38B-197 (4) 206 SOUTH ST BP-2017-1257
GIS4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 197 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:replacement windows/siding BUILDING PERMIT
Permit a BP-2017-1257
Project# JS-2017-002100
Est.Cost: $25000.00
Fee:$100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JIM BIALOWSKI 070129
Lot Size(sq.ft.): 11194.92 Owner: KAYE ERIC R&NANCY G
Zoning: URB(Ioo)/ Applicant: JIM BIALOWSKI
AT: 206 SOUTH ST
Applicant Address: Phone: Insurance:
PO BOX 161 (603)209-7220 SOLE PROPRIETOR
SPOFFORDN H03462 ISSUED ON:5/3/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:NEW SIDING AND 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:
FeeType: Date Paid: Amount:
Building 5/3/2017 0:00:00 $100.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1257
APPLICANT/CONTACT PERSON JIM BIALOWSKI
ADDRESS/PHONE PO BOX 161 SPOFFORD (603)209-7220
PROPERTY LOCATION 206 SOUTH ST
MAP 38B PARCEL 197 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ,`
Fee Paid
Building Permit Filled out `t� 4
Fee Paid
Typeof Construction: NEW SIDING AND REPLACEMENT WINDOWS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 070129
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOBMATION 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
D • 'lif.n -lay
Signa :
. i,12. I uilding Ifficial 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.
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE-0RDEMOLISH A ONE OR TWO FAMILY DWELLING
I MAY
SECTION 1 -SITE INFORMATION
1.1 Property Address: p - c mon o t�exo Fd
b �` v+
O\ DIOb .. t
µ„gtmb�ekdct .., er�ldisGlvti..t
.
SECTION 2-PROPERTY:OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
L z �O.% J w(o c")t NOr 1 Sot tN$S
Name(Pr ) / Cu Img Addressefts—bO\O _h
Ii
0,7-7 i Telephone (/y� / /' 1N ! D
Signature �mGi Yi r G `ric. 2-o G C q Q., 4 M
2.2 Authorized Agent: t 11/11 JI
i �.b • '('SOK \ L\ SC11}CDVT%. (C9-
Name
\ Current Mailing Address:
or
(o��--zn h We
Si Telephone
SECTION 3•.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only,
completed by permit applicant
,u
1. Building ( Q2e1bt„ -C vs`!l' A= (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 pp
6. Total=0 +2+3+4+5) Check Number// Q � / fy
This Section For Official Use Only
Building Permit Number: Date
Signature: 1f-✓"�-�” Si, 17
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AR 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
Side :f� R: I L: 1 R: LI I .1
Rear
Building Height I I
Bldg.Square Footage I % 1
Open Space Footage L._ tt I
(Lot arca minus bldg payed I J I _ J
parking)
#of Parking Spaces
Fill:
Jvolume&Location)
A. Has a Special Permit/Variance/Finding ever been is .ed for/on the site?
NO 0 DONT KNOW 0 YES Q
IF YES, date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book J Page and/or Document ML
B. Does the site contain a brook, body of water or wetlands? NO O liONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation ommission?
Needs to be obtained fl Obtained O , Date Iss
C. Do any signs exist on the property? YES O NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? ES O NO O
IF YES, describe size, type and location:
E. WII the construction activity disturb (clearing,grading,excavation,or filling)over 1 acre or is it part o a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement WI ows Alteration(s) ❑ Roofing n
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [Ell Decks [[] Siding[i31_ Other[
Brief Des�gption of Pro ose{I -/ 1c t) p r, ((�� t
Work: t��,W �;��li�•�\ ` \lAl-Uti.� �a��IfUit � .
Alteration of existing bedroom Yes I No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ( No
Plans Attached Roll -Sheet
a. Use of building :One Fa . Two Family Other
b. Number of rooms in each fami nit: Number of Bathrooms
C. Is there a garage attached?
d. Proposed Square footage of new constructi. Dimensions
e. Number of stories?
f. Method of heating? ..aces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck •-rgy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within '0 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 AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, � ( . ✓ /V y)- , as Owner of the subject
property I
hereby authorize �r11 ,�y� `lit�TA, y
to act on my behalf,in all matters relative to work authorized by his building permit application.
Signature of Owner Da e /
I, JnAN-.. (b ' 1
1 ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the hest of my knowledge
and belief.
Signed under the pains and pallies of r�ju�ry.
— J i {51 L LS -I _._
Print Name
6s / oI / zot7
Si not of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / o
,t11 Not cApplliicable 0 '�J1 // 17 (/.;�
Name of License HoLicense Number
ulder: `` qr n; NN.,. 1 N.yr,{O LFS ' 2 r +01 C- /`/�`
Address f \ Expiration Date
s�- '"if '. !I 717— 0 — I
s:17- Q "TTelephone �1
£mar'/: ---- 111Ar� j 7 It' 1 e, CA AA' .......
\ Mr
Not Applicable ❑
Company Name `t Registration Number
Address{sI
� +`�/ uUlr Expiration Date
U ' V , ti ‘ tok Telephone Lx 3
- -tY' 7+1by
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(Sf.
Workers Compensation Insurance affidavit must be complete 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 0 No +I
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,an 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 pot 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 an inch work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,duringand 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,von 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 _ ,_
The Commonwealth of Massachusetts
w Department of IndustrialAccidents
)E7-" (_ 't Office of Investigations
"eel_=k 7 1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information \' Please Print Legibly
Name (Business//Organiizatio ndividual c vc- �i �LC� 1
Address: `� .t)- eDUx( \ (0\
City/State/Zip: �fl�i[�i-S9* Sone#: 19 t) )(, 7i7—h
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
erp6oyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P tY t 9. ❑ Building addition
[No workers' comp. insurance comp.insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees, If the sub-contractors have employees,they must provide their workers'comp.policy number.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Company Name: 14. 1
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/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 MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify !er the a' p allies of perjury that the information provided above is true ad correct-
s DSignature: b
Date: S --Leq
Phone#: ce hU5 7zb c 1 Z2
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License IS
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL
`c\11a1�, S150.k
Address of the work: b r c*->NI111'0�1�\1,�t1 kt\-_ -
The debris will be transported by: 3 ,5, -k \\•zkab\lv, *W S %
The debris will be received by:
Building permit number:
Name of Permit Applicant (-3- ; W +
DS J D 112-D1' (
Date Signature of Permit Applicant
THE COMMONWEALTH OF MASSACHUSETTS 1BR Use Only.
OCA
OFFICE OF CONSUMER AFFAIRS AND FoForr OCTA No:
A BUSINESS REGULATION
I �� St 10 Park Plaza, Suite 5170 Effective Date:
5 Boston, MA 02116
er�, 9 Application for Reeistration as a Home Improvement Expiration Date.
, rag Contractor or Sub-Contractor Reference: WS
(MGL c. 142A;201 CMR 18.00)
Only certified checks or money orders can be accepted with applications submitted by mail.
NOTE: You may also renew onlineliinand pay withcreditcard at www.mass.gov/renewHlC
1. NAME OF APPLICANT: �� U'� "i�,\tiLl��[l_I
(Mt ST BE A LEGAL ENTITI--INDIVIDUAL,COR
QORATION,LLC,PARTNERSHIP,LLP,TRUST,ETC.)
2. APPLICANT TYPE: INDIVIDUAL(V) CORPORATION/LLC( ) PARTNERSHIP/LLP( ) TRUST( )
(MUST BE THE SAME LEGAL ENTITY IDENTIFIED IN#1--FOR ORA APPLICANTS,ALSO SEE 149)
3. NUMBER OFEMPLOYEES: U
(NOT INCLUDING APPLICANT)
4. APPLICANTSOCIALSECURITY#: FEDERAL TAX IDN: ` 7-J b') —1„--1,0liet,, A
(IF APPLICABLE;PLEASE SEEEATTACHED INSTRUCTIONS)
5. EMAIL ADDRESS(REQUIRED)):�. ��\z- •� IONE#: (j'D±rZ—bet—f2Z0
6. MAILING ADDRESS: CC . U• \OK \ lj) . D0(-)4Sits,A(� \A , lb-4 �.
STREET CITY SNi
STATE\ ZIP
7. PERMANENT ADDRESS: 7D hhV STREET 1;'.N\1,- I.%,` s CITV\,t ,11 \ jV' .E [/ 3\
ZI
(PLEASE NOTE THAT A P.O. BOX IS NOT ACCEPTABLE FOR PERMANENT ADDRESS VOL NLLST LIST A STREET ADDRESS.)
8. INDUSTRY TYPE(Select all that apply): arpentry ainting _Roofing _Other
9. IF THE APPLICANT IS A CORPORATION,LLC, PARTNERSHIP, LLP,OR TRUST, PLEASE PROVIDE THE NAME,
ADDRESS, SOCIAL SECURITY#,AND TITLE OF THE INDIVIDUAL WHO WILL BE RESPONSIBLE FOR ITS WORK
(PLEASE SEE ATTACHED INSTRUCTIONS;ADDITIONAL DOCUMENTATION REQUIRED):
ul
LAST FIRST SOCIAL SECURITY# TITLE
10. IF APPLICANT IS DOING BUSINESS UNDER A D/B/A,PLEASE PROVIDE ITS NAME.ATTACH A COPY OF THE
FICTITIOUS NAME CERTIFICATE FILED WITH THE CITY OR TOWN CLERK:
D/B/A NAME: /
11. (a)DOES THE APPLICANT OR RESPONSIBLE INDIVIDUAL D ANY OTHER CONSTRUCTION-RELATED STATE,
CITY OR TOWN LICENSES OR REGISTRATIONS? YES NO
(b) IF YES, PLEASE FILL IN INFORMATION BELOW.ATTACH ADDITIONAL SHEETS IF NECESSARY.
LICENSE TYPE IISSUED
p BY I LICENSE/{REG.# EXP. DATE LICENSEE NAME
Uv �� -w�15t)'--- I �l, Jam, � -1
5 0 �C � 1YAfA�
� � �� �11P V(Z