No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.]t152, §1(4),and we have no
emploc. yees. [No workers' 13.E1 Other
comp. insurance required.]
"Any applicant that checks box d I must also 511 out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. lithe sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ,
Insurance Company Name: f7� P XII 0
a //� ) f
Policy#or Self-ins.Lic. #:_ �J _ Expiration Date: / f
Job Site Address: d7, gieijeIMpd6/ z /t/o✓/f'�^ a t't4"City/State/Zip; 4/060
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the(um of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for • ranee coverage verification.
I do hereby ser ; de• oi..;and penalties of perjury that the information provided abo e is me and correct
p1
Sitnature: )) gr Date:
!� [ ,{ Date:
Phone#: it( . — V /�e
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#:
.w�wau�oxs;13.a • :
• to `, iI
For Registration For David Jagadzinski
d 6M0 !a home Improvement Contractor and keep the same HIC Number. complete the steps below.
q " b@lo ensure the Information Is up to date.
Ws_
R 'Completed the steps, you will submit your application for approval
0; tion has been approved, you may pay for the HIC registration online by credh card or electronic check. ,
" twpilytaent has been received, you will receive the HIC registration by mail.
Df5Cnption Status
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Enter the name. Tax ID. address, and other basic information
about the contractor The application has been Submitted
Enter information about the responsible person. owners. and HIC_•
-rd heelers for the contractor The application nos been subml�#s3f},dnd
r °vide answers to questions that are requued for this apuircatv_r. -'he application Pas been Submrtlt ,= }
Fdpfbad any required documentation including D6r1 Cerh'icates and '••rhe a rpucaLon has been submitted and
Proof of Incorporation <;
bent the application for apDrov,li 7n, y,„„pacaaaailNas been submitted t
� fothe Ira• ' rqJ " r;n,t ni !I@::'torn .•, u'a t"V d, .aii) online
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