07-024 (2) BP- 2010 -0156
GIS #: C OMMONWEALTH OF MASSACHUSETTS
ha CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categrv: 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(sq. ft.): 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 Si
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 O
PROPERTY LOCATION 489 NORTH FARMS RD
MAP 07 PARCEL 024 001 ZONE RR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp, 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
INF941MATION 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
I i' 1 26 v r i l
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.
�r
flepartmen# use only
City of Northampton 5ta #us of"Permrt
Building Department Curb, ut/{3n✓eway Permit
212 Main Street SevverlSep #�t Availability
Room 100 Wk&M/ell Availability
Northampton, MA 01060 Two 'Se'tsofStructural Plans
phone 413-587-12M Fax 413 587 - 1272 Plot/Site Plans
Other Specif�i
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
At Ft Map Lot Unit
Zone Overlay District
Lim St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
T3 arr j b . cr2 y 8 5 lj• Fa ✓.ti, 5 R.e . , 'L ?,4 .
Name (Print) Current Mailing Address:
'
Signature Telephone � � 3 f b-4 4 7 -q Y ?9 3fo
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
completed by ermit applicant
1. Building f/ coo. (a) Building Permit Fee
2, Electrical (b) Estimated Total Cost of
Construction'' from 6
3. Plumbing Building Permit Fee'
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) f dGi7 Check Number
This Section For Official Use onl
Ruilding Permit Number: Date
Issued.
Signature:
Building Commissioner /Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size _5..r,.,�? {v t.` _ " r
Frontage S vr _. �u r ! R
Setbacks Front
Side L. ._..._. R. .., L. ___ R :-- .._
Rear ._... —
.
Building Height ti
Bldg. Square Footage
Open Space Footage %
(Lot area minas bldg & paved
Arkin
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 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 ._...�..._. Page� and /or Document #.,.....
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signsexisi 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 NOY
IF YES, describe size, type and location: f
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 Alterations) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [CI] Other [a
Brief Description of Proposed " p
Work: L ar 1-0 eV rt G" v C 4 1 0 y+ f � 4 �, 1" �, s � CGt r �1111
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; complete -the following:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a qarage 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
ot r y Rot t[+e,n�ie.•q 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
I, � as Owner /Authorized
Agent hereby de fare that the statemenA 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.
— 3 a vey /`O ewb
Print
Signature of Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9. Registered Horne >Improvement:Contractar. 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` Ho.rne..Ownr, Ee�nptio
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 -vear 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 Massachusett€ General Laws Annotated, you may be liable fui peisuii(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Build ing Co de, -City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
` -. The Colnrnonwealth of3Iassachusetts
Department of Industrial Accidents
a = Office of In vestigations
600 iT'ashington Street
Boston, 31A 02111
www. rnass.g av /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Le6jbtN
Name ( Business /Organization/Indivi dual): ' F? a y it y P -o t v4.e�q
Address: y �� /V ► �R ✓ S 1'�e'
City /State /Zip: F I O rf " Oe / 0/0 Phone #: y I Z 4
Are you an employer? Check the appropriate box: Type of project (required):
1. F1 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 S. ❑ Demolition
working for me in any capacity. eniployecs tud Dave wuikers'
9. F Building addition
o workers' comp. insurance comp. insurance.
t ]
e uired. 5. ❑ We are a corporation and its 10. El Electrical repairs or additions
q officers have exercised their
3. I am a homeowner doing all work 11.❑ 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 13.❑ Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information.
' 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
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 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 tip to .$750 00 a clay 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 under J/the pains and penalties ofperjui) that the information provided above is true and correct.
Signature: /1 Date'
Phone #: t 3 Y t 4 CoO y/ 3 z & z- 7 g 3(w
Officio/ rise only. Do not w rite in this arcs, to he completed by city or tower ucfuL
City or Town: Permit /License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrica] Inspector 5. Plumbin71nspector
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 final 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
1, 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 9
Address of work
location Y �s c1 /V ' Fa'''''' } /-
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-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.
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09
17'
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55'±
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
SURVEYOR il!E -�vy -NOTE-
Owl THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
-- MORTGAGE LOAN INSPECTION PLAT -
RANOALL NORTHAMPTON, MASSACHUSETTS
E PREPARED FOR
mm HAYES FAMILY REALTY TRUST
13'5032
: �,�1► SCALE: I"=100' JANUARY 23 1992
HAROLD L. EATON AND ASSOCIATES, INC.
�• - � ` � REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET - HADLEY - MASSACHUSETTS
5 814 5 q �