38B-025 7
COMMONWEALTH OF MASSACHUSETTS •
HAMPSHIRE, S.S.
On this twelfth day of May, 2011, before me, the undersigned
Notary Public, personally appeared MARY E. O'NEILL who proved to
me through satisfactory evidence of identification, which was either a
driver's license or long time personal knowledge, to be the person whose
name is signed on the preceding or attached document, and
acknowledged to me that said person signed it voluntarily for its stated
purpose, before me,
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.............. ■AP
, J M F < ' -_ Patric f elnik, Jr.
o P;AR F'F
9 NO ' ARY PUBLIC
4 1-' ' 1V53 I MY COMMISSION EXPIRES:
N oc'o,� 1, ��:' February 9, 2012
5919poa(1 -7) Oj .SSACH' \�
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22. ENFORCEMENT:
Should a third party refuse the authority of this valid instrument, I
direct my Agent to use any of my resources, as necessary, to achieve a
remedy by whatever means required, including litigation.
23. VALIDITY:
This instrument shall be valid unless specifically revoked by me,
regardless of how long ago it was executed.
In the event that protective proceedings are commenced by any
person, for any purpose, I hereby nominate, pursuant to the provisions of
Massachusetts General Laws, Chapter 201(B), Section 3(b), my Agent
to be my Conservator or Guardian of my Estate or other fiduciary as
applicable.
Any third party may rely on a photocopy of this document which
has been attested as a true copy by a Notary Public.
IN WITNESS WHEREOF, I have hereunto set y hand and seal
this tw- fth day of May, 2011.
�/
ss Mary E. O'Neill
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17. DISCLAIMERS:
To execute any disclaimers of any interest I may have in another's
estate of assets as my Agent determines is consistent with my Estate
Plan.
18. SAFE DEPOSIT BOXES:
To gain access to any safe deposit boxes I May have and to remove
the contents thereof.
19. HIRE OTHERS:
To hire Accountants, Attorneys, Clerks, Workmen or others to
provide care for me, to remove them and appoint others in their place,
and to pay such persons such salaries, wages or other remuneration, as
my said Agent deems fit.
20. CONSERVATOR/GUARDIAN:
If it becomes necessary to appoint a Conservator or Guardian for
me I nominate my Agent named herein to serve in those roles.
21. GENERAL:
Without in any way limiting the foregoing, generally to do,
execute and perform any other act, deed, matter or thing whatsoever, that
ought to be done, executed or performed of every nature and kind
whatsoever as fully and effectually as I could do if personally present. It
is my specific intent that my said Agent shall have the power and
authority to undertake all and any manner of activity regardless of
whether such activity or a category of activities has been specifically
mentioned in this Durable Power of Attorney, and all persons dealing
with my said Agent may rely upon this provision as providing him or her
with authority to act in y behalf, even if no other provision appears to
give him or h r tha ority.
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13. INSURANCE:
To sell, borrow upon, assign, collect proceeds or otherwise deal
with any insurance policies, including life insurance, health insurance
and National Service Life Insurance or Annuity Contracts I own,
including changing the beneficiary of any such policy.
14. BORROW:
To borrow money and execute such notes, mortgages, pledges or
other agreements, upon such terms and with such security as said Agent
shall deem necessary or incidental thereto.
15. TAXES:
To receive and inspect confidential tax information from the IRS
and from relevant state tax authorities and to execute on my behalf any
tax return and act for me in any examination, audit, hearing, conference
or litigation relating to taxes, including authority to file and prosecute
refund claims, enter into any settlements, and to make any tax election.
16. PUBLIC BENEFITS:
To apply for, on my behalf, any public benefits to which I am
currently entitled or may become entitled to in the future including, but
not limited to, Medicare, Medicaid, SSI, SSDI, unemployment, workers
compensation and social security. I authorize my Agent to obtain any
and all verifications required in order to apply for said public benefits
including, but not limited to, bank records, investment fund records,
stocks and mutual fund transactions, life insurance information, and birth
and immigration records. I authorize my Agent to receive such benefits
on my behalf, if necessary.
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required by brokerage firms, and to make, executed and deliver
assignments of any such shares of stock, bonds or other securities, as
well as to vote shares, sign proxies, and exercise any other rights I may
have as a shareholder, including the surrender of shares.
9. SAFE OF ASSETS:
To sell, any and all of my property real, personal or mixed for such
price as may be fair and reasonable in the circumstances, and upon such
conditions, including credit, as may be necessary to meet my needs.
10. REAL ESTATE
To enter into, on my behalf, any agreement to sell, rent, lease or
exchange any real estate in which I have an interest including, but not
limited to, signing leases, broker's agreements, closing papers,
warranties and deeds. My Agent shall have authority to sign Deeds in
his or her own name, identified as my Agent and to have their signature
acknowledged by a Notary Public.
11. "TRUSTS:
To transfer assets into any existing Trust created by me, to
withdraw funds from a Trust, to execute, amend (to the extent permitted
by such instruments) and to fund revocable and irrevocable inter -vivos
trusts in order to carry out the dispositional purposes of my estate plan,
and to revoke any Revocable Trusts I may have established.
12. GIFTS:
To make gifts during my lifetime, including gifts of real estate, to
family members (including my Agent), as well as to such other persons
or institutions named in my Will.
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4. CONTRACTS - GENERAL:
To enter into, make, sign, execute and deliver, acknowledge and
perform any contract, agreement, writing or other document that may, in
the opinion of my said Agent, be necessary or proper to be entered into,
made or signed, sealed, executed , delivered, acknowledged or
performed.
5. CLAIMS:
To demand, sue for, collect, recover and receive all goods, claims,
debts, monies, interest and demands whatsoever now due, or that may
hereafter be due, or belong to me (including the right to institute any
action, suit or legal proceeding for the recovery thereof), and to make,
execute and deliver receipts, releases or other discharges therefor, under
seal or otherwise.
6. SETTLEMENT:
To defend, settle, adjust, compound, submit to arbitration and
compromise all actions, suits, accounts, reckonings, claims and demands
whatsoever, that now are, or hereafter shall be pending between me and
any person, firm or corporation, in such manner and in all respects as my
said Agent shall deem fit.
7. INVESTMENT:
To purchase, sell, invest, reinvest and in general, to manage my
assets in a manner which is consistent to meet my needs.
8. STOCKS, BONDS AND OTHER SECURITIES:
To buy or sell any and all shares of stock, bonds, debentures,
mutual funds, or other securities that I own or may own issued by any
association, trust, partnership, limited partnership or corporation,
whether private or public, to collect the dividends, interest, or other
payment thereon, tope ) u� counts and sign any and all forms
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DURABLE POWER OF ATTORNEY
MARY E. O'NEILL
I, MARY E. O'NEILL, (hereinafter "Principal ") of 22 Fort Hill
Terrace, Northampton, Hampshire County, Massachusetts with a Social
Security Number of 016 -20 -2744 do hereby make, constitute and appoint
DAVID CORBETT of 38 Fort Hill Terrace, Northampton, Hampshire
County, Massachusetts 01060 as my agent and Attorney -in -Fact
(hereinafter "Agent "), to act for me and in my name.
This Power of Attorney shall be governed by the Uniform Durable
Power of Attorney Act, pursuant to the provisions of Massachusetts
General Laws, Chapter 201B, Section 1(b). It is my intention to obtain
for myself and the person appointed by me as my Agent, the fullest
benefits possible under said Law. This Power of Attorney shall not be
affected by any subsequent disability or incapacity.
1. GRANT OF POWERS:
I hereby grant to my Agent the following general powers ,
intending by this enumeration to enlarge, rather than limit his or her
ability to do in my behalf anything which I might do for myself.
2. DEBTS AND EXPENSES:
To pay all sums of money at any time or times that I may hereafter
owe upon any check, draft or note made, executed, endorsed, accepted
and delivered by me, or for me, and, in my name, by said Agent.
3. BANKING:
To make, execute, endorse, accept and deliver any and all checks,
drafts, notes and other instruments; to deposit or withdraw any funds
belonging to me in one or more savings or checking accounts or in
certificates of deposit and to open or close any such accounts in my
Agent's discretion.
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• City of Northampton
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g DEPARTMENT OF BUILDING INSPECTIONS w w,
" '`` " 212 Main Street • Municipal Building
Northampton, MA 01060417
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any 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
I, 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.
Date
Address of work location
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Dr
� �;�„•, _�. 600 Washington Street �. .
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
i ''.
Name (Business /Organization/Individual): 6 S ' 2i
Address: -// 6 1j" .3?
C f( , � 7
City /State /Zip: 6,, n q -j t r"��` Phone #: (/ 5;2- �. '" q
Are you an employer? Check the appropriate Ifox: Type of project (required):
1. ❑ I am a employer with 4. J I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. New construction
2. Z4 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
These sub - contractors have
ship and have no employees 8. Demolition
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. [] We are a corporation and its 10.gi<eCtrical repairs or additions
3. El I am a homeowner doing all work officers have exercised their 11.EHTumbing 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.
Insurance Company Name:
Policy # or Self -ins. Lic. 14: 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 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 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 the pains an allies of perjury that the information provided above is true and correct
Signature: lG� Date: —3 /--Z
Phone #: l „c:21 - 76 1
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 #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicablg
Name of License Holder : (./V ��'�./t.0 . % Cci f�� 1-2;&
License Number
`� � �• i s �c � 7 i I1/
PA-
Address le; 7 Expiration Date
'//3 3.72 2-0
Sig nature Telephone
- ist -• �_ i , .7 a , �,x: . -- Not Applicable Re • istered�.�onie -Im • rovement; %Contractor . , �.� °� . , , . PP licable ❑
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 ❑
A= a �P " ale ° l s
ption
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 1083.5.1.
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
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`SECTION 5- DESCRIPTION OF PROPOSED WORK. (check all applicable)
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New House . [❑ Addition ❑ Replacement indows Alteration(s) [ Roofing n
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [D] Other [D]
Brief Description of Proposed _ l
Work: /fret 44..0 .Z tat w ? ' - ha - 'T /t a r
ck' �� �c ✓ IT C /3/
Ai k �1i ►� /1wr"T7 ( c /{ CUt- - /
Alteration of existing bedroom Yes V No Adding new bedroom Yes V No
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll - Sheet
sa ;t ` > e house. and.Znddition.to, housing, comp ete.the;,fo lowing:
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? I0
d. Proposed Square footage of new construction. mil" 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 .
I. Septic Tank City Sewer Private well City water Supply
$ EC CION 7a , OWNER AUTHO,RIZA1 ION , TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, O c /i f,' C . as Owner of the subject
property /^
hereby authorize j ° t3 c_ 4 _ . / 1, ct e
to act on my behalf, in all matters relative to work a6thorized by this building permit application.
-t .
Signature of Owner Date
, A , as • A uthoriz-
Agent heresy declare that the sta ents an. 1 • a ion on the foregoing application are true and accurate, to the best o nowledge
and belief.
Signed under the pains and penalties of perjury. /J "D
Print Name
�r / s
.i► i,nsds�r rte a ..._; . _ _ _ ;/ 3 4 z !'
Signa ure of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required byZoning
This column to b igby
Building Departmen ``
Lot Size i ' ! " .
Frontage
Setbacks Front f i ! 1 F
i
Side L: I R:' L:. R:i 1 ! i i E
Rear ' ,
Building Height _ _ 1 1 i 1
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved s 1 1 I I I
parking)
I i i
# of Parking Spaces 1 '
Fill:
(volume & Location) 1
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:t
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i f Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0-
IF YES, describe size, type and location: i 1
1
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO ef
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excav on, 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.
■ ��� < Deo rtmett u ort� m ,� - �
C y of Northampton S tus o F'ermlt
L B (ding D a t y ert
2 Main Street r �i c a ila b 1 1 , �
I t , Room 100 a e ( �Ay a ibli .
S ha pton, MA 01060 M o ru °farq, � ;
w» + ■ :y - - '7 -1240 Fax 413 587 - 1272 P n 'Si
+'�" tither S pecrFy � . 'f , x ,, :'
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address:
a This sect to be camplete office
7 y y . _ . i,:- „� ` 7. z M r ' l g ° �" # t .-, •
t -- rt .t �/ � 0 / f t j. 1 / �'� r , s '� Lot ks , t � ' + �. Unr t,,,---.7. r. -�' a
ell il.
Zone Overlay Drstnct
E St. D CB strict
is
SECTION 2 - PROP OWNERSHIPIAUTHORIZED
2.1 Owner of Record:
Name (Print) Current Mailing Address
Te
Signature '
2.2 Authorized Agent:
1) 19P r c) /C r, � ,i, - y7 1i �. !� 3 /� -'o�Zi 1� /LC /� l.7-6
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS „
Item Estimated Cost (Dollars) to be OfFcial Use.Onty
completed by permit applicant
1. Building t , ( Building Pem11t F
t
2. Electrical , (b) Estimated Total {l:s of
00 c Co nstr u c tlon from(6) _
3. Plumbing �' 0 S L, `,, 2> Bu dding Permi Fee ,: ,
4. Mechanical (HVAC) ,
5. Fire Protection: `'
6. Tota = (1 + 2 + 3 + 4 + 5) �i 5 �� .) t ,'"-;6 4. Check Number #1
,I, ` �
T This Section For Official use Only
. D a t e
Budding jPermit'Number: : `
Issued. :_ � ;. . , � :..
Signature.
Building Commissioner /Inspector of Building
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File # BP- 2012 -0816
APPLICANT /CONTACT PERSON EUGENE THOMAS
ADDRESS /PHONE 49 GRANT ST EASTHAMPTON (413) 529 -0902
PROPERTY LOCATION 22 FORT HILL TER OK_ .'�'
N OWN 6�
MAP 38B PARCEL 025 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY: 0 GLu l
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / `
Fee Paid
Typeof Construction:_REPLACE 2 WINDOWS,SHEETROCK KITCHEN CEILING & REPLACE CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 81882
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION PRESENTED:
I
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
3 / e 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.
�'�
2 -A U ( = `Z -t-3 SE rJ l S ivAvi L
22 FORT HILL TER BP- 2012 -0816
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 025 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- 2012 -0816
Project # JS- 2012- 001429
Est. Cost: $8500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EUGENE THOMAS 81882
Lot Size(sq. ft.): 4138.20 Owner: O'NEILL MARY E
Zoning: URC(100)/ Applicant: EUGENE THOMAS
AT: 22 FORT HILL TER
Applicant Address: Phone: Insurance:
49 GRANT ST (413) 529 -0902
EASTHAM PTON MA01027 ISSUED ON:3/27/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE 2 WINDOWS,UPDATE KITCHENS &
BATHS - UNITS 20 & 22
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 3/27/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner