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I0.:___—� � �.•t,• ,y.yy, AS oa£ Eli V AMR 0,41 _ -- i 1�ff •-F.�o� �°��raajy W M�..It•;I s. 17 !I r�• {I k f7Ctf EN � �PbROaM ///{� OOYUGK- -air - 1 7 Ole i o d 3fi It I I e m q a J" �li� --_ � — _�— -=•,.ate _�— =—._—�_ _' - - - F%ISTP4r 8sM ' . nur fto+c 6 YC-IQ"' CbSTINb SLAh f75rf1R1� Lwwf: Rven ? %2d �aoAoon OPfN f . FOYER • 1 • i MORTGAGE LOAN INSPECTION r \ LOCKS HEFEAE7►LE BOOK 7391 PAGE 320 PLAN BOOK 74 PAGE 66 SLB.ECT TO AN EASSW TO AEIV BWLAKI TEL. r TEL. CO. w \ SEE BOOK 1562 PAGE 373. ek JIL M ,T CZ'3 a r b f �7 c a 1 SEED � F�-c 101f/—0Ff LEGEAD K0 g�OCKADE [i CONCRETE BOUNO FOUND 9.70,+1— GtAV BA!?9E;. FOUNNO ,l s.l l tO IF?- -,� .. ....€', I Li 0 N � SaM,U�a9 �i 71.SVt,✓ I \ I A I \v/ 1 I �r LillFs I - - 4/ / 4-1 v 1 - New Cell-•�6v �r6-��L3� /14 ko I II � - r ' II IT( E-N I I aFO�ooN, '; II / 11 BA-rH I s �y II rn I I ro WE5,�EI ii F'ZPST FLaL g'ou� � E'�l5'rS�v�13L-llh C75FfCPoR- Limn, Room ' Y2 oojq Be o Roori �6 00601 FOYE R 5C4LE—��a MORTGAGE LOAN INSPECTION \ LOCUS REFERENCE BOOK 7391 PAGE 320 PLAN BOOK 74 PAGE 66 * S"CT TO AN EASEMENT TO AEM EWAAV TEL. 6 TEL. CO. x \ SEE BOAC 1562 PAGE 373. M r,. 1 B S E Syr STORY w/F \ m can a �o + O m c� m m SHED LEGEND S MOOD roCK ADE FENCE 10•f/- OFF �. CONCRETE BOUND FOUND 09.70'+/- GUN BAnncL Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the.foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 1521 §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s), address(es)and phone number(s) along with their certificate(s)of insurance, Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/licease number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress.Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-20 10 Fax# 617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts Department of IndustrialAccidents ( Office of Investigations . I Congress Street,Suite 100 f Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print L,eQibly r Name (Businn''ess/Organization/Individual): Se / �t r'%, l r � Address: , City/State/Zip: CT _r Phone #: �}` 7/62137 Are you an employer? Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1.❑ I am a employer with 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.� I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance., 9. Building addition required.] 5. 7 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 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 12.7 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 131-1 Other comp.insurance required.] *Any applicant that checks box C 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. $Contractors 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. lam 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$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 under tl;e pains and penalties of erjury that the information provided above is true and correct. Si-o-nature: •° ' '' _ - Date. . ' of . 1 /] __7 Phone LOther only. Do not write in this area, to be completed by city or town official Town: Permit/License# hority(circle one): Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: City of Northampton y Y .fir Ke Massachusetts DEPARTMENT OF BUILDING INSPECTIONS *, 67 $, 212 Main Street • Municipal Building Northampton, MA 01060 ss s�� li INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 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, C(IA r- �C�� understand the above. (Home o er/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date-1�/Zo`5 Address of work location_2 !/Vt-C.ASc-.1 TW SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Re istration Number 2t?� G�-e��- l�-S �.,� - -;� r-- / Address Expiration Date ur 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. - Home Owner Exemption 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 buildin!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 an Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition F3q Replacement Windows Alteration(s) ❑ Roofing IK Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs,[❑] Decks [Q Siding [yam.] Other[❑] Brief Descri tion of Pro_posed Work: l I �u\\ Alteration of existing bedroom Yes Y_No Adding new bedroom_ Yes No , Attached Narrative Renovating unfinished basement Yes No Plans AttaQhed Roll -Sheet sa. 1 New house and or addition to existinci housing complete the following 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?—A d. Proposed Square footage of new construction. �(�V Dimensions � e. Number of stories? ,,/, - f. Method of heating? .NQ�✓Q 'n �G2S Fireplaces or Wood stoves/0 Number of each g. Energy Conservation Compliance Masscheck Energy Compliance form attached? h. Type of construction 5'1� _ — 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 / T A k. Will building conform to the Building and Zoning regulations? Yes No. yeL.s v 7 �ts(sip /� I. Septic Tank City Sewer X Private well City water Supply> v SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT �A\c 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. Signatqev55&<ner Date I `,&r �1'C" , as Owner/Authorized Agent herebydeUar&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. Gvlr�( C-10 Print Name Signatu f ner/Agent 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 t . Building Department Lot Size � .� 7 /"/ Frontage �313'Iq 410 _Cl�o,� C Setbacks Front -100 Side L:23 R: % L: R: Rear /oi# Building Height 3.('+ Bldg. Square Footage Itto % /fM Open Space Footage (Lot area minus bldg&paved If,' parking) 2 #of Parking Spaces J Fill: ,/ (volume&Location) ��/ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES IF YES, date issued: 31 M170o IF YES: Was the permit recorded at the Registry of Deeds? �j V'3 v,0� c�o NO DONT KNOW YES 1 �1eAY\�, y"i bbc� IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q 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 NO 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 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 Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. , Department use only City of Northampton Status of Permit: 1:j Building Department Curb Cut/Driveway Permit 17 AW 192015 212 Main Street Sewer/Septic Availabitit Room 100 Water/Well Availability Ek ctric, Plurnoing&Gas Inspections Northampton, MA 01060 Two Sets of Structural Plans Northampton, MA 01060 1 1 pnone 13-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify_ 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 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record.: Name(PFA) Current Mailing Address: Telephone 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 10-71'6 7 (a) Building Permit Fee 2. Electrical (b)Estimated Total Cost of 3. Plumbing 000 00 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection This Section For Official Use Only Date Building Permit Number: Issued: Building Comm issioner/I nspector of Buildings Date File#BP-2016-0200 APPLICANT/CONTACT PERSON HICKS GARY J&SHANNON HALABOV ADDRESS/PHONE 27 PENCASAL DR FLORENCE01062(413)341-3529 Q PROPERTY LOCATION 27 PENCASAL DR MAP 29 PARCEL 295 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT -- Fee Paid Building Permit Filled out Fee Paid Typeof Construction• CONSTRUCT 2ND FLR ADDITION Q BEDROOMS&FULL BATH)&REMODEL KITCHEN) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 182761 3 sets of Plans/Plot Plan THE FOLLO G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF R ION PRESENTED: roved 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 Vt- ONING BOA PERMIT REQUIRED UNDER: § - '� Finding + cial Permit Variance* Received&Recorded at Registry of Dee oof 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 Demo ' � n la Signa re u' g ficia 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. 27 PENCASAL DR BP-2016-0200 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-295 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: ADDITION BUILDING PERMIT Permit# BP-2016-0200 Project# JS-2016-000345 Est. Cost: $130000.00 Fee: $780.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MATT MCBRIEN 182761 Lot Size(sq. ft.): 15899.40 Owner: HICKS GARY J&SHANNON HALABOV Zonine: Applicant: HICKS GARY J & SHANNON HALABOV AT. 27 PENCASAL DR Applicant Address: T Phone: Insurance: 27 PENCASAL DR (413) 341-3529 O FLORENCEMA01062 ISSUED ON.812112015 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2ND FLR ADDITION (3 BEDROOMS & FULL BATH) & REMODEL KITCHEN) 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 Si nature: Feel e: Date Paid: jj�tjl �)� Building $780.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner