29-357 (2) • • MORTGAGE LOAN INSPEC'1'1ON
t
BOX 2000 PACE 214
FLAN 8XX 74 PACE 46
REJECT TO EiSTNENIS 7D
MEM 6 !EI=it SEE BOOK 1444
PA.T 222 i mot 2362 PAGE 373
SW-a ♦:
✓ti
I
rovv ,vx - - -- DS. Fe e+
ti
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i
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To. Merrimack Mortgage Co., Inc.
OWNER Albert E. Gagne
AND Stewart Title Guaranty A. Gape
I hereby report that the premises shown on this plan are LOCATION:
259 Acrebrook Drive
not located within a Flood Hazard Area as shown on the Northatltpton, Massachusetts
Federal Emergency Management Agency's Flood
Insraance Rate Map,
CotmmmityNo. 250167 - 0001A HOLMBERG & HOWE, INC.
Effective Date April 3, 1978 PROFESSIONAL LAID SURVEYORS & CIVIL ENGINEERS
87 UNION STREET, EASTHAMPTON MA 01027.0945
I also iopoit, to the best of my Imowledge, information ation 37 DAMON POND ROAD, CEiESTERFI& D MA 01012 - 0176
and belief that this inspection plan shows the 73 PRINCETON STREET, NORTH CHELMSFORD, MA 01863
improvement or improvements as located on the premises
described, that the improvements are entirely within lot SCALE:
lines, and that there are no encroachments upon the l et = 30'
premises described by the improvement or improvements t{ ps "°Ass
of any adjoining premises, except as noted. I further a tiP` ^ y
report that there are no easements of record affecting the of E twi DATE:
tract shown hereon, except as noted. May 26, 2009
e Ho0 ABE R G
„. 3 4308 4
� *fsisik'g'9 Q JOB NUMBER:
S S 'lanai. w_t 09 -057
THIS PLAN IS FOR IDENTIFICATION PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY.
AND IS NOT TORE USED FOR CONSTRUCTION PLANNING OR LAYOUT_
1 1
HOME OWNER EXEMPTION ACKNOWLEDGEIV. EN 1
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. 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 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
xegu1ationc The inspection n_� roc�s ires 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 occupancv
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
perrnitsin_conjunction to_the-building_permitissued, _ 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, A'' an (/ 66y►)hA understand the above.
(Home owr /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
/ .
Address of work /� ,(1
location C ? 1 C br dc)k N
Float ill A 6/06
• ' The Commonwealth of Massachusetts
'
Department of Industrial Accidents
E W i l Office of Investigations or i
_ _0 . _
600 Washington Street
a T M : =7 b Boston, MA 02111
� � . www.mass gov /dia •
- Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone. #:
Are you an employer? Check the appropriate box: 1
Y Type of pro]ect (required). ' I
1.0 I am a employer with 4. Q I am a general contractor and I
6. Q New construction
employees (full and/or part- time).* have hired the sub - contractors
2. El I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling
ship and have no employees These sub - contractors have. 8. Q Der:iol on
worlds for me in any ca aci employees and have workers'
g Y P tY 9 Q Building addition
[No workers' comp. insurance comp.. insuranrp
required.] 5. ❑ We are a corpo ration and its 10.0 Electrical repairs or additions
Q cersisave exercised h iz _ 1. ]'tomb' r airs or additions
- 3. I -am a�oraeo-�vser- dsm� -werk- -- -- -- -- ❑ � eP
right of exemption per MGL
myself. [No workers' camp. 12. ❑ 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 #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit: indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
1 Contractors that check this box must artnrhed 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
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 51 and/or one -year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 8250.00 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 d hereby_ - +' under the p and penalties of perjury that the information provided _above _ir_ t-me _andcorrect
Si•..tore i , � I'. ®O Date. L1 0
Phone #:
Official use only. Do riot White in this arrea, to be cotrtpteted by city or town offciaL
City or Town: Permit/License # _ -- ___ _
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. PIumbing Inspector__
6. Other -
Contact Person: Phone #:
.
s
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
N ot Applicable ❑
9. Registered ,l {ome- impco�iemenlw,Gortteaetor 4 ,� .,�. � � „� . ���. ,;; pp ”
Company Name Registration Number
Address Expiration Date
Telephone
_ SECTION 10- 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 ❑ No ❑
11.. s ag e . _ 1 ` � e m itti o
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
.1 . r • Massachusetts Annotated.
Tlortlamptori State d - T✓o�: " • :. ��
Homeowner Signature 7u / /
.. r a
s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ I Addition ❑ i Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bidg. cZ1 I Demolition ❑ I New Signs [D] Decks [C] Siding [0] Other [0]
Brief Description of Propgsed �/
Work: 4 8/`�' 000
Alteration of existing bedroom Yes / No Adding new bedroom Yes V1 No
Attached Narrative . Renovating unfinished basement Yes `Y No
Plans Attached Roll - Sheet
6a i New use'at dor_additirn to existiii4liousinq,-:compCe a lie folfoier c :
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. 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, , 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
/6/ f
!Ai ,i r.1. �4._,
ignature of Owner /Age v 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 . ��� d _. ._
Frontage
72 _ Al
Setbacks Front N 1
Side L. ., _ R: ,.. L ? R :_
TI a
s ,
Rear ....v
Building Height , ...._. _' """
Bldg. Square Footage 2 ° "'
Open Space Footage %
(Lot area minus bldg & paved 8 �
parking)
# of Parking Spaces - - - -—°
Fill:
(volume & Location) _.
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page: and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to oradrdifions orsigns intended for the property ? YES 0 NO
.J
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
Departmentjise only
City of Northampton S tatus
Building Department gurb:,ckftztjvew:,,,
212 Main Street a I ` 1.1a at :eW
Room 100 at • , ,
V4e4/47gitat `
Northampton, MA 01060 - MrithSa
1114.9ne 413-537-1240 Fax 413-537-1272 84,<-
090 pe•
APPLICATION TO CONSTRUCT. 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:
Atre. bci)el& D( Map Lot Unit
PIO rutr / 0 !C.' 61_
- Zone Overlay District
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
44--0413/1 60-imlocd ) il-cm bra& Or
Name Print)
Current Mailing Address:
'/13 ;•31 - /
tot.. fA, A Telephone
Signature W
2.2 Authorized Agent:
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 4 2L' (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 6
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File # BP- 2010 -0396
APPLICANT /CONTACT PERSON BOMBARD ANTHONY
ADDRESS /PHONE 259 ACREBROOK DR FLORENCE (413) 250 -7051 ()
PROPERTY LOCATION 259 ACREBROOK DR
MAP 29 PARCEL 357 001 ZONE URA(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out il/ ��
Fee Paid ( �
Typeof Construction: ERECT 8 X 8 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
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
t/ Approved 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
� 2j Zoo
ure
Signat 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.
2WACkEHROOK DR f: BP- 2010 -0396
Gls 4: COMMONWEALTH OF MASSACHUSETTS
tipillockr 9 -357 . '' 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- 2010 -0396
Proiect # JS- 2010 - 000532
Est. Cost: $350.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
C onst. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 13111.56 Owner: BOMBARD ANTHONY
Zoning: URA(100) / /WSP Applicant: BOMBARD ANTHONY
AT: 259 ACREBROOK DR
Applicant Address: Phone: Insurance:
259 ACREBROOK DR (413) 250 -7051 ()
FLORENCEMA01062 ISSUED ON:10/23/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: ERECT 8 X 8 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 10/23/2009 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
4
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. 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 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
pcv\AA4m understand the above.
(Home ownerfresident's esident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date /3/0
Address of work IJ —
location a -'- tik_
1 v►rc A 00(P).-
,
, .
,---• .. , . . ,
\ The Commonwealth of Massachusetts
Department of Industrial Accidents .
lt '&--:..- 0 ,
Office of Investigations .
600 Washington Street
(1g Boston, MA 02111 .
-
.,>..•.,..„.„-..,-.-.. . - , www.mass.gov/dia
. .....
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly
Name pusineseorgardzationandivienaD: ..
•
Address: r • •
City/State/Zip: - Phone.#:
•
Are you an employer? Check the appropriatelox: • •Type of project (required): 1'
1. 0 I am a employer with 4. El I am a general contractor and I ,.
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
lis-ted on the attached sheet. 7. 0 Remodeling
2..0 I am a sole proprietor or partner-
.8. Ej Deinolition
• ship and have no envloyees These sub-contractors have •
envloyecs and have artiricers' -
working for me m any capacity. 9. -0 Building addititin
[No wo rkers' comp. ins 0 We are a corpoiation and its
urance
10.0 Electrical repairs or additions
4 require • .- • 5.
3. 71 I am a homeowner doing all work officers have xercised their .
11.0 Plumbing repairs or additions
( right Of exemption per MGL
myself. [No workers' corap. 12.0 Roof repair' s . -
insurance requirecL] t • c. 152, §1(4), and we have no •
, employees. [No workers' 13.0 other •
.
- comp. insurance reignited] •
*Any applicant that checks box #1 must also fin out the section below showm• g theirworkers' compensation policy information.
t Homeowneri who submit this affidaVit indicating they are doing an work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whother. °root those entities have
employees. If the sub-contractors have employees', they must provide their woricers comp. policy number.
lam an employer that is providing workers' compensation insurance for my einployees. Below is the policy and job site
information. •
.
Insurance Company Name: •• • , • .
•
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 eaNration date).
Failure to secure coverage Mitt& Seetiarl'25A c 152 can lead the imposition of crimidal penalties of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in th.e form of a STOP WORK-ORDER. and a fine
of up to S250.00 a day against the violator. Be advised that a copy of thi.s statement may be forwarded to the Office of___
_ I Id hereb_ycertz:67 under the' , ' , ! d penalize' s ofperjmy that the infattnationproviderlitboveiitrize:tindiorrPrt.
S. .tare: _ 0 .4. 4.11__i.... , - . . ate- 0 1. -. 1 - ,
—
- ..
Phone 0: lt: -- ,), -.`") 6.7 I - • -
• - Official use only. Do not write in this area, to be cOnipleted by city or town official
• . .
City or Town: - Permit/License # ___ • ...
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other . • • . •
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9.120f istet'eda' iii,e litproverr a :(i atoii i=fi . i Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 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 ❑ No ❑
�t)t1 tltll61
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 buildine 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, 44 i and Ls al Zoning ws and •te • Massachusetts General Laws Annotated.
Homeowner Signature / /
.--i 1 .r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors CI
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [I J Siding [0] Other [0]
Brief Description of Proposed (� _ 6 eti . A , ‘ ra W1 �' 1�4��
Work: �( 3! 9
Alteration of existing bedroom Yes No Adding new bedroom Yes }'d No
Attached Narrative Renovating unfinished basement Yes jif No
Plans Attached Roll - Sheet
sad Cf lt e vcno lse nd o a dd o c � i f sinc �uf theta o a :
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. 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 --Pr3t=6-/M4264---- , as Owner of the subject
property
II 1
hereby authorize 10.-T ` " 0
to act on my .ehalf, • II m - rs r-lati - to work authorized by this building permit application.
�
, natu 'rof • Alli Dat-
1 JVI. b , as Owner /Authorized
Agent hereby d fare that a statements - - information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pal and penalf s of perjury.
-P C1(\
Print 1
*d
Signat W "Ow "rA: en 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 1 '3 S 7 3 7 A ( - !
s '
Frontage
Setbacks Front I
Side Li ' R:i ! L:i l R:` =. =. i.,_,,,
Rear LJ l
Building Height `"— = € .._..
Bldg. Square Footage
Open Space Footage % r----1 ,
(Lot area minus bldg & paved 1 1 _ i j t !
parking)
# of Parking Spaces -) l _ _.
Fill: i—w € € ',
(volume & Location) 1 L:
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO if) DONT KNOW 0 YES 0
IF YES, date issued:1 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO a DONT KNOW Q YES 0 .
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
3
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 4
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department 7 r W °- �� �g�
212 Main Street
/ Room 100
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aSiE
Northampton, MA 01060 4
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phone 413 -587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, 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:
/1 CIO k 1i' .Map L ot Unit
F l o VVv e M 1 C� Ifs �0 zone Overlay District
(
EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
11,111 a + /AC 444-2,. Telephone 913 ast _ .
Signature
2.2 Authorized Agent:
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 �P /� 1) (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 7//
_ This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: % l�
Building Commissoner/Inspector of Buildings Date
2.154 DR BP- 2011 -0348
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:13lock: 29 357 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP-2011-0348
Project # JS- 2011- 000535
Est. Cost: $675.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 13111.56 Owner: BOMBARD ANTHONY
Zoning: URA(100) //WSP Applicant: BOMBARD ANTHONY
AT: 259 ACREBROOK DR
Applicant Address: Phone: Insurance:
259 ACREBROOK DR (413) 250 -7051 0
FLORENCEMA01062 ISSUED ON :10/18/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK: RENOVATE BATHROOM
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 10/18/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner