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06-064 BP-2011-0458 GIS # COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categor: BUILDING PERMIT Permit # BP- 2011 -0458 Project # JS- 2011- 000738 Est. Cost: $150000.00 Fee: $1170.90 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ED JAZAB 050099 Lot Size(sq. ft.): Owner: MELNIK PATRICK J Zoning. URA Applicant. ED JAZAB AT: 62 CHESTNUT AVE EXT - UNIT 8 - 28 EVERGREEN RD Applicant Address: Phone: Insurance: 9 SHEPHERDS HOLLOW (413) 222 -4910 0 LEEDSMA01053 ISSUED ON :11412011 0:00:00 TO PERFORM THE FOLLOWING WORK.- CONSTRUCT SFH WATT GARAGE 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 Siinature: FeeType: Date Paid: Amount: Building 1/4/20110:00:00 $1170.90 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0458 APPLICANT /CONTACT PERSON ED JAZAB ADDRESS/PHONE 9 SHEPHERDS HOLLOW LEEDS (413) 222 -4910 Q PROPERTY LOCATION 62 CHESTNUT AVE EXT - UNIT 8 - 28 EVERGREEN RD MAP 06 PARCEL 064 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid r Typeof Construction: CONSTRUCT 9FH W /ATT GARAGE New Construction J. V ®�$ � 1 _ r� P Non Structural interior renovations Addition to Existine Accessory Structure beW o w / Buildiniz Plans Included: Owner/ Statement or License 05009 3 sets of Plans / Plot Plan ' THE F9JkMING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN F ATION 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 e o a 1 - 17 1 -11 Signature of uilding Off ial 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. Department use only City of Northampton Status of Permit: Building Department CurbiCut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Noithampton, MA 01060 Two Sets of Structural Plans phone 413- 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 C Nest,. uT .4 �� Ti's► a.✓ Map — —_ Lot unit 6J —C) 1 Zone Overlay District if s J Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of c rd: Patrick 1 ik, Trustee Beaver Brook Nominee Trust 110 King St . No rth ampt on Ma 01060 Name (Print) Current Mailing Address: 413 - 584 -6750 Telephone Signature 2.2 Autho ized Anent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building 100,000 (a) Building Permit Fee 2. Electrical 15,000 (b) Estimated Total Cost of Construction from 6 3. Plumbing 15,000 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 20,000 6. Tot Iff (1 2 + + 4 + 5) 150,000 Check Number d ; This Section For Official Use Onl Date Building Permit umber: 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 25 Acres 25 Acres Frontage 250 250 Setbacks Front 0 800 Side L: R: 0_ L 120 R: 500 Rear 0 30 Building Height 0 20 Bldg. Square Footage % 1550 1% Open Space Footage % (Lot area minus bldg & paved 24A 99 %', p arkin g) # of Parking Spaces 2 Fill: 0 (volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO o DON'T KNOW Q YES Q IF YES, date issued: 04/09/2008 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW 0 YES Q IF YES: enter Book 9482 Page 3 and /or Document #. B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q 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 0 NO Oi 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 0 NO Q 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 ❑✓ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors I] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [0] Brief Description of Proposed Work: Construct single family home which is unit 8 shown on approved cluster site plan. Work I comply with speci emit conditions including any required fire sprinklers Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa: If New house and or addition to existing housing.>cowlete the following: a. Use of building : One Family x Two Family Other b. Number of rooms in each family unit: 6 Number of Bathrooms c. Is there a garage attached? ye s d. Proposed Square footage of new construction. r 7 Dimensions J " ` e. Number of stories? 1 f. Method of heating? gas Fireplaces or Woodstoves no Number of each l g. Energy Conservation Compliance. `! )A Masscheck Energy Compliance form attached? I A h. Type of construction W ood frame i. Is construction within 100 ft. of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes No I 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 A. 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 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 Signature of r /Agent Dat SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder : ED CS fl S c'D 9 3 CS 0 5 a License Number H `lL�D5 «OLLOw UL �. 0 105-3 ti - 2 2�I � C Address Expiration Date ' - 222 - t Signature V Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 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. = 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 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 The Commonwealth of Massachusetts = Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /Individual): �/t' k J /'^ f C i✓d k _ Address: / / 0 k t ,✓,p h' City /State /Zip: u Phone #: S�� L f Are you an employer? Check the appropriate box: Type of project (required): l .® I am a employer with �_ 4. ❑ I am a general contractor and I employees (full and /or part- time).* have hired the sub - contractors 6. ®New construction 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' 9. F1 Building addition [No workers' comp. insurance comp. insurance. required.] 5. F1 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 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box #1 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. /� n Insurance Company Name: /,,,b/lfaLK Policy # or Self -ins. Lic. #: W E Q 9 S �,? A Expiration Date: 4 av j Job Site Address: d �- C IN4 11i✓U r 4 df (rk-t eiv1/ ai✓ City /State!Zip: ZF 'f --� U > b 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 9painst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the for insurance coverage verification. I do hereby cer ' y der the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: /l 9 1 D Phone #: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 2009 IECC Climate Zone Map - Massachusetts Ittp:// energycode .prd.gDv/EnerpyCodeRegs/ ?state = Massachusetts Meets Federal Stimulus Tax Credit Requirements MASSACHUSETTS Climate Zone 5 & 4 Marine Ceiling R -value 38 t Wood Frame Wall R -value 20 or 13 +5 h Mass Wall R- value' 13/17 # Floor R -value 30 Basement Wall R -value c 10/13 Slab R -value d , Depth 10, 2 ft Crawlspace Wall R -value ` 10/13 a r Fenestration U- Factor b 0.35 Skylight U- Factor b 0.60 Glazed fenestration SHGC b, a NR 4 s Vv Ex P tZr 1 �^^ O l X CLtf9 Au UV,� C- GU 1 of 2 11/11/2010 7:08 AM DOE Building Energy Codes - Status of State Energy Codes http: / /www.energycodes.gov /states /state_irifo.php ?statcAB =MA g Building Energy Codes program Status of State Energy Codes as oV Do you know of updates to the information on this page? If so, please let us gov) Current News On May 6, Massachusetts was announced as one of the states that will participate in BECPs Compliance Evaluation Pilot Study. Residential Residential Code MA's Board of Building Regulations and Standards (BBRS) has amended the code as of Jan. 1, 2010, requiring the use of the 2009 IECC with MA's amendments instead of the 2006 IECC. BBRS is allowing a sloe month concumency period through June 1, 2010 during which either the 2006 IECC with 2007 Supplement and MA's amendments or the 2009 IECC and MA amendments may be used. When using REScheck, the 2009 IECC code option should be chosen for compliance. �c 93 07_Energy Conservation - _2009IECC ( httpWy vywenergycodesgo_/pdf /states/MA 93 _ MA Amendments Approved Compliance Tools REScheck can be used for demonstrating compliance. MA- Specific Research Impacts_ of the 2009 IECC for Residential Buildings in the State o_f Massachusetts_(BECPRepod Sept. _20W - (http /l www_ enegycodes.-qovlpuublic _ationMechassis7resiqpntial w. /Residential Massa_chuse-ttspdD_ Approximate Stringency As stringent as teh 2009 IECC. Effective Date January 1, 2010 with a six month interim DOE Determination /State Certification Commercial Commercial Code MA's Board of Building Regulations and Standards (BBRS) has amended the code as of Jan. 1, 2010, requiring the use of the 2009 IECC with MA's amendments instead of the 2006 IECC. BBRS is allowing a sic month concurrency period through June 1, 2010 during which either the 2006 IECC with 2007 Supplement and MA's amendments or the 2009 IECC and MA amendments may be used ..r 13.00 Energy Conservation -2009 IECC jhttp; l/ www ,e_nergycodes,_qovpdf/stateslMA corlprercral 13_- 00pdfZ MA Amendments MA- Specific Research Impacts of Standard 90.1 -2007, for Commercial Buildings in the State of Massachusetfs_(BECP_R_eport Sept._2009�Lhttp: //wrvw ene�codesgo_vpu_ blications /techa_ssisticommerciai r� /Commercial_Massachusetts , pdf) Approved Compliance Tools Approximate Stringency Effective Date I of 3 11/11/2010 7:10 AM Titi4 of Nart4ampton (' IRtt$$ttrl�u$Plts W' { DEPARTMENT OF BURRING INSYECTIOM5 , e 212 Main Street • Municipal Building Northampton, MA 01060 LOU HASBROUCK BUILDING PERMIT FEES Phone: (413) 587 -1240 BUILDING COMMISSIONER Effective July 21 , 2008 Fax: (413) 587 -1272 DEMOLITION $ 20.00 ACCESSORY STRUCTURE $ 35.00 PRINCIPAL BUILDING —Residential d p $200.00 PRINCIPAL BUILDING - Commercial 0 * / W CONSTRUCTION $ .50 per square foot for 1 floor �� .30 ,. �, 2nd floor .20 " '/z floors, attic, basement, garage �- y STRUCTURAL ALTERATIONS IN ALL USE GROUPS �� 7 $6.00 per thousand dollars of estimated cost or fraction thereof, with a minimum fee of $55.00 6,e A-4r $25.00 WOODBURNING STOVE 7 * NEW ACCESSORY STRUCTURES one hundred twenty (120) square feet and over $ .20 per square foot with a minimum fee of $25.00 * NEW ACCESSORY STRUCTURES under one hundred twenty (120) square feet $25.00 per inspection ` 0 * SWIMMING POOLS $30.00 for above ground $60.00 for in-ground * SIGNS & AWNINGS $30.00 * DECKS $50.00 REPLACEMENT WINDOWS $35.00 SIDING & ROOFING Residential $35.00 per structure Commercial $55.00 min. per structure OR $6 /K of estimated cost TENTS $25.00 * ZONING REQUEST FORMS $15.00 (includes home occupation registration) REISSUE OF LOST PERMIT $25.00 CERTIFICATE OF ANNUAL INSP. $100.00 (minimum) Temporary Certificate of Occupancy $25.00 PERMITS REQUIRING ONLY 1 (1) INSPECTION WILL BE A MINIMUM OF $25.00; ALL OTHERS WILL HAVE A $50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton AND SUBMITTED, WITH THE COMPLETED PERMIT APPLICATION, TO THE OFFICE OF THE BUILDING INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE. !! NO CASH - CHECKS OR MONEY ORDERS ONLY!! * Filing deadline is 12:00 pm (noon) on Wednesday. MELNIK LAW OFFICES Attorneys at Law 110 King Street i '00 Northampton, MA 01060 Telephone (413) 584 -6750 Fax (413) 584 -6789 Patrick J. Melnik, Esq. pmelnik a verizon.net Patrick J. Melnik Jr., Esq. patmelnikjrgverizon.net November 9, 2010 Mr. Louis Hasbrouck Building Commissioner for the City of Northampton 212 Main Street Northampton, MA 01060 Re: Unit 8, Beaver Brook Development off 28 Evergreen Road, Leeds, MA Dear Mr. Hasbrouck: Enclosed please find my application for a building permit for a single home which is Unit 8 on the cluster permit I had approved by the city in 2008. Also attached to the building permit request is a filing fee and the payment of the balance due that I owe to the City of Northampton c/o Planning Office for the traffic mitigation fee that I am required to pay as part of my special permit. If my permit is in order I would appreciate you forwarding on the traffic mitigation fee to Wayne Feiden at the Planning Office. If my application isn't complete, or if there is any problem, please return to me for completion. I understand that in connection with the application for a building permit I will be required to install residential sprinklers. As long as the requirement for residential sprinklers is a permit condition for my project before a certificate of occupancy is issued by your office, I will comply with this requirement. Please contact me if you have any questions. erely, trick J. Melnik, Esq. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 14 600 Washington Street Boston, MA 02111 www.mass.gov/dia - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Le .gibly Name ( Business /Organization/Individual): 1= 'D Address: 9 SHC?0CRIDS City /State /Zip: LL — fD5 ° Phone. #: L A i3 - 222- y 9 10 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time). * have hired the sub - contractors 6. New construction 2. 5� I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no enTloyees These sub - contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. F] Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 1 ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption 'per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box #1 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. I am 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 crimina penalties of a fine up to $1 and/or one -year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a file 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 u der the pains and penalties of perjury that the information provided above is true and correct Si afore: Date: IV , j .. 1 � 20 1 O Phone #: 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 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." ; v Additionally, MGL chapter 152, §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 Liaility Partnerships (LLP) with no employees other than the members or,parmers, 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 permitllicense 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 _affidaviL_ ... 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 600 Washington Street Boston, MA 02111 Tel. # 617- 727 -4900 ext 406 or 1- 877- MASSAFE Revised 11 -22 -06 Fax # 617- 727 -7749 ww'w.mass.gov /dia MUNICIPAL WATER AVAILABILITY APPLICATION Northampton Water Department 237 Prospect St. Northampton, MA 01060 587 -1097 A Department of Public Works Trench Permit shall be required prior to any construction or connection activity associated with this application. Location: 28 Evergreen Road Un it 8, Beaver Brook, Leeds Inquiry Made By: Pat Mel 584 -67 Date of Inquiry: 11/15/10 Number of Type of Single Family X Type of Private X Units: 1 Unit(s): Accessory Apart. Ownership: Condo Multi- family Rental lAnnlicant to fill out the abovel Municipal Water Main in Existing service to Front of Location? Yes: X No: site? Yes: X No Size of Water Main: 8 Material: Ductile Iron Age: 2006 Approximate Static Street Flow Test Conducted: Yes: X No: Pressure: 40 If done attach results Size of Service Connection j" 3 99 Suggested Meter Size: Comments: The Water Department cannot guarantee a w pressure during peak demand ti me s at elevations above 320 feet. • A corresponding water entrance fee shall be paid prior to making any connection to the municipal water system. • Arrangements of such instal n shall be made with the Northampton Water Department with a minimum of 5 wor ing days otif ti n. All wo shall on to Northampton Water Department specifications. David W. Sparks, Superintendent of Water Water Entry $200.00 Meter $190.00 Radio $100.00 cc: Ned Huntley, Director cc: Louis Hasbrouck, Building Commissioner Note: If this availability is for a new construction, it must be hand delivered to the Building Inspector. 't, MUNICIPAL SEWER/ AVAILABILITY APPLICATION Northampton Streets Department 125 Locust Street Northampton, MA 01060 587 -1570 A Department of Public Works Trench Permit and Sewer Entry Permit shall be required prior to any construction or connection activity associated with this application. Location: 28 Evergreen Road, Unit 8 Beaver Brook, Leeds Inquiry Made By: Pat Melnik 584 -6750 Date of Inquiry: 11/15/10 Reason for Hook into City Sewer Request: Municipal Sewer Main in Front of Location: Yes No Municipal Storm Drain Available: 5'/2 deep Yes No Size of Sewer Main: -- Material: Age: Depth of Sewer Main: . Size of Service Connection: Type of Service Connection: Tie -in to Sanitary Main Tie -in to Sanitary Stub Comments ry A f Note: If this availibility is for new construction, this form must be hand delivered to Building Inspector. A corresponding "sewer entrance fee" shall be paid priorto making any connection to the municipal sewer system. Arrangements of such installation shall be made with the Northampton Streets Department with a minimum of 5 working days notification. All work shall conform to Northampton Streets Department specifications. John Hall Sewer Department cc: Ned Huntley, Director DPW Louis Hasbrouck, Building Commissioner ' s r )�Pj$ §�pl w I %A N 1 9 Tgl V $ _ �1' � gg �=99�,c a 6'HL - J l a Bf I ! .ev5w1• — GROVE AVENU �Mp'IB I'll NOJ'St•JJY _ � g Wbt yly� J9.P 1�91.>J' _ EF nl.e9' �� m fop gm a�. 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PACE b - - - - -- --L III ��EEnn It ,y vi `- Au a miw+ x. I � I Fi ,gi °' ��Z�R Q* N Al BUN B09x�N9. w9E�, I I I .orsu — a,f0. � ¢ IX ��S,+ — _ et 3lvd •roe w99 J' — g 1 � + 9 -- aalra •aa w9e aas -------------- _.---------- ---------- - - - -�. �>i'Jk�tld fi� —_� oac woe '_________—___ �_—___—_ ____�_— _— _______,_______— _ —_ —__ � ����Y .wrexa2 arnuna suasmnssm--------------- .------------------- - -.- -- Bk: 09482 Pg: 4 Planning - Decision City of Northampton Hearing No.: PLN- 2008 -0038 Date: April 9, 2008 Upon motion by Ken Jodrie and second by Keith Wilson the Planning Board voted unanimously (5-0) to issue the requested special permit and site plan approval with the following conditions: 1.0 To mitigate expected traffic Increases from the project and ensure adequate pedestrian safety: - ❑Applicant shall pay the offered $50,000 In traffic mitigation, In -lieu of providing off site traffic Improvements to address the incremental impacts of Increased traffic, PRIOR to obtaining a building permit for the sft -0 The money shall be segregated within a traffic mitigation account with the funds to be used for the soft or construction costs of providing traffic calming and traffic safety improvements on Leonard Street, East Center Street, Front Street, Upland Road, Evergreen Road, Chestnut Avenue, and Grove Avenue. -0 The roadway width shall be 22' wide (not 24). - ❑Sidewalks shown shall be constructed of cement concrete. -0 The sidewalk shall be extended easterly along the entire distance of the property's frontage on Evergreen Road; 1. ❑A speed hump shall be located Just east of the southerly driveway on the access road, and designed In accordance with standard engineering practice. The sidewalk across access road shall be cement concrete and be located as close to the intersection as practical. H.❑Sidewalk shall Include wheelchair ramps to Evergreen Road Immediately east and Immediately west of the Chestnut Avenue extension. - ❑Prior to the Certificate of Compliance for the 15th housing unit the applicant shag provide traffic counts and speed study necessary for the analysis of the Chestnut/Evergreenlnew access road intersection. - ❑Prior to the Certiffcate of Compliance for the 15th housing uni4 the applicant shall install three speed humps on each of the three existing roads entering the Intersection of Evergreen Road, Chestnut Avenue or such other traffic mitigation of the same approximate cost approved by the Planning Board and the Departmentof Public Works and designed and built in accordance with commonly accepted engineering practices. Alf structures within the public right - of-way shall be designed In accordance with Department of Public Works standards. - ❑Stop signs shall be Installed on the new access road at its intersection with Evergreen, consistent with the MUTCD. 2. ❑ To ensure adequate potable and fire flow requirements: - ❑Each dwelling structure shall be constructed with a sprinkler system that meets the design and other requirements of the applicable sections of NFPA 13 and that the sprinkler system be approved by the fire chief, and - ❑Wafer system Improvements shall be made consistent with "Exhibit B- Agreement to Upgrade the Water System," Included here by reference. 3.o To provide clear engineering standards: - ❑Street trees along Evergreen Road shall be required an average of every 30' - ❑Along the access road (Chestnut Road extension) all drainage Improvements, roads, street, sidewalks, water lines, storm sewers and sanitary sewers shall be constructed in accordance with the design standards provided in the Northampton Subdivision Regulations. -❑ There shall be a triple gated interconnection with a valve at the property line where the proposed water main connects to the existing water main on Evergreen Road. - ❑Provide at least two swing ties from permanent locations to each water main isolation valve. -D The one -way driveway loop shall have a hydrant between each proposed isolation valve. - ❑Provide inverts at the proposed manhole connection on Evergreen- -U Provide a sewer cleanout at the property fine. -❑Four foot (4') fall evergreen shrubs shall be planted and maintained (and replaced as necessary) along the entire curvature of the access road to block headlights from the Yankee Hill condominium site east of the proposed road. These shall be located along the property boundary or within the planting strip, from a point 120 feet north of Evergreen Road and thence continuing an additional 190 feet. - ❑The name and certillcation number of the arbodst overseeing tree protection shown on the plans shall be submitted to the Office of Planning and Development prior to commencement of construction. - ❑Prior to construction, the arborist must identify a detailed plan of tree protection and prevent a plan showing preservation of two large maples (one close to the entrance to the project and one behind the largest building) and any other sensitive areas, subject to approval by Office of Planning and Development staff based on determination of whether trees are sufflclently protected from construction damage. Trees within the area marked "existing woods to remain, selectively cleared or thinned upon approval by arborist ", such trees shall only be removed with speciflc approval by the arbodst and by OPD review. No more than 10% of the trees in the area may be cut shall be cut In this area. -DAt the Intersection of the proposed paved bike path connector by developer" and the access road, the bike path shall be extended from the sidewalk to the roadway itself. - ❑Orange tree protection fencing shall be located on the individual lots around the areas shown as "trees to be protected with some selective thinking determined by arbodst" in areas within 100' of any construction and any tree clearing. Trees may only be selectively cut upon approval by abodst AND Office of Planning and Development staff. No more than 10% of the trees In this area shall be thinned Any trees cut or damaged during construction not approved by this method shall be replaced at a rate of 1 " diameter caliper planted, In it location approved by the Office of Planning and Development, for each i" diameter caliper cut 4.0To ensure offered public use, public ownership, project mitigation: -[]Parcel A shall be transferred to the Northampton Conservation Commission, if City Council accepts, PRIOR to obtaining a Building Permit in fee subject ONLY to the recorded Conservation Restriction and public access easement with no timber or other rights reserved to the property owner or applicant or any third party. - ❑An easement for the public to pass and repass on the new access road (Chestnut Avenue extension), its sidewalks, and the planned blkepath to be provided for by the developer shall be provide to the City PRIOR to obtaining any Certificate or Temporary Certlficatb of Compliance. Permanent signage shall be designed and placed at both ends of the bikepath announcing this as the Norwottuck/Chestnut Avenue link, prior to selling or marketing any unit -0 The Planning Board approval specifically allows the reduction in frontage shown on the plans to allow the donation of the proposed open space shown on the plans. -❑ There shall be permanent marking along the Development Limit Line In a manner acceptable to the Office of Planning and Development and the Conservation Commission prior to the final plans being approved. S. ❑All work shall be done in accordance with plans entitled "Beaver Brook Estates, Northampton, Massachusetts, Cluster Development Plan & Site Plan for Zoning Special Permit & Site Plan Approval' last amended 311212008, provided, however, that PRIOR to Issuance of a GeoTMS® 2008 Des Lauriers Municipal Solutions, Inc. Bk: 09482 Pg: 5 v Planning - Decision City of Northampton Hearing No.: PLN -2008 -0038 Date: April 9, 2008 Building Permit, these site plans shall be revised and filed with the Office of Planning and Development (OPD) consistent with the existing DPW Stonmwater Management Permit and these permit conditfons and approved by OPD staff in accordance with these permit conditions. Said plans shall show both site plan views, construction detall sheets, and utility profiles. Water system plans shall specifically show construction details, sizes of plpes and valves, thrust blocks, and other requirements . of the subdivision regulations. Sold plans shall be provided In both paper (three copies) and PDF electronic format B.DPR/OR to any construction, there shall be a preconstruction meeting with the Northampton Office of Planning and Development, the Department of Public Works, the contractor, and the developer's engineer to review plans, permit conditions and to ensure that all construction bee protection measures necessary to protect the trees destined for saving In the plans and this permit; Including the large bee to be saved closest to Evergreen, shall be In place prior to consrrction. 7. DPRiOR to the sale of any units or the Issuance of any temporary orpenmanent CArtlflcate of Occupancy, the applicant shall provide covenants or ensure adequate financial and Institutional controls to ensure maintenance of the road, utilities, and drainage facilities, and to ensure that buyers are aware that the road and utilities must remain In private hands and never be dedicated to the city and that the bike path will be Installed with a public easement, with the covenants subject to OPD staffapproval consistent with this permit Alter staff approval, said covenants shall be recorded at the Registry of Deeds PRIOR to the sale of any units or temporary or permanent CO. 8.0Except as noted below, PRIOR to any final Certificates of Occupancy, as -built plans prepared by a professional engineer showing all work shown on the plans, any variations between the approved construction plans and the actual work performed and documenting city approval of all changes. Said plans shall be provided In both paper (throe copies), and in both PDF and AutoCad 2000 DWG (with full and clear data dictionary) electronic files. The Planning Board will accept a Letter of Credit: consistent with the standards In the Subdh4slon Regulations, to guarantee all work Is done and all plans are property prepared if the applicant wants to obtain Certificates of Occupancy prior to the completion of the project Findings: The Planning Board reviewed the special permit and site plan approval criteria: Criteria 1- detrimental use...: The board found that within the context of the zoning and the comprehensive plan, this project Is not detrimental or more detrimental than any other project developed consistent with Northampton zoning. Criteria 2-covenence and safety ...:The board found that with the proposed traffic mitigation measures (bike path, Intersection Improvements, sidewalks, payment In -lieu of fees) the project will not have adverse effects. Criteria 3- harmonious relationship ... :The board found that the layout Is consistent with development In this area and as such meets this criteria. Criteria 4- overload city services...: The board found that with traffic mltigadon, water Improvements and compliance with subdivision standards, and considering fire and DPW recommendations, the project will not overload city services. Criteria 5- special regulations...: The board found that the standards of the zoning ordinance have been met Criteria 6-positive relationship...: The board found that the project will provide housing with traffic mitigation, a rall ball spur, private street and infrastructure built to many of the same standards as public streets, open space, and keeping In mind that the traffic volumes are not huge. Criteria 7- promote city planning objectives...: The board found that the project Is consistent with Sustainable Northampton, with housing primarily in the traditional development area and open space primarily in the conservation development area. (((� M �5 E 1 " P E O V Lea D , APR 10 2008 CITY CLERKS OFFICE NORTHAMPTON, MA 01060 May 1, 2008 I, Wendy Mazza, City Clerk of Northampton, hereby certify that the above Decision of the Northampton Planning Board was filed in the office of the City Clerk on April 10, 2008, that twenty days have elapsed since such filing and that no appeal has been filed in this matter. Attest: City Clerk -Ci of 'NoXt GeoTMSV 2008 Des Laurlers Municipal Solutions'. Inc. � .. A.TTBST: HA SHM, a ,y 0 Qd a18T3R MARUNNE L. DONOH'UE January 4, 2011 Ed Jazab 9 Shepherds Hollow Leeds, MA 01053 Subject Property: 62 Chestnut Avenue Ext. (Unit #8 Evergreen Road) Leeds, MA 01053 Mr. Jazab The plans for the Single Family Residence dated 09 -04 -08 have been approved as noted; 1. Stamped engineering for I -joist submitted electronically before rough inspection. 2. Stamped engineering for roof truss system submitted electronically before rough inspection. 3. Stamped engineering for 13R sprinkler system submitted electronically before rough inspection. 4. Room by room heat loss calculations submitted electronically before rough inspection. 5. Structure conforms to 780 CMR 7 th addition 1 and 2 family with 2009 IECC prescriptive requirements or RES Check 4.4.1 and mandatory requirements. 6. Smoke and CO detectors per code, plan and as noted. a. See Plan markups 7. Add exit landing at atrium door. Summit additional plans for landing or deck before rough inspection. 8. A continuous air barrier is required behind tubs, spas, showers, fire places and electric boxes on exterior walls! Watch out of the tub comes out. Charles Miller Assistant Commissioner of Buildings Bk: 09482 Pg: 3 LLM Panning - Decision P City of Northampton Noarsn9 No.: PLN- 2008 -0038 Date: April 9, 2008 F APPLICATION TYPE: SUBMISSION DATE P8 Major Site Plan b Special Permit 2/13/2008 CITY CLERKS OFFICE App licant's Name: Owner's Na NORTHAMPTON, MA 010SOirve is Name: NAME: NAME: COMPANY NAME: Pat Melnik Beaver Brook Nominee Trust ADDRESS: ADDRESS: ADDRESS: 311 Chesterfield Road 110 King Street TOWN: STATE: ZIP CODE: TOWN: STATE: ZIP CODE: TOWN: STATE: ZIP CODE. Leeds MA 01053 NORTHAMPTON MA 01060 PHONE NO.: FAX NO.: PHONE NO.: FAX NO.: PHONE NO.: FAX NO.: 5841155 EMAIL ADDRESS: EMAIL ADDRESS: EMAIL ADDRESS: Site Information: limp 11111 STREET NO.: SITE ZONING: Bk• 9482Pg: 3 Page: 1 of 3 28 EVERGREEN RD URA Recorded: 05/12/2000 02:28 PM TOWN: SECTION OF BYLAW: NORTHAMPTON MA 01060 Ch t. 350 -10.5: Open Space Residential Development -- MAP: BLOCK LOT: MAP DATE: ACTION TAKEN: 11A 003 001 Book: ape: 1 NATURE OF PROPOSED WORK: ZPA - 25 UNIT CLUSTER DEVELOPMENT b COMMON DRIVEWAY HARDSHIP: CONDITION OF APPROVAL: FINDINGS: COULD NOT DEROGATE BECAUSE: FILING DEADLINE: MAILING DATE: HEARING CONTINUED DATE: DECISION DRAFT BY: APPEAL DATE: 2/21/2008 3/612008 4HO12008 REFERRALS IN DATE: HEARING DEADLINE DATE: HEARING CLOSE DATE: FINAL SIGNING BY: APPEAL DEADLINE: 2128/2008 411812008 3/27/2008 411012008 413012008 FIRST ADVERTISING DATE: HEARING DATE: VOTING DATE: DECISION DATE: 212812008 311312008 3/27/2008 4110/2008 SECOND ADVERTISING DATE: NEARING TIME: VOTING DEADLINE: IDECISION DEADLINE: 3/612008 7:30 PM 6125/2008 6/2542008 MEMBERS PRESENT: VOTE: Katharine G. Baker votes to Grant Stephen Gilson votes to Grant Jennifer Dieringer votes to Grant Keith Wilson votes to Grant Kenneth Jodde votes to Grant MOTION MADE BY: SECONDED BY: VOTE COUNT: DECISION: Kenneth Jodrle Keith WAson 5 Approved with Conditions MINUTES OF MEETING: Minutes are available In the Office of Planning b Development Appeals of this application may be made In the appropriate court within the statuatory 20 day appeal period. 1, Wayne Felden, as agent to the Planning Board, certify that this is a true and accurate decision made by the Planning Board and that a copy of this has been filed with the Board and the City Clerk on the decision date shown above and has been malted to the Owner and Applicant GeoTMS® 2008 Des Laurier Municipal Solutions, Inc.