32C-212 (2) Y3. MP`FNS TION 'That for the consideration named herein, the CONTRACTOR proposes
to rah.kI the aterials and do all the work described in, and in accordance with, this
C`
ContrltGtor the s tna of
--PtrnL-- iousand Four Hundred Dollars and no cents($3,400.00)
Upon completion of this agreement, the PROGRAM will provide a DPL not in excess of
53,4011.00 be applied os.final payment for the completed rehab ilition work. The balance of$ 0
shall be paid by the 0PYNLR(S) to the CONTRACTOR.
14. 'This AGPE' MENT shall not become a Contract
binding upon the parties connected until these parties have properly signed this AGI?FT,M1:7V7'
and the CONMA( 7'Oli for the respective grant has received authorization to proceed.
15. All contract prices are final. They are firm quotes, not estimates. No changes will be
allowed on the work as bid unless authorized by the PROGRAM.
16. ALL CONMACTORS agree to abide by the Material and 1'erf�rmance S'landards.
Owners S'?gnaiuYe ('ontrac .r�s .�?gnattlre
-- -- n1 -
Dale Date
Owl-w- Ni«r..rt71, - - /)aie
/Llal�
0
Director Council on . ..0 bate
4ttiMlp�0
B g Grxt� Of wort4alliptialt
B �asaaclfnsctfs'
m DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal Building '
Northampton, Mass. 01060 y
WORKER'S COMPENSATION INSURANCE AF t AVTT
(IlcenserJpermittee)
with a principal place of business/residence at:
9' 6 Arty— l I) )Qd 661,l r_awar OLIvC?I IY11� 9�e(Phonef#) ��G 7:�P9
(street/city zip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following workers compensation coverage for my
employees working on this job:
(Inns-a=ce Company) (Policy Number) (Expiration Daze)
O 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 Compauy/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Compaay/PoLcy Number) (Expiration Date)
(Name of Contractor) Gnnzraace Company/Policy Number) (Expimbon Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach addi600il shx ifntcczuy to ii d information peztnining to all axi�ndn s)
�+Q 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 awart that white bomcovvcn who cmpfay pc:o s to do m in�cc cons:ruc'.ion or rtpau work oo a duelling of
not more than Ihtco units in which the homoov n rmdcs or oa the pouodi appurtenant thjtr o ere not grnerally mmidcred to be
employrrs unicr the worker's.compcuution Act(GL152,s3 1(5)),application by e homcowacr for a Uccwc cc permit may-id—the
legal o-tuc of an amployer undertho Workoet Compomaiion Aci
I uadcrtund tfut a copy of this rwcmcnt may bo foaww dod to tho Dcpartaxni of Indzuhial Aocidmti Off ioo of IO%u—for the
oova-age wrification and that failure to secure cowmV under Scciioa 25A of MGL 152 can Iced to tbo imposition of criminal pcml>:ca
oaisisimg of a fine of up to S1,500.00 and/or imprisonmcat of up to one year and Civil prnaltia in the form of a Stop Work Order and a
fim of 5100.00 1 day tgainzt try
Foe deputaridal—only
Permit Number
L-OA Map; Lot
Stgnat u e of Li crmittee Date
3 3
SECT ONB CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
—�I Not Applicable 0
Name of License Holder : �DRv�� ,7 J;iA yao,n 0 S a 3
License Number
.41q Z3 sr��� � ZAII!1 ru,�,�.p bu M lC —,:2 9-0�
Address Expiration Date
12zti-t—�1 C� yJal1�� ��, Co 8 7 3 r7
Signature Telephone
Rm eeeoW R im) : . :. Not Applicable ❑
Cc
Company Name Registration Number
Address Expiration Date
Telephone _.)_tea b'9
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 affic
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
��vne�_
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famili
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner act
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 then:
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 buildine 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
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
x ECTi0N�5 DESCRI TION OVfPROPOSED NOR f check ag
aI a V In 116ble <
i T M9P2Y -N0.P 9 NN3 fi^� ie - #c 3iM 6 d13N'Yx� F h .,N'+ 3 3F
New House ❑ Addition ❑ Replacement Windows Alteration(s) Rl Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: K—�'T,60 ��4i� y,,dawr o-J 6,%4k 7,e&,es �A TMbSum�,�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6a„ If�Newtio�useantloraddition�to�eXist�nm�housin'
g g.�cample�e�the-:�follo�iri :
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?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes
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'�OR-,13UII:DING PERMIT
as Owner of the subject prope
hereby authorize to ac
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
CDP 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 e e
—prn-allties of perjury.
/
A
Print Name
.2h" a.
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 t� 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 tZ 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:
ity of Northampton
�r-- uilding Department
212 Main Street
i JAM - v 2002 � LJJ Room 100
j No thampton, MA 01060 e s
p P e�4-Iti�l 413- 87-1240 Fax 413-587.1272 'R / ate
#�r Speo- .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION_
This office
1.1 Property Address: `fit
MapLot Uni#
zone verlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam�(Prin Current Mailing A dress:
Telephone�O 7 Cf
Signature o
2.2 Authorized Agent: Ol09/v
QD v,d PO box -39 n to ff(a vYsrhu 3 fVl'4
Name(Print) Current Mailing Address:
_ 3 0 c &S 73 R'9
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Q (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 =0 + 2 + 3 + 4 + 5) 3 Check Number
is Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2002-0619
APPLICANT/CONTACT PERSON David Johnson
ADDRESS/PHONE P O Box 390 (413)268-7389
PROPERTY LOCATION 41 HOLYOKE ST
MAP 32C PARCEL 212 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid sm�^
Typeof Construction: REPLACE 2 BATH WINDOWS&BATH FLOORS&TUB SURROUND
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055903
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
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 Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street C ssion
Signature of Building Official D a te/
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
1 r
OLYOKE ST BP-2002-0619
GIs#: COMMONWEALTH OF MASSACHUSETTS
32C_212 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinl7
Category Non structural interior renovations BUILDING PERMIT
Permit# BP-2002-0619
Project# JS-2002-0967
Est. Cost: $3400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin David Johnson 055903
Lot Size(sa. ft.):: 9104.04 Owner: JARZEMBOWSKI JOSEPH F&MARY T
Zoning:URC Applicant: David Johnson
AT. 41 HOLYOKE ST
Applicant Address: Phone: Insurance:
P O Box 390 (413) 268-7389
WILLIAMSBURGMA01096 ISSUED ON:117102 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 2 BATH WINDOWS & BATH FLOORS
& TUB SURROUND
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 si nature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/7/02 0:00:00 497 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo