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35-185 (3) t' v ` >/ri oop U c?ciNc 5P1 T SiilNt;t,F,y i v !, icA F 7YF',, - - .\ i ) LIN hi 1'10F5ot -< Po5 . p, Y k y ` K DEC* 't o 6 d 30 i{-11 f B ig 1 4 .“25d 141 S 91-611 7 Sitij - L - 0 I 0 p cp/ 6 1/64VCFM°:9-6 7) D_I purvey =or disclose. - - -- I PLAN FOR MORTGAGE PURPOSES ONLY 0 Tt4,42. L. 104■•z..) ci r /"�"le. i G, AL rir.o S ", - ..._.a. * ( l i ' L -1'4 ,i :, 1 I- : =0 i i / 1 *-, (,.IM 1T' €F t • 1 ; / „./...... . ..... .... . .411.010a...v.,..0. �'` - r 't: r. C Tt•1 L 4w0 O P 32. # G • 644.4z, lz, s j i ror Q o To RNrrs 1 pi r frolko - 4 • r : -' c.:Li .G., property Relarence:idtee ileE County To the Bank United of Texas, p`SB Deed Bk. 153 IPlan. Bk._ P3• and the COeunOnwealth Land Title Inst. To the best of my knowledge, iuforatat CITYPEOWN:.. /r Cr .0"Y .1 and belief, 1 hereby report that I ha .~""""- — examined the premises and that this , . Owner :_ /'4tQ „ c 2': inspection plat shows the buildings a Address: ,, : ',,-,001P the on the premises described, th the buildings are entirely within lot • alt• Alit S. S" lines, and that there are no encroach upon the promises described by builds • Dare t yrie-,/ 5 Scale: /1 „co: --- of any adjoining premises, except as indicated. 1 further report that to t D 1 bssc of my knowledge there are mo vis • . BEAN, easements of record affecting the crs INC. ITV shown hereon, except as noted. 1 furl LANDCONSMTANTS certify that is roperty is not 4 .... located in es abli ood haze Forty :01.1i. - cjiz......_.........1. scs.d stets %mod. mi.... ova area- RA 9114) -- c‘a ravr‘ I I N. i 1 N 's\ i 1 N 1 \ 1 \,..,. 1 I / i ' \ \-, 1 N. 1 / / / 1 ..,,, N / / / ,, _ --- ------ _-- _ - - - - - - - - - _,- - _- -- ____---- 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, 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 occuoancv 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 emits 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 understand the above. (Home owner /resident's signature requesting emption) I will call to schedule all required building inspections necessary for the building permit issued tome. Date C /6 //* Address of work location , 5' (7 f7 r + r • • • t The Commonwealth ofMassachusetts _,■• Department of Industrial Accidents Pk = .77Vi� � y Office oflnvestigations • _ 600 Washington Street it mg r° a Boston, M4 02111 . . • . www.mass gov/dia -Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/Piumb.ers Applicant Information - Please Print Legib1v Name ( Business /Organiintion/1ndividual) : I RA 4S-L Ce C 1 IL d J . • • Address: 3 Y p' 4✓ e 0/7- -I -cam. City /State/Zip: l701..,w4: f' 9- Pi 04 Phone .#: y" /3 '`.S7( * 0 `( Are you an employer? Check the appropriate box. - . Type of project (required) : / 1.0 I am a employer with 4.. 0 I am a general contractor and I employees (fall and/or part-time). # have hired the sub- contractors 6. ❑New construction listed on -the attached sheet. 7. D. Remodeling 2.0 I aai a sole proprietor or partner- . ship and have no employees These sub - contractors have. .8. 0 DeinOlition ' . - - working - eimces_ lo -andliave workers' • ;king for me m any capacity. incnra„, #:_ .. 9 �us'l mr, a dttcon 1/40-we � con ipsttranee - . r j 5. 0 We are a corpolation and its 10.0 Electrical repairs or additions • 3. am a homeowner doing all work officers have xerc�sed. their • . 11.0 Plumbing repairs or additions myself o workers' co - right of exemption per MGL Ys comp. 12.0 Roof repairs - insurance required.] t ' c: 152, §1(4) and we have no • :. emzployees: [No workers'. 13.10 Other �t9 v e.4.4 C • • • . comp. mmH c req�:�). 8- ` ea - , F I Y 3 4 . r , (r - `Any applicant -that checks box #1: must fill out the section below .showing tlxsworlo:rs'..compensation policy information_ t Homeowners svho submit this amdavit:indicating they are doing all 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 whe ie notthose-eatities have - employees. If the sub - contractors have must provide their workers' li y nrmrber. employees, they' . provr coarP-Po cY _ - I am an employer that is p 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: C' /Sta . ' fel7�p: • Attach a copy of the workers' compensation policy declaration page'(showing the policy number and expiration date). Failure to secure coverage.as regiured rider. Sectton'25A of1GMGL 2' - c: 15 can d lea to the imposition ofcn aI penalties of a tine up to 51,500.00 and/or one -year imprsonment 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 , ] esttgations ofthe DIA for' msu coveiaire'verification. - , :_ _ ..: rt herebyCertify -under the airs grid a aalties o f p -- _ p p fpet�+thafthe irr orna#nn r artru iaadeoll`eCf ' ._ � ...- Signatare: y -- / . ® ate • 6' - < O--- '- 7. _ : , Phone #: • �3 p , .. y : .- . -. . • . 1773 .- Official use only. Do not write in this. area, to be completed by city or to wn"offrciaL City or Town: Permit/Lfcense.# 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 #: • • • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supery iisor: 1/ (,, / Not Applicable 0 • Name of License Holder : Jt I � � fl Al A' 1CA, r\ LQ ' 0 a 0 / 7 1 p License N mber .41 A, L v"�" .._, � ... A • , 0) X 1 31, 1 ao) Address Expiration Date L /l3 - a50 -3007 Signature Telephone li. ,,r•. , i t,, - . : N A 9,Realstere�l dome rrifrroiremen: an�ac#or �,����. ��.0 ;�'' x.� ,��: ��,...�� .. Applicable ❑ 1 L II 9(4 Company Name Registratio Number N f l 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. --fi t ` a ` elm n 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 D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Nj Siding [D[ Other [0] W oi o e r f k Description of Proposed kus �� � `i G 1� y *?4 /'7" Alteration of existing bedroom Yes No Adding new bedroom Yes y No Attached Narrative Renovating unfinished basement Y s No Plans Attached Roll 1(55;;;) 4. 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 l , 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 , 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 - ►w, �/ �� 9 Signa re of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 1 Existing Proposed Required by Zoning i This column to be filled in by, erik d Building Department , Lot Size i / f Frontage Setbacks Front i I ; I i i Side L: I R:' L:i . R: 1 i i 1 1 I Rear =1 71 , Building Height /5 = I l Bldg. Square Footage = I 1 % —n I l ( i Open Space Footage % (Lot area minus bldg & paved L . ,I 1 1 .J. E parking) # of Parking Spaces a ; Fill: 1 (volume & Location) A. Has Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES Q IF YES, date issued:1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 I - IF YES: enter Book I Pages 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW Q 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 Or. IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO '10 IF YES, describe size, type and location: ( 1 E. Will the construction activity disturb (clearing, gradin• excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO l'► IF YES, then a Northampton Storm Water Management Permit from the DPW is required. i. W , ..._ te a, • t ' ' . - RECEIVED City of Northampton Building Department � �r t J 201 f 212 Main Street �� = Room 100 ; x., ` Northampton, MA 01060 °En OF BUILDING INS � ,MA 01060 hone 413 - 587 -1240 Fax 413 - 587 -1272 9 f e if APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION 1.1 Property Address: This section to be completed by! office 3y � INE ∎/ArLl -f y ROC�.c� Map" Lot Unit Pl ren(.e 1 Ma 0icxo Z one , Overlay District Elm St District " CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Ro1Jq LD L • CO I LD5 3+4 C-larene_e tskAo 0 1Otoa•3600 Name (Print) Current Mailing Address: 441 3 - 513eo 4048 Telephone Signature (Print) 1 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 Ltd do (a) Building Permit Fee 2. Electrical NiOy (b) Estimated Total Cost of Construction from (6) 3. Plumbing /I)/ Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection r U 6. Total =(1 +2 +3 +4 +5) 000 -- 51't' '' Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -1036 APPLICANT /CONTACT PERSON CHILDS RONALD L & CYNTHIA M CHILDS ADDRESS/PHONE 34 PINE VALLEY RD FLORENCE (413) 586 -2048 0 PROPERTY LOCATION 34 PINE VALLEY RD MAP 35 PARCEL 185 001 ZONE SR(100)//WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 7f 9n' Fee Paid /�1/� * Typeof Construction: CONSTRUCT COVERED PORCH (8 1/2 X 30) 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: 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 tis-r,•-•- i If II 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. 34 PINE VALLEY RD BP- 2011 -1036 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 185 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit # BP- 2011 -1036 Project # JS- 2011- 001675 Est. Cost: $5000.00 Fee: $51.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Gram: Homeowner as Contractor Lot Size(sq. ft): 134600.40 Owner: CHILDS RONALD L & CYNTHIA M CHILDS Zoning: SR(100) //WSP II Applicant: CHILDS RONALD L & CYNTHIA M CHILDS AT: 34 PINE VALLEY RD Applicant Address: Phone: Insurance: 34 PINE VALLEY RD (413) 586 -2048 0 FLORENCEMA01062 ISSUED ON: 6/17/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT COVERED PORCH (8 1/2 X 30) POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: f Footings: (k .?` 74 f 4. �' Rough: Rough: House # Foundation: Driveway Final: Final: Final: / 4 1 Rough Frame IC/ ft Gas: Fire Department Fireplace /Chimney: Rough: Oil: Ifisulat o . Final: Smoke: Final: q., 1/ THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. I:WA" AfiCto ‘2,42 Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 6/17/2011 0:00:00 $51.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner