36-078 (2) 340 WESTHAMPTON RD
BP-2011-0294
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 36 - 078 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-2011-0294
Project # JS- 2011- 000487
Est. Cost: $13500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KENNETH LYNDS 013668
Lot Size(sq. ft.): 108900.00 Owner: NELSON DAVID
Zoning: SR(100) //WP/WSP II Applicant: KENNETH LYNDS
AT: 340 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
P 0 BOX 448 (413) 584 -9282
LEEDSMA01053 ISSUED ON:
TO PERFORM THE FOLLOWING WORK :12' x 16' deck - Follow prescriptive residential
guidelines
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 10/1/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
File # BP-2011-0294 ?..")1
APPLICANT /CONTACT PERSON KENNETH LYNDS 7 itagleAd
ADDRESS/PHONE P 0 BOX 448 LEEDS (413) 584 -9282
PROPERTY LOCATION 340 WESTHAMPTON RD
MAP 36 PARCEL 078 001 ZONE SR(100) //WP/WSP II
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:_ 12' x 16' deck
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 013668
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INJW4ATION 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
a emoliti : l el. y
/ Z7 / 7 - /6
Signature of Building 0 icial 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.
at
City of Northampto ���
Buildin Department , _ = : ' .„ ; �
212 M ain Street =
' ,,
Room 100 m E 4 E
Northampton, MA 01060 °k ,5
phone 413- 587 -1240 Fax 413- 587 -1272 - ,
ff � ®rte 7; °` i . ,,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ON OR TW FAMI DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pro a Address: �t � This sectio to be c pfd by o ffice
3 � 0 Q.oT444.1014.... /[.� c✓tl Overlay Map Lot Unit
Zone District
. r6)-e-vuti--- Elm St Dis trict CR. District
SECTION 2 - PRO
PERT( 'OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: n / D
3 0, idAliailibii-if-%1 Ph'',
Name (Print) Mailing Address:
�j.� -6 4 -3h 7
I�+i✓L ----+ Telephone Current
Signature
2.2 Authorized Agent:
/(e.- w t � . .1. y
/?0 , 00 VW 4" ,vj j . aV o (J
Name (Print 1 Current Mailing Address:
Ai AL
Sign - �e Telephone e / r� O ^/ 9 $
SECTION 3 - ESTIMATED CON STRUCTION COSTS
Item Estimated Cost (Dollars) Official Use Only
completed by permit app cant be
1. Building 4b 2 g V, (a) Bu Permit Fee
J •
2. Electrical (b) Estimated ilding Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 13/5a • v' Check Number 4 ,_....-
This Section For Offi Use Only
Building', Permit Number: Issued:
Signature: � ) 0/ 5-/ d
Building Commissioner/Inspector o Buildings Date
T
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 om'•
1 A t . J is Gi� l _....._.
Frontage 1 Lf Y7 ' _ if (i7
Setbacks Front [31 Jr i
Side L: , R:= .2S L: 1 Y R: ;r
Rear I
Building Height
Bldg. Square Footage % WV C/ I i ` 2 ' 4 `
Open Space Footage
(Lot area minus bldg & paved iip. [12
wo. an .... _
parking)
# of Parking Spaces
Fill: '' � ' 1
(volume &Location) an Al Olt , ,
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds? .
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pagel E and /or Document # '
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO 76..
IF YES, describe size, type and location: ! ,
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO t
s
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, x vation, 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 Managem nt Permit from the DPW is required.
SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ j
Name of License Holder : Q M e1 v • 41,4 ° 'J v - / 3 ‘114
License Number
If 4,4.1/Mc- AO 4' d 1 2.44 A4 . o f PSDP 7. 2.4 -
Address / Expiration Date
4 /./ - 7"/ 9
S' ure Telephone
9 1ie4istenett lIci verelt Ccntractbr ... . ,, Not Applicable ❑
N w �,� , u i 3 6 7 7
Com a nv Name Registration Number
7/ ,i1, L.4.4.4) , ./1.41). d 1 2J .2 8— pi )/
Addres Expiration Date
V /3 C
Telephone S 7 // L
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 ty No ❑
1 om ° er E "� ' 3 nOn
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 D Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors y
Accessory Bldg. El Demolition ❑ New Signs [D] Decks [0 Siding [D] Other [D]
Brief Description or
Work: ��r 64 ' P Al £<4 1.4) 4. 0lt'C_ f• 1�y!/'.t..
Alteration of existing �b Yes V No Adding new bedroom Yes fNo
Ai - a -d Narrative , Renovating unfinished basement Yes L. No
"lens Attach • - o - Sheet ✓ Pe:4/
sa fN Si '.S aiil� c dl Vexistnct.` io in ci titi Mh .f tiie ` :
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, b A I, I` d t' /6.-t. �ad Q i , as Owner of the subject
property [ '
hereby authorize ' o2
to act on my behalf, in al m H M " "'� matters relative to work authorize by this building permit application.
y `p�,.A P Nom.
Signature of Owner 9 2 ' 0 10
1, 0 hi 1. Vt4 I/" , 1,1 W A -) ' ?-- , as C#t*er/Authorized
Agent he y declare that the statements and Information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under t e pains and p nalties of perdu
Print Na d c /
1------- g L - `0
Si at re of Owner/ gent Date
The Commonwealth of Massachusetts
---- Department of Industrial Accidents
i Office of Investigations
al.
_ 600 Washington Street
Boston, MA 02111
Au www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
A' • licant Information Please Print L • ' 'blv
Name ( Business /Organiiationflndiviinal): eh rr J 4• 4
Address: 1 tI)A 4 •
City /State/Zip: 1, 2 J /440 01 o Phone. #: 4 i/ 3 " 58 V ` Z
Are you an employer? Check the appropriate box: Type of project (required): /
1. ❑ I am a employer with 4. ID I am a general contractor and I 6. New construction
employees (full and/or part-time).*
have hired the sub- contractors
2_. [tI am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
!!
ship and have no en loyees These sub - contractors have. 8. j] Demolition
working for in any capacity employees and have workers' �'(_
_ comp. nsnranc-P_# :. 4 ET Building addition
[Ni, workers' eornp. insurance 10. Electrical repairs ] 5. 0 We are a corporation and its epairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exempt MGL
ion per 12.0 Roof repV k _
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.Other
comp. insurance required. }.
*My applicant that checks box #•1 must also fill out the section below showing theirworkers' coition policy information:
t Homeowners who submit this affidavit indicating they are doing aft 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. lithe sub-contractors have employees, they must provide their workers' comp. policy number.
.1 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 /Stafe/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 ofMGL c 152 can lead to the imposition of 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
Inv " "estieations of the DIA for insurance coverage verification
I do hereby certify u der the p • a3lp s of perjury that the information provrded.above_ s true_and correct
• Signature: Date; 9. 2 lV
Phone #: 1 - --at/. t. v
Official use only Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plmbing Inspector
6.Other
Contact Person: Phone #:
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 ctures. A
person who constructs l ore than one home in a two -year period shall not :e considered a
home owner."
The building department • • r the City of Northampton wants pe . • n(s) who seek to use
the home owner exemption, to act as their own construction pervisor, to be aware that
by doing so you become res • onsible for compliance • 41 state building codes and
regulations. The inspection p cess requires that the • • ldng department be called to
inspect work at various stages, • I *ch include foun tion /footings (before backfill)
sonotube holes (before pour), a ' ugh buildin . inspection (before work is
concealed), insulation inspection reauir and a final building inspection. The
building department requires these ins • ecti • before the work is concealed, failure to
secure these inspections can result in ure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades t• pe • . work (electrical, plumbing & gas) the
homeowner will be responsible to •r . e sure • • t the trades hired secure their proper
jermits in conjunction to the buil • ng permit is` ed, and that they get their required
inspections. Failure of the indiv trades to s' e the permits and inspections as
required can DELAY the proj : ct until such time a' the proper permits and inspections are
made
I, understand the above.
(Home owner /re dent's signature requesting eaem I ion)
I will call to schedul all required building inspections neces ary for the building permit
issued to
Date
Address of wo
location
Office of Consumer Affairs & Bdssiness Regulation
1► e9 HOME IMPROVEMENT CONTRACTOR
i Registration : *136677
I L_ a Expiration: & Type:
; - Individual
'>
KE '= E H WILLIAM:
KENNETH LYNDS�,
71 RESERVOIR RD
LEEDS, MA 01053 �°`��
Undersecretary
'+�. Massachusetts - Department of Pilo , ,afet■
4 Board of Building Regulations and Standards
Construction Supervisor License
License: CS 13668
Restricted to: 00
KENNETH W LYNDS air. 1 1, -. i
;., k .
71 RESERVOIR RD .. a = .;
LEEDS, MA 01053
��- —� ---3„ Expiration: 7/24/2011
( 's•d ner Tr#: 20177
OSHA 001953631 0
i s__,,e4,147 - 7( (A
u.s. Department of Labor
oocupatwna' Safety and Health Admirmstrafion
has successfully completed a 10 -hour Occupational Satety and Health
Training Course in
Construction Sate & Health
(Trainer) mate,
ocom ut
Nie 0 i I
ll a 10 hour OoC°°� ,
Has Health completed Try C in C
&
difib* Safer9 Health
d (id
_,4, Date
Trainer
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
W 4/
Not valid without signature
Restricted to: 00
00 - Unrestricted
1G - 1 2 Family Homes
Failure to possess a current edition of the
Massachusetts State Building Code
is cause for revocation of this license.
Refer to: WWW.Mass.Gov/DpS
OSHA retiarNreads O■wearh Traiw; rooms as as oriewaliso to aeeep.is.wa/ safety
21111 health for worker. Parlicipatoa is velaalary. %Obeys mast recei a1111it:ia�i
traiwie; ao sper fw hxards of their jab. This coarse con/lcl sa earl dots ail gybe.
For farther iaformatiso see wr web site 04 www. osha.r.wl. 0reaeh.ktad
SAFETY �y OSHA 10
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Fall Protection
Training & Consulting Services
Tel.: 508- 332 -8959
Bill Kershaw 61 Eisenhower Road
Safety Consultant Swansea, MA 02777
Member of ASSE SafetyEquippedgcomcast.net
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