44-052 1140 FLORENCE RD BP-2011-0040
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Bloc 44 - 052 CITY OF NORTHAMPTON
1 .,
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 -0040
Proiect # JS- 2011- 000069 _
Est. Cost: $145500.00
Fee: $860.00 PERMISSIONIS HEREBY GRANTED T
Const. Class: Contractor: License:
Use Group: ROY OMASTA 006763
Lot Size(scl. ft.): 165963.60 Owner: SHEEHAN JEAN C
zoning: SR(100) Applicant: ROY OMASTA
AT. 1140 FLORENCE RD
Applicant Address: Phone: Insurance:
21 North St (413) 247 -5666 Workers Compensation
HATFIELDMA01038 ISSUED ON. 712012010 0 :00.00
TO PERFORM THE FOLLOWING WORK.- CONSTRUCT 2284 SQ FT ATT
GARAGEM/ORKSHOP - RESIDENTIAL USE ONLY
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:
Finals 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 7/20/2010 0:00:00 $860.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2011 -0040
APPLICANT /CONTACT PERSON ROY OMASTA
ADDRESS/PHONE 21 North St HATFIELD (413) 247 -5666
PROPERTY LOCATION 1140 FLORENCE RD
MAP 44 PARCEL 052 001 ZONE SR(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 2284 SO FT ATT GARAGE/WORKSHOP
New Construction ,
Non Structural interior renovations 7K • y l
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/ Statement or License 006763
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
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
Demolition Delay
e.�� - rq r0
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413- 587 -1240 Fax 413- 587 -1272,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
:SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address
40 F' og-m -vtt Map Lot Unit
F ' Zone averloy'Ali nc
Elr►t St - District ' m District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
- o
Name ( t) Current Mailing Address: ryi 3S�S
Telephone d
Sign
2.2 A thorized Agent:
Name (Pri nt) 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 y J S'bp (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
�d �D Construction from 6
3. Plumbing Building, Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) j $��� Check Number
This Section For Official Use Onl
Date
Building Permit Number. 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
d
r s 1 9 1 f 1" f S �`� �r Building Department
Lot Size
Frontage
Setbacks Front - 670 =6- --
Side L 1 R. d L: Wi ` R• M L f
Rear a i
Building Height
Bldg. Square Footage o0 %
Open Space Footage %
(Lot area minus bldg & paved��
-kin
# of Parking Spaces --
Fill:
volume & Location s
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW (Er YES 0
IF YES, date issued: i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNO YES 0
IF YES: enter Book Page I and /or Document # ;
B. Does the site contain a brook, body of water or wetlands? NO (D-- DON KNOW Q YES 0
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 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 (D'
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTIOK OF PROPOSED WORK he
(cck all aplollcable)
N6w House Addition Replacement Windows Alteration(s) Roofing D
Or Doors EJ
Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [M Siding [O] Other [
Brief Description of Proposed ,
V/ork: A laUSc
l S � .�D '1 o A2 !7
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes . No
plans Attached Roll -Sheet
e
a . Use of building: One Family Two Family Other
b. Number of rooms in each family unit:
C '� Number of Bathrooms o
C. Is there a garage attached? e J -
d. Proposed Square footage of new construction. 07 g 1 Dimensions
e. Number of stories? 0
f Method of heating? 0 / (- de_a< Fireplaces or Woodstoves ----- Nu mber of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction k) _ A 11
i Is construction within 100 ft. of wetlands? Yes 1. , - No. Is construction within 100 yr. floodplain Yes 4--*
J Depth of basement or cellar floor below finished grade �e
k. Will building conform to the Building and Zoning regulations? Yes No.
I, Septic Tank City Sewer Private well City water Supply _k�_
SECTION 7a - OWNER AUTHORIZA11ON 14 B15 COMPLETED . WHEN . .
OWNERS AGENT OR CONTRACTOR APPLIES FOR BCfILDING FERMI L
I,
J& h Y1 G S n e e. A Cif as Owner of the subject
property
hereby author a D (vim`
to act my half, n a a el ' e work authorized by this building permit application.
S' at f Owner Date
rl, as Owner /Authorized
Agent here 6y 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.
/ti�4S�if
Print Name —7//
Signature of Owner /Agent Date /
T
Yie Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
,. www.massgov /dia
•Workers' Compensation Insurance Afffdavif:.BuiIders/ Contractors %Elect ans/PIumb.ers
Applicant Information Please Print L j ibly
Name usiness /orgmiz ionadividual): D h09 Sfl y; t� S ti
( B
Address :
City /State/Zip: T� 1 `�' `�`� /� ► o /9 3 9 Phone. #:
Are ou an employer?. Check the appropriate'box: 'Type of project (required)• " /�
1. I am a employer with 4 .. (] I am a general contractor and I ❑ New constrictio
have hired the sub' contractors 6. n
employees (fill and/or part-time)_* - 7. Remode
2. [] I ant a sole proprietor or.partncr -- listed on- tho:attachccl sheet ❑ � .
ship' .� have n_a epployees These sub - contactors have 8. 0 Demolition
for -me in any ct Ioyces_- andlzave workers'
wor II dmg'a d lion
king Y tY• _ _ m��r� r "..... — '.....
[Ns wolkers''eomF iastuzsice 10 Electxicat airs or add'iti'ons
require J
5.E] We_are a corporation and its rep
officers haveacercised their 11.❑ Plumbing repairs or additibns
3. I am a homeowner doing all work r _
myself [No workers' com}�. right of exempilori per MGL 12: [] Roof repairs
insurance re . ed 1 .c: 152, § 1 {4), and we have no
q� 7 � o9 ees [N" 13.� Other
t : o workers -
comp. insurance regtiued ).
'Any applicant at b cheela box #1:must.also fin out the section belaw showing t�eawackcs' eort�peasatiori po &cy information
t $o�ownets who submit this a$ davit:indicating t doing an workand then. bire outside contractors must submit anew "affidavit indicating such.
iContracton that check this box must.attached as additional shed showing the nanse of the sub = contractors and state wltetlieror not -tbm entities bave
employees. if the subcontractors have employees; they mmt provide then wmi=s' comp. poficyuumbcr.
I am an employer that u providing workers' compensation insurance for m employees Below is the policy and job site
irtf J
Insurance Company Name: h !
nation Date: fl 1
Policy # of ins: Lie # �y 3
Job Site Address: " t x' �Ae� City /Stafe/Ztp
Attach a copy of the workers ' compensation policy declaration page'(showing the policy number and:exp on date).
Failure . for secure coverage: as tequi ed urinf&i Secttony23A of MCrL � 13Z cazi lead to ffie innposrtiiiri ofcri l penalties "gf a
fine up to $1,500.00 and/or one -year imprisonment;' as welt, as civil penalties in the form of a STOP WORK -(MDER and a fine
of up tp $250 00 a day against the violator Be advised that a copy of this statement maybe forwarded to f O# ce of ,
T eby ceriz ..un a;tts aloes u .- erjwy,thethe in ormatton ro vrdeilnbuv lrtce_attdcorrer __.
I do her p p .... fP f p'.
i . hire .
ate.
Phone#
Offtcral use only. Do not write in this area, to be completed by t:#y or town officraL
City or Town: Permit/License #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. Ciq/Town Clerk .4. EIectrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
r
The Commonwealth of Afassachusetts
Department of Industrial Accidents .
Office of Iniestig, ations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information / Please Print Le* 'blv
Name ( Business /organization/Iadividual): D /1/! Sffl t/; l ea
Address � J Qay ,
City /Statdzip: l ` /tit 01!03F Phone. #: 2�
Are ou an employer ?.Check the appropriate'box: - Type of project (required) :
a�dltl . /�
1.I am a employer with 4.. E] I am a general contractor and I ❑
employees (fail and/or part-time). * have hired the sub contractors 6. New coastiuction
2.. ❑ I ani a sole proprietor or partner- listed on- the.attached sheet 7. ❑ Remodeling
' s hip and have no loyees These sub - contractors have. .8. C1 Demolition
working for me in any capacity. �loyees_and Kaye workers' 9 - Biiit
.:C@IItp, mattranrr # dj
R;o workers' comp. instma _ lo. i= r .
re4uiretiJ 5. [f We are a corporation and its ❑ Electrical repairs or addinons
officers have Exercised their 11. Phnnb' r
'3. ❑ I am a homeowner doing all work r . ❑ ing repairs or additions
myself [No workers' comp. right of exemptzori per MGL 12. Roof airs
insurance re quired ] t c: 152, § 1(4); and we have no
1 ees: o wo*ers'. 13.0 Other
.. �P oy �.
comp. insurance re4ired.1
'Any applicant ghat checks box #1 nx=,also M out the section belawshowing d1**orkcs'.v- tioa policy bfomation:
t Homeowners who submit this affida;nt.incficatiag they are doing an work and then bite outside conhactats must submit a new affidavit indicating such.
1 Coanactnr3 that check this box must.aawhed an additional shed showing the name of the subcontractors and state w6therornot3bose entities have
employees. 'If the sub - contractors bave employers; d*y must provide dicir workers' comp - .policy number.
I am an employer that is providing workers' compensation brsurwtce for. ray emPloyeem Below is the policy and jokske
informatfom J
Insurance Company Name: C S
Policy # or Self -ins. Lic. ? 31 Exp i ration 1 f / f 1 i /
J ation Daze: �/
Job Site Address: I l q-0 �tiAe� o� City/State/Zip: /nN %� J D b
Attach a copy of the workers" compensafion policy declara#tou page (showing the policy number and ezPirahon date).
�. a
Fa$ure. to secure coveragd as repaired u si cfdon 25A 'of1v7GL c. 152 can lead to fhe iriipositiiiri I'penat$es of a
fine up to $I,500.00 and/or one- y= as well as civil. penalties in the form of i STOP WORK -ORDE and a fine
of up to 3250. a -day against the violator Be advised that a copy of this statement maybe forwarded to the 0 ` 9 = of ,
�.. _
- fes cations of tticblA: for insurance' coverage vei7fication `
_I do A ereby cerh . u _ - patns enalties o _ that the in ornratcon rovided aZrav= _andrarr
p-..- f-pm*y p
si tulle: ate //
Phone # atp
Offidcal use only. Do not write in this area, fo he completed by city or town o_#zcW
City or Town: PermltUcense #
Issuing Authority (circle one):
J. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical 5. Plumbing Inspector
6.Other F
Contact Person: Phone #: