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07-024 V Ai BP- 2010 -0156 GIS #: C OMMONWEALTH OF MASSACHUSETTS 8§0 04 : ` 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- 2010 -0156 Project # JS- 2010 - 000192 Est. Cost: $1000.00 Fee: $64.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg. 1): 250034.40 Owner: ROTHENBERG BARRY C & AMY S WOLPIN Zoning: RR(100) //WSP Applicant. ROTHENBERG BARRY C & AMY S WOLPIN AT. 489 NORTH FARMS RD Applicant Address: Phone: Insurance: 489 NORTH FARMS RD (413) 586 -4129 (� FLORENCEMA01062 ISSUED ON :811412009 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 16 X20 LEAN TO CONSTRUCTION TO COVER CARPORT 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 Shmature: FeeType: Date Paid: Amount: Building 8/14/2009 0:00:00 $64.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo File # BP- 2010 -0156 , APPLICANT /CONTACT PERSON ROTHENBERG BARRY C & AMY S WOLPIN ADDRESS/PHONE 489 NORTH FARMS RD FLORENCE (413) 586 -4129 Q PROPERTY LOCATION 489 NORTH FARMS RD MAP 07 PARCEL 024 001 ZONE RR(100) //WSP 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 16 X20 LEAN TO CONSTRUCTION TO COVER CARPORT New Construction 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 INF 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 Demolition Delay 1 �x3 1-�6 V 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. }y r Department use-only, . City of Northampton 'j" Building Department Garb 6t/©nv6' a Permit'' 212 Main Street SeWer /SeptacAvailability Room 100 Water/W6,l Availability I !_; Northampton, MA 01060 Two 5etsof Structural PJans " phone 413- 587 -1240 Fax 413 -587 -1272 Rot/Site Plans J"O Or"S.pe 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 A'1 Zone Overlay District Elm St. Distric CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record 154 j Rortht,% y y 8'e; Iy. PQ f^ 5 1ZW • F 7 /n• M, Name ( Current Mailing Address: +r • I& Telephone %11 3 f &'G y /- y/ ?9 3ry Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only com feted by ermit applicant 1. Building f l 000, (a) Building Permit Fee 2 Electrical (b) Estimated Total Cost of Constructionfrom 6 3. Plumbing Building` Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2+3+4 + 5) 'Check Number t This Section For Official Use Onl Ruilding Permit Number: Date Issued: Signature: I 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. ,a._ .._. R. ____ Rear _.. Building Height Bldg. Square Footage + z ....... u % { Open Space Footage ° (Lot area minus bldg & paved',:,,1 p arkin g ) ~ # of Parking Spaces 2 -' Fill: v (volume & Location) _._ ~_. _.~ _...,, ~. _, ~_ ~, A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES IF YES, date issued:Y IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book „._�._�....._ Page� m_.._.___.._ � _ and /or Document #.. B. Does the site contain a brook, body of water or wetlands? NO a DON'T KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , 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 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 ❑ Addition ❑ Replacement Windows Afteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks Siding [01 Other [ Oj Brief Description of Proposed 0 Work: ev r: 4'!. y 41 art rN t 4 . Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes r.-' No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet Ga. if New house and 'or addition to existing housing; complete the follow 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. 1. 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 a"� y Ruttier. S�.- 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. �_- J —O Signature of Owner Date 1, - jA�✓ -y P.wIsG�'y as Owner /Authorized Agent hereby de fare that the statemenf. 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 Signature of Owner /Agent Date 1 J 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 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; ON'* mptio The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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, van may be liable Rn pi isuu(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 a The Commonwealth of ffassachusetts Department of Industrial Accidents � Office of Investigations v := 7 .„. 600 fEashington Street Boston, 31A 02111 WWN'.r7raSS.govldla Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information nn �/� L Please Print Legibly Name ( Business /Organization/Individual): �a d ✓u P� 1 "t ieiy4g_�qi _ Address: ll�/ /1/> Fa ✓MS r?../ T City /State /Zip: F- I o r - t " o e A1# o/DG zPhone #: y 13 X y / Z 4 F 2.re you an employer? Check the appropriate box: Type of project (required): I am a employer with 4. F I am a general contractor and I employees (full and/or part- time). * ave e su- contrach hired thb tors 6. ❑ New construction ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 7 Remodeling ship and have no employees These sub - contractors have 8. D Demolition working for me in any capacity. employccs diid leave wutkcrs' 9. ❑ Building addition o workers' comp. insurance comp. insurance.$ /r equired.] 5. We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing re ;. © I am a homeowner doing all work g airs or additions P 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' 13.0 Other comp. insurance required.] *Any applicant that checks box 131 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 isproviding workers' compensation insurance for my employees. Below is thepolicy and job site inform ation. 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 c rimina l 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 lip to $2.50 00 Hay against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations o f t DIA for insurance coverage verification. - I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date: Phone #• (3 ( ) y _/ 3 ?- 7- 7 C 3 6 Officinl rise 0 n11% Do not write in this area, to be completed by city or town ufficiuL Citv or Town: Permit /License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectricaI Inspector 5. Plumbing 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 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 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 fmal 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 understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Tate (— Address of work location Y 1 � Fq 0 ell s �o r-e .f1 0 id 6 z ON)CRALL' fcc AJ &PC U,4 r 4 Ti 14, y PM5 Foop-t 0 e A Ilk VP fi L L ' I c "' t E- pig e L4 X 5 Ru, T --------- - --NOTE - THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED. � o- 5 Q q v Y �T f . TO: THE BOSTON FIVE CENTS SAVINGS BANK, F.S.B. & FIRST AMERICAN TITLE INSURANCE COMPANY I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING MONUMENTATION ALL EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY # 250167 SURVE -NOTE - THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY p, F -- MORTGAGE LOAN INSPECTION PLAT- RANOALL NORTHAMPTON, MASSACHUSETTS IL PREPARED FOR 135032 tm HAYES FAMILY REALTY TRUST • . Sf� SCAL'E: 1"=100' JANUARY 23, 1992 HAROLD L. EATON AND ASSOCIATES, INC. �4 #4* REGISTERED PROFESSIONAL LAND SURVEYORS • 235 RUSSELL STREET - HADLEY - MASSACHUSETTS