25C-246 (3) SECTION 8- CONSTRUCTION SERVICES
8.1 Licensed Construction St�ervisor: Not Applicable ❑
Name of License Holder :_-_ Gerald Arehambeault
License Number
Address Expiration Date
Signature Telephone
9 Registered Home lmprovemerit'Contiactor 's Not Applicable ❑
Gerald Archambeault Builders _
Company Name Registration Number
West Street, Hatfield, MA
Address Expiration Date
Tel ephone9—?"__` 3
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 Yes....... ❑ No...... ❑
,1 R11 MIr
�Iomie..0...... fer Exemption
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 ft.- 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 1_.am s 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, Statp,and Local Zoning Laws and State of Massachusetts General Laws Annotated.
C� J
Homeowner Si nature
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DEPARTMENT OF FUNDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, '!Sass. OIOGO
WORKER'S COWENSATION INSURANCE AFFIDAVIT
(]ic�nsc�iPt;nlittc�)
v,rlth a principal place of busuiesslresidence it
(phone;
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do hereby cet tiiy, under the pains and penalties of perjury, that
an employer providing the follo-,vintt coverage for my
employees working on thus job:
---- (Iaa=I� Comp3�y) (Expiration Date)
X I am a sole proprietor, general contracto. u h �aieoNvnc, " isle one) and have hired
contractors listed below who have the follow wor -ers compensation policies:
(Name of Contractor) (Insurance, Cot it 1a7, ,!'o'.icr Nurnbcr) (Expiration Date)
(Name of Contractor) (Insurance Com ui,,';Poi q NIImbcr) (Expiration Dale)
(Name of Contractor) (Ins�tranc Cor�} �'rol c} Nulnl �r) (Ft��raCOn Date)
(Name of Contractor) (Insurance Con1,x �ti;G'olicy Numlr�r) (Expiration Date)
(atiacdi ad±iticY:ii slxct ifr,c-c_ziry to include i:fortnatia:pctn:^:r.�,•.,eii�-<:..at.,.:-.) ,
O I tali a sole proplietor and have no one for Ine
O I and a borne owner pelforlllIno all the Ii: iP.`,sClf.
NOT:pte-ae tx aware flat t�fnle hccaca��i�cra�tioo c lay ix:z�s to d� nuIlcaiac� - �'m cpair work eo a dwelling of
not moor thsn dune units in tvfidl tfie fxxxouncr rain or oe tlu Er�c;x� �utr, ri tlx do ct rxt[ t rally ooarid rd to be
criployc-s under the%M a.s arnpc zatim Act(GL152—:s I )),a{ l::zie::by a haaa���r for ct psmi:a:ay c idcaoc the
legal etatas of an aavloyer under thn W"kcc'e comps tion 'xl_
I undcriund that a co-py of tliia rtatcli d may bo forw—dod to tiro DcpuL: i of Indusirinl P.cci1 rfa'Oflicw of 1.s..ncu for tlm
coverage valfication and that fnilurc to!!cure 001"ango ur:3,s xai a 2,5A,_f i,ICII,152 can lr_d to tlx iIrposition of trim rash pcaaltica
a ali_V ag of a fiat of up to S l,S .00 artdlot iu{ritonnyal of up to cn }. r..i civil penalties in d c"c n of a stet'Wori(Or-'C and a
fine oCSl0.0.00 a day Ignint mr
t Foe cics:u L•n'r Csl ui only
- PGrrrnt NLLInb:' _
.. i
u o t
St hate of LICCnsce/PcrnIittcc
F` ---- — — - ¢:
SECTION 5. DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors. jJ
Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Replace 14 stah-da-rd windows. Replace I bow window witFi tia
Brief Description of Proposed Work:_druble- zzng-window —
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet❑
sa.f f§
NewJeaand '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?
i. 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 _- -_.No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning reg,flations? --_-_- 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
-_ Patricia Nowak as Owner of tie subject property
Gerald Archambeault
hereby authorize- to
---- ---- ---------
my b If, in all matters relative to work authorized uy this building permit application.
Signature of Owner Date
I, as Owner%Authorized Agent
hereby declare that the statements and information on the foregoi,g 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/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 X 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 X 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 X
IF YES, describe size, type arid location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No X
IF-DES, describe size, type and location:
C t�;
- y of Northampton Status of Pear' S .
^�Building Department CuCut%Dtwer
, watt
21'2 Main Street S6WWS' Ic,�
` Room 100 Wat60Well, a i
Northampton, MA 01060 Tvvo SetsofStr c tiro atis. �,
phone 413-587-12410 Fax 413-587-1272 Plot%Site Plans ' ;
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 by office`
259 Bridge Street Map 24C Lot 246 "+LIT it
Northampton, MA 01060 Zone Overlay District
Elrn St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Adrian & Patricia Nowak 37 Old Ferri Road, Northampton, MA 01060
Nance-- eat iJ Address
413-587 395-9 9- --{-P-a-t-1;3-wad-2 5b-5-S QOM- 523
—_� elei�none
Signature
2.2 Authorized Agent_
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Signature Te,ep'�on ,
SECTION 3_- ESTIMATED_CONSTRUCTION COSTS
Item stimateo Cost Dollars' to he Official Use Only
-- - � EST. �00v0_�rmit
_. 3uiid�i g (�) F3��i�ding Permit Fee
I
-- - -
---Reglac-ement. v� _ndows--ta-existing dome.- ; ---
2_ El , t: cal (h) tuna ted Total Cost of
r s' action from 6) _
3. Plumbing I Building Permit Fee
4. Mechanical (HVAC`
5. Fire Protection
6. Total = (1 + 2 + : + Number
This Section For Official Use Only
Building Permit Number:— _i Date
Signature: ----- ------ ----- — —
Building Commissioner/inspector of Buildings
BP-2003-0636
—11111111 MCI*GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: B U l l d i ng
Category: BUILDING PERMIT
Permit# BP-2003-0636
Project# JS-2003-1046
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq.ft.): 5793.48 Owner: NOWAK ADRIAN&PATRICIA
Zoning:URB Applicant: NOWAK ADRIAN & PATRICIA
AT. 259 BRIDGE ST
Applicant Address: Phone: Insurance:
37 OLD FERRY RD 15- 7-1M6
NORTHAMPTON MAO 1060 ISSUED ON:1121103 0:00:00
TOPERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT 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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/21/03 0:00:00 1425 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
259 BRIDGE ST BP-2003.0636
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-246 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0636
Project# JS-2003-1046
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sq. ft.): 5793.48 Owner: NOWAK ADRIAN&PATRICIA
Zoning.URB Applicant: NOWAK ADRIAN & PATRICIA
AT: 259 BRIDGE ST
Applicant Address: Phone: Insurance:
37 OLD FERRY RD
NORTHAMPTON MAO 1060 ISSUED ON:1121103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT 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:OK a—'' (�-03 4(4,
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI F
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu anc Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/21/03 0:00:00 1425 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo