25A-049 12 CROSBY ST BP-2018-1273
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map.Block:25A-049 CITY OF NORTHAMPTON
Lot;.001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:window replaced BUILDING PERMIT
Peanut# BP-2018-1273
Proiect# JS-2018-002272
Est.Cost$8000.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group JOHN ZIEMINSKI 017889
Lot Sizc(so ft 7 11282.04 Owner: KELLY JOHN R&DOROTHY J
Zoning: URB(100)/ Applicant: JOHN ZIEMINSKI
AT. 12 CROSBY ST
Applicant Address: Phone: Insurance.
10 WOODRIDGE CIRC (413) 247-9014 SOLE
PROPRIETOR
HATFIELDMA01038 ISSUED ON:61512018 0.00:00
TO PERFORM THE FOLLOWING WORIGREPLACE 10 PORCH WINDOWS & 3 LIVING
ROOM TO PORCH WINDOWS
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 6/5/20180:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
01))A) 000.115
Department use only
tirr.T- City of N rth Tipton Status of Permit:
{'
o JON 4f3gydjng ep rtment Curb Cut/Driveway Permit
f t `` �i"g S feel Sewer/Septic Availabilhy
p L1r; Ito Water/Well Availability
PT.of BUaDI , 01060 Tyro Sets of Structural Plans 413-587-1272 Plot/SRe Plans
Other Speciry
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 609- / g- ! X-7
1.1 PropertyAddress:
(/ Thiis section to be completed by office
Map 11 Lot 0-1eUnit
Zone Overlay District
Elm SL District C8 District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/ riot /otJELc-y �f CRos6y STND.ei7fii+o �� oio6D
Name(Prim) Cunent Mailing Address: 4 .3o 0
pr�c— Tetepiwne
Signature
2.2 Authorized Anent
Tori ✓ zi��
Name(Prim) Cunent Mailing Address',
�/ Llq 3190
Signature Telephone
SECTION 3-\EWTIMATED CON RUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building v u (a) Building Permit as
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) 1 r-5" opootCheck Number iC/
This Section For Official Use Only
Date
Building Permit Numb Issued:
Signatur
Building isar�en1n.pecto,of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column m be filled in by
No Gf+++✓fiE N . L. BuildinS Dcpanmem
Lot Size
Fmnut e G'
Setbacks Front
Side L R:— L:_R:_
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot oma minus bldg&Pavd
kn
N of Parking Spaces
Fill:
volume&La dmo
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW p YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW C) YES O
IF YES: enter Book Page and/or Document A
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O Dale Issued:
C. Do any signs exist on the property? YES O NO O
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:
E. Will the construction activity disturb(clearing,grading,ex avation,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 ❑ Addition ❑ lacement s A
Reptteration(s) Roofing ❑
Accessory Bldg. ❑ Demolition E3 Nm Signs [O] Decks [ice Siding=1 Other[O)
Brief Description of Proposed
Work: XrPLgtE /D 42,KC1Z '7l9 OGnCl/ eJi..ut +_1S.
Alteration of ebsting bedroom_Yes��` No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes � No
Plans Attached Roll -Sheet
6a. If New house and or 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. Masschmk 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 Cay Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 7J�o?f.e /��y�/ ,as Owner of the subject
property Z
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
G y /�
Signature weer Date
Z 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
Signature of Owner/AmData
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable I
Namsol License Holder: --7A/j�,j [J / 7 ,F8 f
License Number
/� /lOob �LID� f C7C / iyit�h D/O3g ����zo
AddAs , Expiration ate
Vt"��f - -// 3 ,--/4 3
/y/U
Signa u
Telephone,
S. Registered Home Improvement Contractor: Not Applicable I
.�� /�/ �E'7r-//Y W/ /5Ld-f/l. / d�c-7,+ . �.✓r�. //JO /33
Company Name , ,lo_4 Registration Number
Address 2/-�, 3 / 9 d Expiratio O-
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C.152,§25C(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 Vesx I No--- l
City of Northampton
Massachusetts
6
x
IY�IY 212 "in Sheet• auviciUILDING al Building ilding'S
=
jynori,he.,ycou, ar. 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR") regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or buildind' he
done by registered contractors.
Note:if the homeowner has contracted with a corporation or LLC,that entity must he registered.
DOt c/f _
Type of Work: Est.Cost D
Address of Work: /2 r_�/� C R_�. .�z. iv—V _z?rsi"a/J
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
Job under$1.000.00
_Owner obtaining own permit(explain):
_Building not owneroccupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONT RAC`3 iI oiluc_,Wb7A,wu
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
�Igned under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
4L�/8 :::;7r/hV .W, 2 ,✓S ¢/ / oot33
(Yate Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date L wn r Name and Si ture
City of Northampton
J`�r rapt,
Massachusetts
BSPART JWT or BUZWZAO ISSPECTZMS
212 Main Street o Municipal Building
Mnrtpamptau, M . 01060
Debr i s 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 fac31i4y, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
/ -Z c,zo s eg �Z J-T, W
(Please print house number and street name)
Is to be disposed of at:
CJMzI. t�/ C u�
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
�"� D t�� L/Y/// 8
Sign to of Permit Ap cant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
t ` I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
\\wirers'Compensation Insurance Affidavit:Builders/Contr ctors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (BusinesslOrganiratioNlndividua0: msl/, �'h'y
Address: /4C,' L." 069 0 z Ly ah f- fi/e
City/State/Zip: / inn A/kit— Phone#: 9/93/9D
Ave you an emptuyes?Check the appropriate box: Type of project(required):
1 Q 1 am a employer with employses(full andlor part-rirtw).' 7. ❑New construction
2.jPI am a sole proprietor,partnership and base no employees working torment g. Remodeling
any capacity,iNu workers comp.insurance untamed.]
3.11 am a homeowner ddng all work myself.IN.workers'compnsurance t«
.insurance l 9. El Demolition
4.�1amahomeownerandwillbehiringcontractorstownduaallworkonmypmpeny. twill IO Building addition
ensure that all contractors either have workers'comicromon insurance or are sole I LE]Electrical repairs or additions
pmpriemrs withno cmployres.
12.[]Plumbing repairs or additions
5.❑I am a general wnbactorand l have hired the sul,emor seers listed on theamobad shoat 13.E]Rwf wpairs
These sub<ommctors have employees and have workers comp.imurance t
6.❑We are a corporation and its officers have exercised their right 4 exemption per MGL a 14.BOlher /,0� Z>Jlj pr_dS
152.§1(4),and we have no employees.[No workers'wrap.insurancereyuiredt
*Any appll.,that checks box 41 most aro fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
f0,ontmetors that check this box must attached an additional sheet showing the name of the sal,rmo a lms and sum whether or net those entities have
cmplayu..- Vth.cail
I am an employer that is providing workers'compensation inswunce for my employees. Below is the policy andjob site
is rnrnrntinn.
Insurance Company Name:
Polio /1 or Set'-ine.11c p: _ Fvpimfnn Dou,
Job Site Address: City/StatelZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
poi hvr to rronrned on Mr MGI r 159 815A is o rinnini,l vinl.bon pun isha Me by a fit ne up to Sl 500.01t)
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a Rne of up to S250.0r,a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verifirafion.
1 do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
C
signature Da &ZY A�
Phone#: 1 /3 /ai 3 / 90- r
Oficial use only. Do not write in this area,to be completed by city or town official.
City or Town: PermiDLicerkse#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: