46-058 (5) 503 MT TOM RD BP- 2010 -0649
G1S #: COMMONWEALTH OF MASSACHUSETTS
Map .-Bloc 46 - 058 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2010 -0649
Project # JS- 2010- 000512
Est. Cost: $28650.00
Fee: $171.60 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CHARLES SEDER 94375
Lot Size(sq. ft.): 117612.00 Owner: GLAZEWSKI HELEN S & MARY
Zoning: SC(100) / Applicant. CHARLES SEDER
AT. 503 MT TOM RD
Applicant Address: Phone: Insurance:
117 MOUNT WARNER RD (413) 315 -0045 WC
HADLEYMA01035 ISSUED ON :11812010 0 :00 :00
TO PERFORM THE FOLLOWING WORK.- RENOVATE INTERIOR 1 ST FLR & ENLARGE
EXISTING DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 1/8/2010 0:00:00 $171.60
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0649
APPLICANT /CONTACT PERSON CHARLES SEDER
ADDRESS /PHONE 117 MOUNT WARNER RD HADLEY (413) 315 -0045
PROPERTY LOCATION 503 MT TOM RD
MAP 46 PARCEL 058 001 ZONE SC000V
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 04 0
Fee Paid
T_ypeof Construction: RENOVATE INTERIO 1 ST FLR & ENLARGE EXISTING DECK
New Construction
Non Structural interior renovations
Addition to Existing -
Accesso1y Structure
Building Plans Included•
Owner/ Statement or License 94375
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Comnnttee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition lay
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.
Department use only
City of Northampton Status of.Permit:
Building Department Curb ''CuttDriveway Permit
212 Main Street Sewer/Septic Availability+
Room 100 Water/Well Availability
Northampton, 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
; '
503 MOUNT TOM ROAD - NORTHAMPTON, MA Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record
MARY GL AZEW S KI 503 MOUNT TOM ROAD - N
Name (Print) Current Mailing Address:
413 - 744 -35
Telephone
Signature
2.2 Authorized Agent:
CHARLES SEDER (DBA SEDER & SON) CHARLES SEDER (DBA SEDER & SON)
Name ) Current Mailing Address:
413- 315 -0045
Si t Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building 28,650 (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) 28,650 Check Number Q
This Section For Official Use Onl
Building 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
Frontage
Setbacks Front
Side L: R: _ L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page' and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 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 U 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 Alteration(s) 0 Roofing ❑
Or Doors M
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[Z] Siding [0] Other [O]
Brief Description of Proposed
Work: INTERIOR FRAMING LAYOUT CHANGED/NON- BEARING PARTITION WALLS /FRAMINGTNSULATION /DRYWALL - EXTERIOR DECK -MISC WORK - SEE ATTACHED PRINT
Alteration of existing bedroom Yes XX No Adding new bedroom Yes XX No
Attached Narrative Renovating unfinished basement Yes XX No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the followina:
a. Use of building: One Family XX Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms 2
c. Is there a garage attached? Y ES
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? 2.5
f. Method of heating? BBHW Fireplaces or Woodstoves NONE Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction W OOD FRAME
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain r' Yes No
j. Depth of basement or cellar floor below finished grade OPJ (o(ZA DE
k. Will building conform to the Building and Zoning regulations? )' Yes No.
I. Septic Tank City Sewer 3, Private well City water Supply A--_
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
MARY GLAZEWSKI as Owner of the subject
property
hereby authorize CHARLES SEDER
to act on my behalf, in all matters relative to work authorized by this building permit application.
01/05/2010
Signature of Owner Date
CHARLES SEDER 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 Nam
01/05/2010
Signatur f Owner /Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder CHARLES SEDER 94375
License Number
117 MOUNT WARNER ROAD 08/18/2011
Addres Expiration Date
413- 315 -0045
SignaturX Telephone
9. Realstered Home Improvement Contractor: Not Applicable ❑
SEDER & SON if Lcanits StDClL 151088
Company Name o Registration Number
117 MOUNT WARNER ROAD 05/16/2010
Address Expiration Date
Telephone 413 - 315 -0045
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...... ❑ ON FILE FOR THIS ADDRESS WITH TOWN OF NORTHAMPTON
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, AL4 02111
www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
A Wicant Information Please Print Le4ibly
Name ( Business / Organization /Individual):
Address: S t GI7 L Jcu.-A y
City /State /Zip: / , A Phone.#: f // 3 I-S
Are you an employer? Check the ppropriate box: Type of project (required):
1. O�T a employer with _c_ 4. E] I am a general contractor and I 6 ❑ New construction
employees (full and/or part time).* have hired the sub- contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7.�Remodeling
ship' and have. no Ploy ees These sub contractors have � l
8. Demolition
wo rking forme in any ca employees and have workers' 7ng - ad
co tntrrran Q Buil gditTOn
[No workers comp. insurance - co .
5. [I We are a corporation and its 10 -Q Electrical repairs or additions
required-]
officers have exercised their 11. Plbin r ails or additions
3. F I am a homeowner doing all work ❑ g eP
myself [No workers' comp- right of exemption per MGL 12. [] Roof repairs
insuran required.] t c. 152, § 1(4), and we have, no -
employees. [No workers' . 13.0 Other
con3p. 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 naive 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.
f 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. #: n Expiration Date:
Job Site Address: 5 U 11-Cr .� City /State/Zip: 01,. i
Attach a copy of the workers' policy declaration page (showing the policy:number; snd.exptration date).
Failure to secure coverage as required ender Section 25A'of MGL c. 152 can lead to the inlposihon of ctiminai penalties of a
fine up to $1,500.00 and/or one -year hnpnsonment, as well as civil penalties in. the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a e py of this statement maybe forwarded to the -Office of
Investizations of th e p for insurance coverase verification
I do hereb • certi der the pains and penalties ofperjury that the information prnvidedlrbovP_is frue�ndorrec�__.__
. ,
Sienature: Date: / / 't L
Phone #: 7 �'l .3/
Official use only. Do not write in this area, to be completed by city or town official
City or T u riu: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical nspector 5. PIumbing 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 Iegal 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."
Additionally, MGL chapter 152, §25C(7) states "Nei*fher 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
P i ase fill out the workers' comnencatinn of ii:ll it r- r,mniPr _� + +;
- -- i atien
- - -- -
dud, if
necessary, supply sub- conti-actor(s) name(s), address(es) and phone number(s) along with their certificates) of
insu ra n ce. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a 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 pe=t 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 permit/license 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
pnliryinfnrmstinn, (if fneresrary) and under "Job Site Addrood' the applicant should writc. "4'6c UjlS is (City or
town)." .A: copy of the affidavit that has been officially stamped or marked by the city or town may provided.to the
applicant as proof that a valid affidavit is .on file. for future permits or licenses. Anew affidavit_must be filled_out each _
year s:or
ere ahouie owner or cifzenss:obta license arpermit not - related °
Wh #o.anybusinesonnnereia venture er - — --
(i.e. a dog - license or permit to -bkim leaves etc.) said person is NOT required.to'complete this affidai&-
The Office oftu'ves4 atiuu5 wuulti like [u hank you in aftatte for your cooperatron and should you have any questions,
please do not hesita by a us a rill. _ _ ,.._ . _
Thei�artrnent's `address ;telephone- and'fax number.
The Commonwealth of Massachusetts
i Department of IndusWal Accidents
Of of l
. — �44 �ag�r.� Street
13oston MA 0-2 111
Tel. # 617-72
7-49M ext 406 or 1- 977- MASSAFE
Revised 11 -22 -06
Fax # 617 727 -7749
Vt?�'W.II2�S.S_�O.V�dT� t
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Vreeland Design Associates a'� DAVID A. tiN
g VREELAND
An integrative approach to residential design, en and site planning ° No. C y
Date: January 5, 2010 ' T``��
Re: Mary Glazewski, 503 Mt. Tom Road, Northampton, MA: ENTRY DECK ENTENSION
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116 River Road, Leyden, MA 01337 Phone: (413) 624 -0126
Email: dvreeiand @verizon, net Fax: (413) 624 -3282