25C-075 (2) V
S
NIA. GIC60
allows tae homeow::er the zL, -, Wider 78OCNER 104.3.4 to
I L r-(S)
a(:L-az Es,zer corst-ruCO'Lon The Is- t C-IaEzes ".H-Tomecwmef" a-�, "Pefso
-a par c--I on which.I e!slae resides or h-atec(L.to be, a v.-ze qr two fm mil
w
Is -ts to such Use andlo am T es
d�,we-E--s-, ate..: cr.dezached- szru.cz.�z= acc scrf J r st U=11-
Constructs Mo tLan, one home in a t-xc-yec,-r period. sLall not �e cons-i-dered a
person-wh.0 re
Ihom
TEe fGF the CII,�i of Nor:h=--ptOn wa=s Z---Y per-S-cra(s)W-Lo seek to
=c 4,,e ex=ptior, to a= as tLeir cl;;�; S—UPCI-Vis-MI, —
tLal by doL.-, so you beco=e re-sporsible for compIL-mce with etafe bading codes
am-d rega L.-fo ns' tL�-t the bi,;TdL-!-:derartment be ca2le-,--r
proce-s-s-re--i'mres
to L-spec wcr-� at-y-ar,cus sta-ges, ,Lich izcli-,d--found-itiom/footings (before badcffll).
S-c-notube holes rbefore uour). a roug-h building'aisnecfion-(be-fore work-is
4�.'44z irszectiaa (if re-guLred)
r-e-,m requires thes*,e i=ppecdons before the-wors' is canceafe,,I failure to
secure these insuections can result fn failure to obt� a ce--d5=te of Occunancv
ET-Im e h.=ec es.czLer.Lrad es to p errorm-worIx(er 7, plu-mb in`&gas) the
Ered d- e r'm ir
er-wE..,z be r_--o c a, sure t�, e tra: s e proper
,ble to r-,=-
r-erz=-Ts La ccr-j,==-or. to tLe builldi=- per=i'-iss-u-d, and that they get their required
e
inspections-Fa�?ure C,-CZLe ir e pe,-=j7 Tons as
—drrtcu�' teal to sec--Ye rL s and insp.ec;�
f-,-, D TLAY tLe projit-I um-L-1 such ti, -e as tLe proper p ef=LL, and iT'S-Pe=;Of,-S are
sale
T, 7,rdler-,tand the above.
(HQ.mw�owme.-/resid,ent2s sigmature rNuesting emem-ption)
to ScLedule aljlre--L:iied buildizz for the builldizgper—zat-
issued to me.
Offi-ce of In vestigtltiDnS
_
600 Washington Street
Boston, MA 02111
WIVW.mass.goL/dirt
Workers, Compensation Insurance Affidavit: Builders/t✓ontractors/E lee tricians/P1umbers
Arol cant Information Please Print Legibly
c
Name (Bus/-ness/Organizati on/In dividual): A-
n 4,4
Zuni ASS.
t
City,/State/Zip- o Prone ( 3 c
Are you an employer? heck the appropriate box: Type of project(required):
.❑ I am a em lox er'with 4. ❑ I am a General contractor and I
p y have lured the sub-contractors 6. ❑ New construction
employees (fufl and/or part-time).T
2. II am 7. Remodeling a sole proprietor or partner- listed on the attached sheet. ❑
These sub-contractors have g. ` 1 Demolition
ship and have no employees Imo.
wonking for me in anv capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp_ insurance.$
required.] 5. ❑ We are a corporation and its 10-❑ Electrical repairs or additions
J.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
Myself [No workers' comp. right of exemption per T fGL 12.7 Road repairs
insurance required.] i C. 152, §1(4), and we have no 1 Other ✓
employees. [No workers'
comp. insurance required.] V � "
'Any applicant that checks box T1 must also fill out the section below showing their workers'compensation policy information.
Ho meowners who submit this affidavit indicating they are doing all wore and then hire outside contractors must submit a new affidavit indicating such.
Contractors ti ai check dais box must attached an additional sheet showing the name of the sub-contractor and state whether or not those entities have
emptoyees. If the sub-contractors have employees,they must provide their worl{ers'comp.policy number.
I am an employer that is providing worriers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy=or Self-ins. Lic. #: _Expiration Date:
Jon Site Address: Citv/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of ti1GL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day azairst the violator. Be advised that a copy of this statement may be fonvarded to the Office of
Investigations of the DI_,for insurance coverage verification.
1 do hereby cerri) -under rlr the information provided above is true and correct
S i an a Dater Ll
Phone c,{( 3 qLi
_JfrzciaLzsse_�u1 . L2r��r,r rvYiiezlhis_ttr_ert to br com�eied bv.cuy or town o -ciaL
s- — - --
_ t
City rr Town: Pernit/Liceuse fi
Issuing Authority (circle one): _
_. i'ard Bu dln'_ D£ artu cnt Cit T vu Cllr ri�ctr:cal IaSpe t r DiL^ i 2 j�J e' ivr
j 6. Gt' er y I
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Superiisor: Not Applicable ❑
Name of License Holder: -&'IAE�4 � "D f` 1�.,Q
S `f
License Number
�f of -� �. a
Add
s Expiration ate
Sign Telephone
S.Registered Home Improvement Gontractor:.', , „„,,, w, „ Not Applicable ❑
Company Name Registration Number
&
Ad ress Expiration Date
`C bU &cial_ 9J. L,44) 06L_ 6ttN-�b Telephone (06� loc? I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M'.G.L.c'.152,§.25C(6 j)
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...... ❑
�t c
.14 ,
_01 E ner
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.CNIR 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-vear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Offcial,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 F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[01 Other D<
Brief Description of Proposed
Work: 2 6114 C VC��f'P eC,c__Q C'
Alteration of existing bedroom Yes X,_ No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. if New house and Or addition,td exiSttng"fiouSing..COmplete tiie 6R64inq
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 1CO 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 7aOWNER AUTHORIZATION—TO.BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize yt LN4 �ClJ2
to act alf, in all matters relative to work authorized by this building permit application.
Signature of ne Date
as Owner uthorized
ge t hereby declare hat the statements and information on the foregoing application are true and accurate, to the best o my now edge
elief.
Signed under the pains and penaities of perjury.
Print Name
Signature Cwner/Agent Date
a
Z
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
LotSize _.......,.. ._.. . __..... ___.._._ .,.
Frontage
Setbacks Front
Side L:_. ._.,...m R. , .,_ L ._.,_..__.. R. ...::_
Rear
Building Height _...__...
Bldg. Square Footage _. _,. %
Open Space Footage ° •-------
(Lot area minus bldg&paved --
parking)
#of Parking Spaces
Fill: w. a
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book , Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW () YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued
C. Do 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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO tj�}
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use dnly
City of Northampton Status:ofPerrrit
{�
c
Building Department Curti Guti'Dweway Pemtrt
212 Main Street Sewiidsepf€ Ava€lability
Room 100 Water/ttVeft Auaiiabitify
T APR 2 Northampton, MA 01060 Two sets oP StFUCturat Plans
` p"hione 411-3-587-1240 Fax 413-587-1272 Ptof/Site Plans'
t-40PLICATJON�ICC ON CT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address: �P t Uf � �r
l Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
t 'Ic bar- ct D ?)r-, o S N om ,, -!
Nam Current Mailing Address:
(-fl � a >-) -�2<)iN
Telephone
Signature
2.2 Authorized Agent:
- �-�T o.; �( a� t �, -► ���„ . 6 its g o
Name(Print) Current Mailing Address:
Sign a 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
l .0
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) p 0 Check Number l
This Section For Official'Use.Onl
Date
Building Permit Number Issued:
Signature:
Building..Commissioner/IospectorofBuildings Date
File#BP-2008-0848
APPLICANT/CONTACT PERSON HENRY J SOUZA
ADDRESS/PHONE 24 OLD FERRY RD HOLYOKE (413)949-3431
PROPERTY LOCATION 290 BRIDGE ST
MAP 25C PARCEL 075 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
vp-
Fee Paid
Typeof Construction: REPLACE 2ND FLOOR PORCH SUPPORTS
New Construction
Non Structural interior renovations
Addition to Existing
_ Accessory Structure_
Building Plans Included:
Owner/Statement or License 087984
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO,4MATION 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 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 Commission Permit DPW Storm Water Management
Demolition Delay
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.
B P-2008-0848
G1S#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
]lerlillt: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate gory: BUILDING PERMIT
Permit# BP-2008-0848
Project# JS-2008-001295
Est. Cost: $1500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin HENRY J SOUZA 087984
Lot Size(sq. ft.): 8319.96 Owner: DEBURI MARIA
Zoning: URB Applicant: HENRY J SOUZA
AT.• 290 BRIDGE ST
Applicant Address: Phone: Insurance:
24 OLD FERRY RD (413) 949-3431
HOLYOKEMA01040 ISSUED ON:41212008 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 2ND FLOOR PORCH SUPPORTS
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 4/2/2008 0:00:00 $50.001224
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo