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25A-139 (3) p ltTl-?X'J p 6,4ti", P 1 01 9 1POT310 a U 1�6,1 2 'y P'779Y "Wool-, 7 tb rZA 'N N; )Ah lots) rh 7b rk 71 NOTICE OF ASSIGNMENT EMPLOYER: COMBO I.D. STATUS OF EMPLOYER HENRY SOUZA DBA NORTHAMPTON HOME IMPROVEMENT 000056385 Individual 24 OLD FERRY RD HOLYOKE, MA 01040 COVERAGE GROUP 0056385 Coverage under this assignment The Waiver of Our Right to applies to Massachusetts Recover from Others Endorsement operations only. For coverage is available on Pool policies. outside of Massachusetts, contact Contact your agent for details. the appropriate Pool or Plan for that state. AGENT WEBBER & GRINNELL INSURANCE AGENCY INC INSURANCE COMPANY: OR 8 N KING ST HARTFORD UNDERWRITERS INS CO PRODUCER: NORTHAMPTON, MA 01061 MS CINDY MAROWITZ P 0 BOX 4903 ORLANDO, FL 32802-4903 (800) 453-9843 AGENCY FEIN:04247 0 7 3 5 CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED CODE TOTAL ANNUAL PREMIUM REMUNERATION -------------------------------------------- ----- -------------- ---------- ---------- CARPENTRY-DWELLINGS - THREE STORIES OR LESS 5651 $0 9.03 $0 CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 5645 $15,000 9.03 $1,355 ROOFING NOC & YARD EMP, DRIVERS 5545 $0 47.57 $0 CARPENTRY NOC 5403 $0 16.48 $0 EMPLOYERS LIABILITY 10011001500 9845 STANDARD PREMIUM $1,355 EXPENSE CONSTANT 0900 $284 TERRORISM CHARGE 9740 $5 ESTIMATED ANNUAL PREMIUM $1,644 DIA ASS$SS. 4.2% OF STANDARD PREM. $57 EST. ANNUAL PREM. PLUS ASSESSkENT $1,701 INSTALLMENT BASIS: Annual DEPOSIT PREMIUM: $1,701 THIS IS NOT A BILL COMMENTS Coverage effective 12:01 AM on 08/31/06 DATE OF NOTICE: 09/01/06 PREPARED BY: Maryellen Nee EXT 532 * * VOLYNTARY DIRECT ASSIGNMENT LETTERID: 1238516 COPY: EMPLOYER The Workers'Compensettion Rating and Inspection Bureau of Massachusetts 101 Arch Street- Boston, MA 02110 (617)439-9030• FAQ(617)439-6055 -www.wcribma.org Li#y ofoz#l��nt >}ort 5 I�1 DEPARTMENT OF BUILDI7�G INSPECTIONS /? INSPECTOR 212 Main Street • Municipal Building Q,y S`sy� Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup,.: sor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before baekfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location f i � . O�-(itAJ•f pTO ` .A b U-I1.�7 L7I �Q.L"tt�i�?I11�JtDli _ — 9 y f 3laaiacilaccIts DEPARTMENT OP DUILDrNC INSp EC M011's 212 Main Street Tlunicipnl Building 6 Northampton, Mars. 01060 WOMCE' !l•S CON11PE NSATTOr MSURA-N'CF- A1't'MAVi-j L, (l1 CCIlS<S�pCTtAJ IICC) ` wlth a principal place of business/residence at: l ��(:1t�_✓ ` V'lj(rt7 (P n one. f do hereby ce ', under tic a_ns and Penalties of e t7> ; h:t I arm an employer providing the followine %vorkcrjs compcns ion coverage for Inv eluptovecs worlang on tilis job: Clnsur-��Conr J1.) (Pclic: . >Lmocr) (r:piruor, Dzz;) O I am a sole proprietor, general cootraczor or homeowner (ccie one) amd Lave hired the consa(nors listed below wbo have the `ollo%,V-ing workers comoensadon policies: ;,qmc of Contmao-) Gri-s-lrallc c COIT1p3,I)'/PGUCi (Y 11'JL'_•Or ID.ILC) r (Name of Conaaaor) (In,-urancc Company/Policy Num6zr) (-ExDir-bon Date) (Nzme of Coaamctar) (Insul-anc; Compan)•/poc-q- Number) (Expirden Datc) (Name of Contractor) (Insuran Comrany/Policy Numb r) (Expin600 Date). (atx�ch •'ti:tocal z'sca,if acccri�y to mead:iaformiaoa pctaia>,as to.11 0047-1a:z) { ) I am a sole proprietor and bave no one work--iog for me. ( ) I am,a home owner performing all the wort` myself NOTE:plesc be evnrc t?i +Ialc hemeo;vcra .6o aapl%Pczoas to do�• -• cr aj'o c rc air-vric ca.d---U-,-Z of oar tnocz the ' u hits is Which the b=oo, oc raid=or as the p-ouac,zppvrteyr�tbeCO�-c ax�-%nY ace:d roi to be aptoyc s„ the..ai d= am _ .,:w Act(G U S L=1(5)),applinrioo try a boawo oa fQ c b«=-=a pama zy c.idco=Lbc Icgs1 n,.,.of na er=rtoyx under d-Wwki el Cooapom.tioa Aa- I uadazs+.od d-a oopy or thi,—'=. w my b.for- -,d>.d to rho pcp,rcm ar erin�+asi;.J ncad.�f OT,_ rL=—roc tb. 00�iSc vcriGeazioa acid tttat f iliac to sc=m`eov,�tmdcr yogis 23 A of MOL 152 m I=d to the iars2ioa of aimia-3l pca,Jri= 000ti.mg or a Gac orup to s 1}Op.00 arzfor oCup to ooc yc3r Lzd cv1]pcaxhua fa t4 Corm or&Stop Wori;Ore and Gm of 5100.00 r dsy rPiast Mr J For dc;s.na+1,t u,c Only Permit NtunbCr Y—c(10 hta�. Lot r rc of Lia-srsJPccmittcc �Ce ?� l SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �Vly► —7 M License Number .qq dicl lU�, (� �L 61aL6 5- 1 -© za Address it Expiration Date Sign ture Telephone . ., x z Applicable ,❑ 9 Reaisfereilloirie lmaraerrrenf Cotrac£er® � r - Not PP Company Name Number 'old 6(OLIO Address Expiration Date Telephone `{l3—yY�1'3Y31 SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAVrI (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...... ❑ II ` ;�.. f` 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 Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors 1:3 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[0] Other[O] Brief Description of Proposed �-- Work: —1 �-(�Z9 rJq t'hVI�.►n J �ZVU d 1,1_c c1 �) VtS�J�� Alteration of existing bedroom Yes L No Adding new bedroom Yes X_No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa Ff G[ernrouse ancocclii�srito eicisir>g' roFrs� :rcilfe frEa� rtq: 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. flcodplain 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 Ta,-OWNER AUTHORIZATION,-TO BE COMPLETED-WHEN OWNERS AGENT OR CONTACTOR`APPLIES.FaR BUILD(NG PtRMIT CJ, as Owner of the subject property hereby authorize to act on my behalf, to work auffiMzed by this building permit application. Signature of Owner Date 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 _ -tL/-�t� Date Signa of Owner/Agent ^ ' ^ " . . . ' Section 4. ZONING All 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 Department Lot Size Frontage Setbacks Front Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces Fill: r (volume&Location) A. Has a Special Perm it/Vahoncu/Findi ng ever been issued for/on the site? �� NO v�� DON7KNOVV v�� YES «�� IF YES, date issued:: IF YES: Was the permit recorded ut the Registry oyDeeds? ' NO �� 7 KNOW O �~� w vv ,ca IF YES: enter Book Poge and/or Document#! ' x�� x�� B. Does the site contain a bruuk, body of water or wetlands? NO ��, DON7 KNOW x�� YES v_� IF YES' has a permit been or need to be obtained from the Conservation Commission? Needs tnbeobtainad �~� Ob�a�ned �~� Date «�� x�� ' . C. Du any signs exist on the property? YES 0 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 &mQ IF YES, describe size, type and location: E. Will the construction activity disturb(clearing grading excavation,nrfi0ng>over 1 acre oris it part ciu common plan that will disturb over 1 oom? YES �� ) NO K�� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. De tertseotlr gm- � � City of Northampton at ► _ ,�ui1din4 Department fic6k,Cuti'flm«'eanca �ettpt� �� 212 Main Street Room 100 �r ella tlt �' .� ,ti Northampton, MA 01060 wetaf�S ° e,;rat>�� phone 413-5 �7-1240 Fax 413-587-1272 i APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Thi sectror 1.1 Property Address: pleted yr ce �to be co m b offi 4z Map L'ot f Jnrt �� _.�-�'( Z'o�e Overla�IlEStcrct' EfttrStyD�strcct . " C�District, µ . SECTION 2-PROPERTY OWN ERSHIP{AUTHORIZED AGENT; 2.1 Owner of Record: C7(O t Current Mailing A ress- Telephone Sign 2.2 Authorized Agent: J� 6log5 Name(Print) Current Mailing Address: g13-12�iti- 3 L Signature Telephone SECTION 3-ESTIMATED"CONSTRUCTION COSTS- Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a),Building!Permit Fee to 000 2. Electrical .(b)'Estimated Total`Costof �j Construction from 6 3. Plumbing 5 O D© Building"Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+415) j Check Number This-Section-For Official Use Only Date Building:Permit Number.. Issued: Signature: Building Commissioner/Inspector of Buildings Date File#13P-2007-6288 APPLICANT/CONTACT PERSON HENRY J SOUZA ADDRESS/PHONE 24 OLD FERRY RD HOLYOKE (413)949-3431 PROPERTY LOCATION 35 DAY AVE MAP 25A PARCEL 138 001 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:_REMODEL INSULATE 2 BATHROOMS New Construction Non Structural interior renovations Addition to Existing_ Accesso1y Structure Building Plans Included: Owner/Statement or License 087984 3 sets of Plans/Plot Plan i FO O WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ATION PRESENTED: pproved 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 Pernut 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 Co sion or Signature of 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. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. ' J ,,35 LAY AVE BP-2007-0288 GiS#: COMMONWEALTH OF MASSACHUSETTS IacTct ` 13 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2007-0288 Project# JS-2007-000436 Est. Cost: $17500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HENRY J SOUZA 087984 Lot Size(sq. ft.): 6621.12 Owner: JOYBRAN DAPHNE Zoning.URB Applicant: HENRY J SOUZA AT: 35 DAY AVE Applicant Address: Phone: Insurance: 24 OLD FERRY RD (413) 949-3431 HOLYOKEMA01040 ISSUED ON.911812006 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL INSULATE 2 BATHROOMS 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 9/18/2006 0:00:00 $50.001158 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo ¢St1M1P�. , Crify of 'Wart4alliptZil z r g � iutassachusoi3s I r _ qL _ DEPARTMENT OF BUILDI7,,'G INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northwnpton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCNIR 108.3.4 to act as his/her construction sup(.: ,- sor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of Northampton wants any person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfill), sonotube holes (before pour), a rough building inspection(before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work(electrical, plumbing& gas) the homeowner will be responsible to make sure that the trades hired secure their proper permits in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required c DELAY the—project until such time as the proper permits and inspections are made r LP r understand the above. V (Home own /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date 7-0z , 0� Address of work location I.... 4TltAl•f p�. �O eca icy 0-f [—— R ti (riff �f '.Inrfll ul�tnl) �Z asanr3l it tr l l a' — i _- 4. o DEPAR MENT OP BUILDING INSPECTIOI,,S i 212 Alain Strcct Municipal Building Northampton, Mass. 01060 I «'OIUCCIZ'S CONCPENSATION INSURANCE' AI,FD�AVIT i (IJ CC'II S."C�OCT II1J ttCC) vrlt-b a pru-icipal place of business/residence at: i -- (S hone-.-!) t J/Sias.-/a P) do hereby certifj;, under the puns and penalties of pcfJuf-y. L ( ) I am an employer providing die following, %vorkcr s comoensarion cove ale for Illy etuplovices worlong on thus job: 1 (LnstLr-� Conrad) (Pclic:Nu--b,--r) (r;•pircion tDaL--) ( } I am a sole proprietor, general contractor or homeoWMer (c r,ie One) and have hired the couu-actors listed below who have the folloI,IeU' g worker's COm—p-- _sa6on pal?C)es: (''' (In�uraltc.:.Colnoa,�wt cuc, utn__.) (`r_x�I,a�_,.l�atc) C (Namc of Contractor) (Insuranc Comoa.ati•IPaUc-, Nuzac^r) (Name of ConinLio.-) Onst,,rancc Company/Pol;cy NambJ) (Expiraoo Datc) (Name of Contractor) (Inauraaccc Company/Policy Numb:t) (Expirdtioo Datc). (Winch�ditoc:al c�,iraccczc�-w c,cuLL u'forta.;oo pertniai.as to.11 u�–...C.a:a) { ) I am a sole proprietor ana have no one workjog for me. `( J I am.a home owner performing all the work myself. NOTE:pl=sc be ea ut tfi••wi la 6emcn"-n vbo�PIoY pczoo'to 4i cc—.:r=ao c rc,an uric on a d..c1,—g of not moct t1La ttSOe—u is-S6 the homoaw=r-.da or cc ttx gvun-ma=n iba ao er ocK uorsde ad to be aitploye'vale the..u�r�x •,;cn A={GL15Zn 1(5)} z gpliczboa try n homeoavc fez a bc==oc perraa ray c.•rdcmc tic 1e¢t rt=-."of m a:ptoyx under din Wock.e,C.oaagomat;oa AeC f uada::and dut a oopy of thin may bo foe-+.vrdod to the of f trz—for t6o - covczbc va%Sc=ioa=id ttu Utxc to"ci. c'eovernsv tmde uezioa 23A of),(GL t 52 na led to the im,xiut of atm'a-d P"W' oo—Lriag of a ruK orup In S 1}00.00—NOr i- LOen orup to ooc yc:r Lod aNil pcnxria is do foci'or a Stop Work Orda and a fl=of 5100.00 a d-,y apia-;,t me For d�.rt:za.�l v.e only PCfLII1t l`ttl.¢2UCS J"Cap„ — Lot . vi A". cf L i cm-uUcc �C ce .J L, r SECTION 8-CONSTRUCTION SERVICES' 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 3 ' Not Applicable .❑ Company Name Registration Number Address Expiration Date Telephone SECTION 1'0-WORKERS'COMPENSATION INSURANCE,AFFIDAUIT(WG 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...... ❑ 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"ce .fies and assum esponsibility for coy pliance with the State Building Code,City of N hampton Ordinances,State oZonin aws and Sta f M achusetts General Laws Annotated. omeowner Signature r 1 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable New House ❑ Addition ❑ Replacement Windows. Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. Demolition ❑ New Signs [O] Decks [M Siding[0] Other(E Brief Description of Pro osed Work: : 2hm aul/ y Or ?I A"A' c r0 t /��' �f Z70L- ,5-h' V Alteration of existing bedroom Yes No Adding new bedroom Yes No 616 SQ r Attached Narrative Renovating unfinished basement Yes No ON Plans Attached Roll -Sheet &a [f° Iernl��` as4nrai d aV-06i ts trra 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 L 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 AlJ,THORlZATlON-:TbQ"BE COMPLETED:WHEbt OWNERS AGENTOR GONTRACTORAPPLIES FOR"6t71LDING PEIRMI:T 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. Signed under the pains and penalties of perjury. Print Na -06 Signature of Owner ent Date Section 4. ZONING All 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 Department Lot Size Frontage Setbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm it/Variance/Fi nd ing ever been issued for/on the site? �� NO ��/ DON'T KNOW «_� YES �_/ |F YES, date isuod: IF YES: Was the permit recorded at the Registry ofDeeds? ' NO �� D �~� uw / mxow 0 ,co IF YES: enter Buok | Page! and/or Document#/ ' �� B. Does the site contain ubrook, body uf water orwetlands? NO �� DON7KNO YES J14) VV �_� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tobeobtoined �~\ 0bte[ned v-� Date �~� �~� . � C. Do any signs exist un the property? YES x-\ NO |F YES, describe size, type and location: D, Are there any proposed changes to or additions of signs intended for the property? YES K l NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading vodon.nr filling)over 1 acre orioit part cfo common plan that will disturb over 1 acre? YES �� l NO IF YES,then a Northampton Storm Water Management Permit from the DPW io required. w 9- x a� w At Am, City of Northampton Statso ` �ss $uiIud'ny DepartmB en+ tf Nr3' t 212 Main Streete+7+ce �€ aI . Room 100 a- 01;.da�ir "'Northampton, MA 01060 lvroetsatr rE phone 413-587-1240 Fax 413-587-1272 P( SCte 'Cans APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION.1 StTE`INEORMATION.- This sectilorrto be compCeted bg office >; 1.1 Property Address: Lot unii h16/r7 �� /�J ' done CverFaUts 00/ ErarSt<Dist tct c nIst�«t SECTION 2--PROPERTY OWNERSHIP[AUTHORIZED.AGENT' /l 2.1 Owner of Record: Name nt) Current Mailin Addre Telephone Sigrfature Q 2.2 Authorized Agent: E�..r A� Na ri t) �• Current Mai f�Addre t1` �` _ L% �Ci/✓`' �"1 �%U — O o,5`cam S nature Telephone SECTION 3--ESTIMATED CONSTRUCTION COSTS, Item Estimated Cost(Dollars)to be Official Use Only c m feted by ermit applicant 1. Building - (a)Buildings Permit Fee 2. Electrical (bp 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) Check Number1—_ This Section:ForOfficial Use Only Date-- Building Permit Number_ Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2007-0351 APPLICANT/CONTACT PERSON MGM Real Estate Associates,LLC ADDRESS/PHONE 1144 AMOSTOWN RD WEST SPRINGFIELD (413)746-8056 Q PROPERTY LOCATION BATES ST MAP 25A PARCEL 139 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,Permit Filled out Fee Paid H Typeof Construction:_ERECT 8 X 12 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THed WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ION PRESENTED: 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 Conuruttee Permit from Elm Street Commission Signature of Buil&dg 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. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. BATES ST BP-2007-0351 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A- 139 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2007-0351 Protect# JS-2007-000519 Est. Cost: $1900.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 61855.20 Owner: MGM Real Estate Associates, LLC Zoning:URB Applicant: MGM Real Estate Associates, LLC AT: BATES ST Applicant Address: Phone: Insurance: 1144 AMOSTOWN RD (413) 746-8056 O WEST SPRINGFIELDMA01089 ISSUED ON:912912006 0:00:00 TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 12 SHED 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 9/29/2006 0:00:00 $25.001073 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo