35-283 (5) 12 SYLVAN LN BP-2018-1098
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-283 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Above ground pool BUILDING PERMIT
Permit# BP-2018-1098
Project# JS-2018-001975
Est.Cost: $12000.00
Fee: 540.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use croup: Homeowner as Contractor_
Lot Size(sa.ft.): 40162.32 Owner. ROBINSON MICHAEL
Zoning: Applicant. ROBINSON MICHAEL
AT. 12 SYLVAN LN
ApplicantAddress: Phone: Insurance:
12 SYLVAN ST (413) 575-9058 0
FLORENCEMA01062 ISSUED ON:4/26/2018 0:00.00
TO PERFORM THE FOLLOWING WORK:ABOVE GROUND POOL
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 Occuoancv signature:
FeeType: Date Paid: Amount:
Building 4/26/2018 0:00:00 540.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2018-1098
APPLICANT/CONTACT PERSON ROBINSON MICHAEL
ADDRESS/PHONE 12 SYLVAN ST FLORENCE (413)575-9058 Q
PROPERTY LOCATION 12 SYLVAN LN
MAP 35 PARCEL 283 001 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
TYneof Construction. ABOVE GROUND POOL
New Commotion
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
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.
_ City of Northampton Staves of Permit Department use ofdy
Building Department Curb CuuDdvewayn Permit
212 Main Street SexerlSep6c Availabifiry
Room 100 Water/Well AvalabiMy
Northampton, MA 01060 Two Sets of Structural Plane
phone 413-587-1240 Fax 413-587-1272 PIoVSRe Plans
Dow Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I-SITE INFORMATION
1.1 Property Address: This section to be cofmapleted by office
Ms, 35 Lot as � Unit
I L sy l WV) LyailE zone overlay District
F1drEVt(q � r1 01061 El.Stthia Ceoiarriot
SECTION 2.PROPERTY OWNERSHIPIAUTHORRED AGENT
2.1 Owner of Record:
m,dLQ
Name( Caren)Mailing
I n '- FoGr
Telephone
Signatu
2.2 Authorized Agent:
Name(Pint) Cumml Mailing Address:
Sgnature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Rem Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Tota Cost of
Construction from fi
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) t'Ut�, Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued,
Signature:
Budding CommisaimvrMspector of Buildings Date
",Vv N V ..Vj (9r k11ml�Q�t.C-t1U
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING AR Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tbis column tob tillej in by
Building Dcremucm
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
( A,t.minus bldg&paacd
pa,kog)
#ofloarking Spaces
Fill:
'.].&lara[ion
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW ® YES
IF YES: enter Book Page ,,,cccand/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 9 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. WIII 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 O NO
IF YES,then a Northampton Stan Water Management Permit from the DPW is required.
SECTION b DESCRIPTION OF PROPOSED WORK(check all applicable)
New Nouse ❑ Addition ❑ Replacement Wintlows Alterationls) ❑ Roofing ❑
w Doo a 0
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [q Siding 101 Other[C9
Brief Work: esaiption of Propos ed FG o'
Alteration of emsfing bedroom_Yes I-I No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rall -Sheet
Ga. N New house and or addition to existing housing- complete the following-
a. Use of building: One Fam ly 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 stones?
f Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of censlmctimn
i. Is consbuchon within 100 R. of wetlands? Yes _No. Is construction within 100 yr. floodplain_Yes_No
1. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zming regulations? Yes No.
I. Septic Tank CitiSeiver 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 wok authonzed by this building permit application.
signal M Onner Dale
1, as Owner/Authorized
Agent herLily declAre at th mems 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 ,uu1y
1 v�,lY`0.� �. kVIgA CSo
Prim Name
Signature of Omrer/Agent Dale
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: [Z Sy�vk� �411 R
The debris will be transported by: Sa f�.f -k/\
The debris will be received by: �ESC��I ✓�c�
Building permit number: (�
Name of Permit Applicant I 1/fin al �� �✓1 S�
Date Signature of Permit Applicant
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The Commonwealth of Massachusetts
Department oflndustrialAccidents
Irv!
1 Congress Street,Suite 700
a Boston,MA 02114-2017
www.mass.gon1dia
11 orkers'Compensation Insurance Affidavit; Builders/Contractors/Elearicians/Plumbers.
TO BE PILED WITH THE PERMUTING AUTHORITY.
Applicant Information t ,\ 1 Please Print Le ibl
]Name (Buxmn c/Or,mrzanoMndividaal): 11`_(.y\4 V V t(�G it,—
Address: F Wes,
t0.��1
City/State/Zip: F(asr6o (e lyy Phone#: I'�lS, ir
Are you an cpk,ar7 Check tine appropriate box.
Type of project(required):
1.❑l arna employer with employws(follmNorpan-time)." 7, New constriction
2.F-]I am a sole pmpretm or partnership and have no employees working for me as $. Remodeling
any capacity.[No workers comp immm , nequhed.]
101 am a homeowner doing all work myself[No workers comp.insurer,required]` 9. El Demolition
4.[plamahomeownerandwi be hiriv 10❑Building addition
g convectors to conduct all work m my property. level
methaa all c000-ecrors diner have workers'nompenaaron invnrmne oraresole 11.0 Electrical repairs or additions
prop^etnas was no employees.
12.E]Plumbing repairs or additions
5r7 1 ha.e e general nemsorwasons,
have
and 1 have hued the subwkert'yrs listed an the atteohed shcet 13. Roof repairs
These sub-convectors have employees and have workers comp.ivsurem.
6.F-1we ares corporation and na ffieers have exetcredescir,tit ofexemption perMGL a 14.E]Other
152,§1(4),and we have no employees[No workers'comp-immanee removed]
`Any aMbeent eralI checks box RI must also fill out the section below showing bleu workerscompensation pohry information.
Holo who submit this offrdavlt indicating duct are doing all work ed then hire outside comisiors must mbmit a new affidavit indicating save.
:Contmctorsethe,check tWs box must emceed an additional sheet showing the were of me sub-conhacmrs and state whether or not those exa ees have
emplovece Ifthe sulveonernmrs have employerstheymastprovidethea workers'comppolicynormar.
tam an employer that is providing workers'compensation insurance for my employees. Below is the policy andlob site
information.
Insurance Company Name:
Policy#or Self ins.Lie #: 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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or ore-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
do hereby ce ti rider fee ns�ri d/a,Pena/tis oepenury that the information provided above is true and correct
Senamre' II s1 v Date' `� —�Y
Phone#' W13 S7er QOS`(f
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit'Licens,#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Ph...go
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 pnsen in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,usseration,corporation or other legal entity,or any two or more
of the foregoing engaged in ajolnt enterprise, and incluc.ing lie 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 apartnents and who resides therein,or the occupant ofthe
dwelling house of another who employs persons to do maintmance,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 luxuriance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neithe'the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpuble work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contacting authority"
Applicants
Please fill out the workers'compensation affidavit com,lemly,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s),address(es;ane phone numbers)along with their cenificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)wilhre employees other than the
members or partners,are not required to carry workers' comeensation insurance Han LLC or LLP does have
employees,a policy is required. Be advised that this aff day t 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 rammed to the city or town that the application for the pe mit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regardng the law or ifyou 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.
Citv or Town Officials
Please be sure that the affidavit is complete and printed legiliv. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of 1,ivestigations has to contact you regarding the applicant.
Please be sure to fill in thepermit/license number whict wit 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 some Ped or ranked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for fun repermits or licenses. Anew affidavit must be filled out each
year.Where a homeowner or citizen is obtaining a license r r permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person:s NOT required to complete this affidavit.
The Department's address,telephone and has number:
The Commonwealth of Massachusetts
Department of Irdustrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE
Fax# 61--727-7749
Revised 02-23-15 mvw.mass.gov/dia