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Q DEPARTMENT OP BUILDFNG INSPECT101.'S
212 Main Street ' Municipal Building
Northampton, Mass. 01060
NV O RICER'S C O MI'EN S ATIO N IN S URA_N CE AF MAVIT
(li ccnscdpermi ttcc) —
V'ritb a principal place of business/residence at: ZI
hone')
(S0=Uci ty/staiz;fa p)
do hereby certify, under the pains and penalties of perjury, that
( ) I am an employer providing the following worker's comoens-ntion cove mge fof Illy
emplovecs wor-�Ding on ulis job
onsul-anc� Concr-nv) (PoLic; Nu_mirr) ---- (T s-pirtion Date)
( ) I am a sole proor-ietor, general contractor or homeowner (circle one) and have hired
the contractors listed below wbo have the following worker's com,nenmation policies:
(Name of Contrncto-) (Ir1R1r-anc-c Coino3rl)'/P(-,6c-, 14=hYr) (T-->I-:)IF-'3"1Q-1. Date)
(Name of Con[Tacior) -- (In -dMcc Company/polio' Number) (Expn.iion Date)
(Name of Contractor) (Insurance Company/Pot q- Number) (Expimbon Date)
(Name of Contractor) (L sufanc-- Company/PoLicy Number) (L-xpuiDon Date) .
(etlach ad�i::ocaJ cxct itncc ,� to mclud:mfocm--600 P-rudning w.11 oDa rim o. )
( ) I am a sole proprietor and have no one wor1,-ing for me.
I am,a home owner performing all the work myself.
NOTE:plc:a be evri t!u'u1:Je hoa="n,n mbo employ per-ion3 to ar rc,�air-ork on,d..ctL g of
ant moce th_n Lt -VJ in«hies the bon.,vcr rcid-,oc oa the g-ou�zapurtcnsm thcan e.c o-x CC lly oecs:d-�d w be
essrploycs unol -tlx Ho i rti o _tie.Act(GL1 52-=1(5)�appLax6cro by n hou=w ocr for c bcs_x a perma=y nidcoce the
legal—of en ePloyee under di Wo,4 t Coavoavlion Act_
1 uodasund tbd a copy of thij cxxic m.y bo fog-anted to tbo Dcgenmmd of lndurrit]ncod Offioo of IrawRnoo for ttm
covcnsc vrri[csioa AM Utat f_iltn<to ccauc covcrtf,,tutdcr soction 25A of MOL 152 can lad to the imoaaifioa of cnmiatl pca+duc:s
eo=L'a- g of a FMC of up to 51}00.00.r.&I-¢�c of up to ooc yr r end aril pm.l'uo in dx focm of n Stop Work Ordcr and e
fun of S 100.00 z d•y cFpiaA mc.
For dcp.rtn�=il u�c—1y
Pc=t Numbes
ltim- f Liccrcm ttc Sign -- �
Route 9 — Bridge Street a
EXISTING SANITARY SEWER — — — — M.H.
- - - - - - - - - - - - - - - - r- - - - - - - -0-- - - - - -
_ _ - - - EXISTING STORM SEWER - -f- - - - - - - - � - - - -
GRAPHIC SCALE
0 20 30 44
IN FEET )
1 inch 30 M
cb \�
co
I ) \ \ \ co
W
a O
' I 2 S 9 � �°� \ `` \
# Bridge St. 7 \
,A a
00
cl \ \
I c) ' house \I
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1
EGTIDN 8 ri:CONSTRU�tION SERVICES
A Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
mm
PP
Not Applicable ❑
r ' ..
Company Name Registration Number
Address Expiration'Date
Telephone
SECTiQN 10-1111O RKERS?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.
'gned Affidavit Attached Yes....... ❑ No...... ❑
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
N rthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
omeowner Signature
Or
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. )g Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: Demolish xi sting storage shed, and r-eplapLls ene e p
Alteration of existing bedroom Yes No Adding new lJMRbtf9 of 01 40 red at hed)
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
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
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-OWN 9ER AUTH `RIzATION,-TO BE'COMPLET ED WHEN
rpw1+I R5 AGENT 0»frt N7'�tl�C"�O.I�;APPLIES FOR BUILDING Pi=13M1'�
1 as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1 , 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.
Print am
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 �v
Setbacks Front -7()
Side L: R: :�R
Rear
Building Height
Bldg.Square Footage ( a ova
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 x property yR-g purchased 6/14/00.
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 and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
Nom
IF YES, describe size, type and location:
1 off- rthampton
epartment
l�u
A 21 in Street
§ ' AAU628M 100
i s
Northa . pt ±n, MA 01060
grte
Z4,2 Fax 413.587-1272
.......,..s _.-,t ,. ...._ ..,....,,.,.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-S1TE":INFORMATION /Y
1.1 PropertyAddress: yr
259 Bridge Street
Northampton, MA 01060
SECTION'2-PROPERTY OWNERSHIPJAUTHORIZED AGENT
2.1 Owner of Record:
Adrian K. Pntri ri a Nnwak 37 Old Ferry Road,Northampton, MA
ame(P ' ) Current Mailing Address:
'�'` /) (413)587-3959
�!� .�. Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTMON COSTS
Item Estimated Cost(Dollars)to be Official Use Only
co m le ed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical - (b),Fstimated Total(host of
Construction from 6
3. Plumbing �� BuildingP+ermitfee�
4. Mechanical (HVAC)
5. Fire Protection
6. Total =G +2 + 3 +4 + 5) 1 j CheckMu ber
Th.i Section F,or Official Use Onl
suildittg'Periit Number: . . Date Issued:.
Signature:
Building Commissioper%Inspector of Buildings. Date
a
File#BP-2001-0222
APPLICANT/CONTACT PERSON NOWAK PATRICIA
ADDRESS/PHONE 37 OLD FERRY RD
PROPERTY LOCATION 259 BRIDGE ST
MAP 25C PARCEL 246 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building,Permit Filled out
Fee Paid
Typeof Construction: REPLACE EXISTING 8 X 10 SHED
New Construction
Non Structural interior renovations
Addition to Existina
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION:
Approved as presented/based on information presented.
Denied as presented:
Special Permit and/or Site Plan Required under: §
PLANNING BOARD ZONING BOARD
Received&Recorded at Registry of Deeds Proof Enclosed
Finding Required under: § —w/ZONING BOARD OF APPEALS
Received&Recorded at Registry of Deeds Proof Enclosed
Variance Required under: § w/ZONING BOARD OF APPEALS
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 Commis ' Permit from CB Architecture Co ittee
�aoo
Signature o Building Official Date
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.
259 BRIDGE ST BP-2001-0222
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block:25C-246 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: shed BUILDING PERMIT
Permit# BP-2001-0222
Project# JS-2001-0364
Est.Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:
Lot Size(sq.ft.): 5793.48 Owner: NOWAK PATRICIA
Zoning URB Applicant. NOWAK PATRICIA
AT. 259 BRIDGE ST
Applicant Address: Phone: Insurance:
37 OLD FERRY RD
NORTHAMPTONMA01060 ISSUED ON:911100 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING 8 X 10 SHED
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 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 Sienature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 9/1/00 0:00:00 1003 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo