23A-079 (25) }
41 MAIN ST BP-2004-1096
GIS#: COMMONWEALTH OF MASSACHUSETTS
, :079 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-2004-1096
Project# JS-2004-1634
Est. Cost: $9000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: WILLIAM SYMANSKI 028505
Lot Size(sq. ft.): 7318.08 Owner: FALK SYLVIA
Zoning: GB Applicant: WILLIAM SYMANSKI
AT: 41 MAIN ST
Applicant Address: Phone: Insurance:
P 0 BOX 129 (413) 247-9939 ()
NORTH HATFIELDMA01066 ISSUED ON:5/6/04 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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: Receipt No: Date Paid: Check No: Amount:
Building 5/6/04 0:00:00 2528 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
* • Version .7 Commercial Building Permit May 15,2000
Department use only ` n
City of Northampton Status of Permit:
Building Department Curb Cut,/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Vlell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address: This section to be completed by office
/ frIbtb' ��`' �-- Map Lot Unit
P/1 _ 6,4)e 1 4 Zone Overlay District
� Elm St.District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Name P� Current Mailing Address:
/U� � 7
Signature TelephonI29°7-7 e/- c_
l
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
�. Building 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
6. Total = (1 + 2 + 3 + 4+ 5) Check Number cytl--)1 YF5e,'
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
t
Versionl.7 Commercial Building Permit May 15,2000 • v
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations Existing Wall Signs Existing Ground Signs Additions D Roofing -,k
❑ ❑ 1
Exterior Alterations Demolition❑ New Signs [ ] Change of Use [ ] Other [ ]
El Accessory Building [ ] Repairs [ ]
l
Z l
BRIEF DESCRIPTIQ /C) (,LL �L O()r-(toC� .5 ii)c- - �j / 2 d (j) �/7//Uda-G!-"S
SE 5 USE GROUP AND CONSTRUCTION TYPE /
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly I 0 A-1 0 A-2 0 A-3 ❑ 1A 0
I A-4 0 A-5 ❑ 1B 0
B Business El 2A 0
E Educational El 2B I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional 0 I-1 ❑ I-2 0 I-3 ❑ 3B ❑
M Mercantile ❑ 4 0
R Residential ❑ R-1 ❑ R-2 0 R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 0 5B ❑
U Utility 0 Specify:
M Mixed Use ❑ Specify:
S Special Use 0 Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf) 1n
2nd
1st '.. .'
2nd 3rd
3rd
4th
4th
Total Area (sf) Total Proposed New Construction (sf)
Total Height(ft)
Total Height ft
Versionl.7 Commercial Building Permit May 15,2000
7. Water Supply(M.G.L.c.40,§ 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone: Outside Flood Zone ❑ Municipal ❑ On site disposal system ❑
8. NORTHAMPTON ZONING
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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 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 Obtained , Date Issued:
C. Do any signs exist on the property? YES 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:
•
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone
92 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10- STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 - OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT.OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , 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
I, , 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
Signature of Owner/Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder :LU ! 44(04kei D. 5'`Ii'f g►Ustk/ Gj . 2$SO,j
License Number
a 3, STRAIT D.
Address / /� Expiration Date
j4g,11h4tVolif,etz., (/ �� 7/f7
Signature Telephone
SECTION 13 -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 0 No 0
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9Q."��L7- E .5ZisaRchascti.- —_
tir�1^-�__5 ; -
t `�� DEPARTMENT OP DulLDrNc INSPECTIONS •
212 Main Street Municipal Building \tir — ._.•
Northampton, Mass. 01060 r'
WORIQ.R'S COMPENSATION GNSURAIN'CE AFFIDAVIT
I, -- ---- - — --- __-
(li ccnsaJpermi tux)
with a principal place of business/residence at:
(phone)
(str=t/city/staIda p)
do hereby certify, under the pains and penalties of perjury, hat
( ) I am an employer providing the followine worker's compensation coverage for my
employees wor3ng on this job:
- ( c1Lr,nc Company) (Policy Number) --- (r:-pir::tion Date)
( ) Iam a sole proprietor, general contractor or homeowner (ride one) and have hired
the conuactors Listed below who have the following worker's compensadon policies:
(Name of CO_•'.tr c orl (ins ranc^. CoRloanyi?oUc- Numb) (txDtracon Date)
(Name of Contractor) (Insu ancc Company/Policy Number) (Exi-n non Date)
(Name of Conn-acio;) (Insurance Company/Policy Numbu) (Expirlion Date)
(Name of Contractor) (Insurance Compwy/Policy Numb:r) (Expiration Date)
(attach ad•ikiocal beet if 000`—s.try to,ochre infoc-o ion pcsu' to.1J ooacracora)
( ) I am a sole proprietor and have no one working for me.
( ) I am.a home owner performing all the work myself.
NOTE-.plea be nortrc the„t.3e bomeasven o:oo ecupioy pe-ioal to dd c•. ,,, ta+ -.:e,00 c rcpair work ov.dwthinz of
not more tJ, c rot tart,in wiry the bornoo-woer re ado or co he grou.ncla a-pp.ulco_at then..-c cue b._-'..illy oecsid='J to be
ranployc--uo the..tea rt 'pc-tt-:ion Art(GL152„sa 1(5)),eppliatZioo by•boon fv:hi or pcsmit r—y.s-tdeaoc the
Icga.J o. ou of en coployer under thn Worieer%Coceapaccution Act
I und ,tand thQ _.-
a copy of chi. - " +z na+y be Cofo sded to tbo Dopam rccox of ln8u-tri.J Aac �d �'Ofnoo of Lr�+m for th. '
c
oovcn.sc vcircaaioo and Cut CalJtac to scauc bovvrt under toction 25 A of MOL 152 can lob to the i^7,cKftion of criminal pcoa1bn
000sisag oh a fine of up to S 1_500.00.ndror comFaciaozezcat of up to one year end civil pr,,llio io the form of a Stop Wort Order and M.
rtm 0(5100,00 t day tpinsl roc
For drp.rca..%�u.e only .
Pta nit Number
Map:: — Lot
S Lic .sec/Pcrmiucc 1 to 1 J ,
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.m DEPARTMENT OF BUILDING INSPECTIONS 4 __TVE
• 212 Main Street • Municipal Building 1
Northampton, Mass. 01060 ow'''�
WORKER'S COMPENSATION INSURANCE i AVIT
I, L a��14.4% - -..J11.Td_y c&i.- —---- - ---
(Iic ns=:.lc:Crnnitc) •
with a principal place of business/residence at: .
. 13 7/1 i/S-2-D _ . TIIi_._f14/J44? 14, c.1C c t (phonc? )_Z92'_�_ ..,;
(strxt/city!,:r:ttr zip)
do hereby certify, under the pains and penalties of perjury, that:
(() I am an employer providing the followint workers compensation coverage for my
employees worldng on this job:
A,1 6, _211G3' °Ste' 3/ ery-
- (Insuranc Company) (Policy Number) -pinion Date)
( ' I am a sole propriet r , general contra or or homeowner (circle one) and have hired
the contractors listed beiow-who have the rollc'v ing worker's compensation policies:
(0 ,u,14,f4 ) -5tiplz,vi • 5i ' T+Nfc' ' _
(Name of Contractor) (insunancc Company/Policy Number) (Expiration Dat )
•
(Name of Contractor) (7ns-urance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance CornpanyiPolicr Number) (Exr ration Dat )
•
(Name of Contractor) (Insurance Comer:yfPoticy Number) (Expiration Date)
(attach.6:lit c,,J c.':eet ifna c..-,-co i:.c}�.5c i.::.:•r:•:.:io:pc:c:air:;,..:all cx:'or::r.•)
( ) I am a sole proprietor and have no one working, for me.
( ) I am a home owner performing all the work nivs"l., f.
NOTE:plcaac be aware that•A'aile 1KSr owucrs t1')O C^.piay;r7n::.s to c'. S "." ,r
��.�-�sat as:_r�c:m Cra r: v :i:c:..d cl!i::,cf
not more than throo units in t:i icli the hoer»:tin re oc-on',Se p':.unela appartee ni th-,to are not calerally ocr.:ifierrd:o be
employe-3 under the tvori•tea coca c_:zticn 1..a(OL152.s t(5)),application by a homeowner for a Beau cc prrtni:r.r.y e...'er:.c the
legal status of an omp loycc under the Woriccla Compensation Act.
I
I understand that a copy of this ctatrn:cm may be for-worded to the Deportment of Industrial Accidents Ofrico of blew-nom for the
coverage vrti6catioo and that failure to recast coveTago undrra.section 25A of 1.M0L 152 can lad to the imposition of cr;:niarti pcnaii:a
consisting of a tine of up to S 1.500.00 at:Jcrr in rin.xzrr.1 of up to ere:}tar r.:.j civil paultics in the form of a Ste;,Wert Ord. and a
rim of S100.00 a day again:l in:.
For departs:Ines!lies only
tt.)41,14-0.:_..4_'‘4',pe.4
Perrnii Number
Sir-naturr - _.— - -
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(I rtj of Naztf � ttptort • 1_ _* /
S i�rVIyr $ fflassachusctts =�.41"=- DEPARTMENT OF BUILDING INSPECTIONS -,77=-=-BS
= /=
INSPECTOR 212 Main Street • Municipal Building = ,,,`�
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc: ,'isor. 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 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
• •
bpaewAx
City of Northampton S atusoPermt ��
Building Department C b1C e:40 vewa F' p _ v x ;�°
212 Main Street SewerlSOp is A al lab' ;r{
Room 100 Wa e 7Well,„Avaijab
Northampton, MA 01060 ;Two Sets of t c'itral" arts•
y%r "•p �, > t
phone 413-587-1240 Fax 413-587.1272 Plot/Si`tePlan *4
Other4Specifyx
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
"Ink section to be completed by office
1.1 Property Address:
%T4-2.7— Map .>::.rq.: Lot — - Unit_
44e---11)07
Zone� ----------__._.__Overlay District
ElmSt_District ae ___ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
l (wAt �►i Ka ,o 5 ieYT lCozEwc,t,
Name(P al) Current Mailing Address:
/d :*e/� �J Telephone
•gna
2. •uth erized A:ent:
.,LL t 14-,a.. t� JAI wl,�iu S� �i & o- (27 iUcs.-11/fl4,%�tZ� t14 0 !a L 4,
Name(Print) ;' Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only,
completed by permit applicant
1. Building (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
6. Total =(1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings 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 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 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
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:
SECTION 5,DESCRIPZJON OF PROPOSEI]WORK(check all aaphcable)
New House ❑ Addition 0 Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll D• Sheet 0
MI WThtiu'se a:nd o "Va it 6trito e d Ling Wi inpternpit :e.thelfo fading:
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. 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 regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECT.4.0 7-4 0} ER AI T ORIZATION TO BE COMPLETED WHEN
OWNERS AGENT CONTRACTOR APPLIES,FOR BUILDING PERMIT,
1 , as Owner of the subject property
hereby authorize 4 � �1 te'i 11 r�• to ac; on
my •ehalf, in all a'tters relative to work authorized by this building permit application.
Signa e 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.
Sig ed under the pains and penalties of perjury.
Print Na e
N. /0` q-- 03
Signa re o er ent Date
•
SECTIONS-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : l_ 5 4.a ,S (
License Number
13) 57i21u r wc'en{ H _t ,_ �����
Address ` Expiration Date
(2.3 -z 4-7
Signature Telephone
nateg s e:e 4rr ntrat IPM Not Applicable 0
JJtit r v►�. . 5 /2_ 'Z[
Company Name Registration Number
Address Expiration Date
�u L L TI 44-1,-/eiLo Telephone 2:9 7-l� '7
.SEGTION`10WORKERS' 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 0
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)fami:ies
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