35-271 (5) 165 WEST FARMS RD BP-2017-0179
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -271 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit tt BP-2017-0179
Proiect n JS-2017-000290
Est.Cost: $12924.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RENEWAL BY ANDERSEN 090125
Lot Size(sq. h.): 165092.40 Owner: OMASTA JOHN P&FAYE A
Zoning: Applicant: RENEWAL BY ANDERSEN
AT: 165 WEST FARMS RD
Applicant Address: Phone: Insurance:
30 FORBES RD (508) 919-0900 WC
NORTHBOROMA01532 ISSUED ON:8/9/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 12 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 8/9/20160:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
RECEIVED y of Northampton Status of Permit
B ilding Department Curb Cut/Driveway Permit
AUG 9 2016 212 Main Street Sewer/Septic Availadlity
Room 100 Water/Well Availability
No hampton, MA 01060 Two Sets of Structural Plans
DET CIF eulLPvc ISP` -
Na-m;..- rr7�&LjffiP1113 •87-1240 Fax 413-587-1272 Plot/Site Plans
Other Spedfy
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:
165 W. FARMS ROAD Map Lot Unit
FLORENCE, MA 01602 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
FAYE OMASTA 165 W. FARMS ROAD FLORENCE, MA 01602
Name(Print) Current Mailing Address.
978-852-4186
Telephone
Signature
2.2 Authorized Agent:
JAIME MOR 30 FORBES ROAD NORTHBORO,MA 01532
Name(Print) Current Mailing Address:
_ 508-351-2214
Signature Telephone
SECTIO. 3- TIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 12,924.00 (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) 12,924.00 Check Number veia6R0 els
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings 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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage .o
(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 Q DONT KNOW er YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regis ry of Deeds?
NO Q DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW e5 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO V
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NOel
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,ex ation,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.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing in
Or Doors I
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C Siding[D] Other[0]
Brief Description of Proposed
Work: REPLACE 12 WINDOWS - NO STRUCTURAL CHANGE
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes __No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing 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?
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
FAME OMASTA ,as Owner of the subject
property
hereby authorize JAIME MORIN
to act on my behalf, in all matters relative to work authorized by this building permit application.
SEE CONTRACT
Signature of Owner Date
JAIME MORIN
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.
JAIME 'O N
Print Name `X' 'yl I I
Signature of O, Date V 0 l la
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisof: Not Applicable 0
Name of License Holder: JAIME MORIN 90125
License Number
86 GARP 1%ER STREET LYNN, MA 01905 10-06-16
Address air Expiration Date
508-351-2214
Signa . : Telephone
9.Registered Home Improvement Contractor. Not Applicable 0
RENEWAL BY ANDERSEN 170810
Company Nam: Registration Number
30 FO:: -SAD NORTHBORO,MA 01532 12-23-17
Addres Expiration Date
Telephone 5 0 8-351-2214
CTION 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 b No 0
11. - Home Owner Exem t tion
The current exemptio br"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homco .er to engage an individual for hire who does not possess a license,provided that the owner acts
as su'ervisor.CMR 780 th Edition Section 108.3.5.1.
Definition of Homeowner:Pc . (s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to he,a one or two < ily dwelling,attached or detached structures accessory to such use and/or farm
structures.A Jerson who constructs mi than one hoi e in a two-'ear ,eriod sh+II not be considered a homeowner.
Such"homeowner"shall submit to the Buil(`t Official,on a form acceptable to the Building Official that he/she shall be
res I onsible for all such wor I erformed unde he bu'Min• •ermit.
As acting Construction Supervisor your presence o e 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 ..mpensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusett. . -neral Laws Annotated,you maybe liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeowner"certifies and assumes responsibility for comp_,ice with the State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachuset _ eneral Laws Annotated.
Homeowner Signature
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YOU.THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME NOT LATER THAN MIDNIGHT
OF 0'12112016 OR THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION.
WTHCIIEVER DATE IS LATER. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN
EXPLANATION OF THIS RIGHT.
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