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41-075 (3) dcr Massachusetts Department of Conservation and Recreation wr...a v....m Office of Water Resources G O Well Completion, Report 15- MAY -09 09:12:59 e WELL LOCATION 260663 , GPS North: 42 17.539' GPS West: -72 44.14' Address:23, Loudville Rd Property Owner /Client: Isamsgmgessmitmessaleellmis aka L.' O C'Plapoifu T cep Subdivision Name: Mailing Address: sr City /Town:Northampton City /Town, StateeRastha MA Assessors Nap: Assessors Lot #: Permit Number:2009 -01 ` Board of Health permit obtained :Y Date Issued: 04/07/2009 f 1 BBDROC[ From To Code Comment Water Drill Extra Drill Rust Loss/ # of (ft) (ft) Zone Stan Large Rate Stain Add of Frac Drou per ft 15.00 35.00 Schist Yellow Brown No N/A 35.00 46.00 Schist Yellow No N/A 46.00 51.00 Schist Brown Yellow No N/A 51.00 151.00 Schist White Gray Yes Yes Fast N/A 151.00 251.00 Schist White Gray No N/A 251.00 293.00 Schist Green White No N/A 293.00 393.00 Schist White Gray No N/A 393.00 403.00 Schist White Gray No N/A 403.00 420.00 Schist Gray White No N/A i 2/2 , d C r Massachusetts Department of Conservation and Recreation tir .a�..xm Office of Water Resources CD Well Completion Report 15 MAY - 09 09:12:59 WELL LOCATION 260663 GPS North: 42 17.539' UPS West: -72 44.14' Address:23, Loudville Rd Property Owner /Client 10.Mi- af(gelet4 ere r cdAp Subdivision Name: Mailing Address: m City /Town:Northampton City /Town, State:Eason MA Assessors Nap: Assessors Lot *: Permit Number:2009 -01 ` Board of Health permit obtained: y Date Issued: 04/07/2009 ( Work Performed Proposed use Drilling Method Overburden Drilling Method Bedrock New Well Domestic Air Hammer Air Rotary CASING From (ft) To (ft) Type Thickness Diameter 1.00 -40.00 Steel 17* 6.00 SCRS®T From (ft) To (ft) Type Slot Size Diameter WELL SEAL / FILTER PACK / ABANDONMENT MATERIAL From (ft) To (ft) Material Description Purpose WELL TEST DATA (ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) Date Method Yield Time Pumped Pumping Level Time to Recover Recovery (GPM) (hra is min) (Ft. BUS) Mrs is Min) (Ft. BUS) 04/21/2009 Air Blow with Drill Stem 2.0000 1:00 420.0000 1:00 30 STATIC WATER LEVEL (ALL WELLS) PERMANENT PUMP (IF AVAILABLE) Date Depth Below Ground Pump Description: , Measured Surface (ft) Type: Intake Depth: 04/21/2009 30 Mem na7 Pump Capacity: Horsepower: WELL DRILLER'S STATEMENT ADDITIONAL WELL INFORMATION Driller: Claude Barnes Developed: Yes Fracture Enhancement :Yes Supervisor: Kirke R. Henshaw Rig #:196 Disinfected:yes Well Seal Type:None Firm: Kirke R. Renshaw, Inc. Total Well Depth: 420.000 Depth to Bedrock: 15.000 Registration #:196 Date Complete:04 /21/2009 Comments: OVERBURDEN From To Description Color Cadent Water Loss /Add Drill Drill (ft) (ft) Zone of Fluid Stem Drop Rate .00 15.00 Gravel Light Gray No N/A l - 1/2 ZUMPJ -}S a'[:jj l4 0144 1 •+� Howard Laboratories 62 Main Street - Hatfield, MA 01038 Tel, (413) 247 -5533 Fax (413) 247 -9599 WATER ANALYSIS REPORT Henshaw Well Drilling Invoke Number: 14058 Sample Location: 23 Loudville Road, Northampton. Client: 1111111111111111 19 .•frt.L. i'e'ci Cv Sampled By: HWD '� Date Sampled: 05108/09 Date Received: 05/08/09 Parameter Results Limits Comments Total Conform Bacteria Absent Present/Absent OK E.Coll Absent Present/Absent OK Color 27 PtCo Color Units 15 PtCo Color Units # Iron 0.24 mg/L 0.3 mg /L OK Manganese 0.007 mg /L 0.05 mg /L 0K Nitrate 0,73 mg/I 10 rng /L OK Nitrite 0.006 mg /L 1 mg /L OK pH 7.22 pH Units 6.5 - 8.5 Ph Units OK Sodium 2 mg /L 20 mg/t. OK Conductivity 021 mS /cm No Standard No Standard Turbidity 2.53 NTU No Standard No Standard Chloride 51 mg /L 250 mg/I OK Hardness 86 mg /L No Standard <50 soft >100 hard Recommendations: This sample meets acceptable standards of potability. The parameters with an asterisk that are over the limit should go down after a few weeks as the water and materials floating in the well settle. Analyst: SEL Date: 05/13/09 Microbiology Certification: M -00851 Permit No. D12 -08 Conditions: Driveway Permit In lieu of plan approved by the City Engineer I agree to the following added conditions: 1. I will contact the Department of Public Works and have an inspector check and approve the graded gravel base prior to paving to insure compliance with slope and location; 2. I further agree that if in the inspections, any of the permit conditions are not met that I will at no expense to the City remove and replace the driveway as directed by the City Engineer. By: — 74 &de Petitioner Signature Name: Torn Bacis Address: 67 Division St. Easthampton, Ma 413 -529 -0801 Note: The Public Works Department recommends that you provide a plan showing the proposed driveway with grades and location in the future to avoid possible expense which you will incur by not getting approval of actual plans in advance. For Commercial and Industrial applicants, a plan showing the proposed driveway with grades and location is required. Cc: Building Inspector Li a p n i Permit No. D12-08 CITY OF NORTHAMPTON, MA DRIVEWAY PERMIT Date: 3/20/08 Check #: 4080 FEE: $25.00 THE BOARD OF PUBLIC WORKS Driveway must be staked and house & lot number posted The undersigned respectfully petitions your honorable body for: Permission to install a driveway at: 23 Loudville Road, Northampton, MA Fifteen (15) foot maximum width at the street line. Gutter drainage not to be disturbed. All Drainage shall be directed off the driveway surface to adjacent land and not on the existing Roadway. Driveway surface to be paved as soon as possible if the grade of the proposed Driveway exceeds 3% or more. Homeowners will be held responsible for any cost to the City Of Northampton in the event of a washout of this driveway. By: Tom Bats, 67 Division St. Easthampton, MA Telephone: 413 -529 -0801 Signature: A 75& Proposed Location Inspection By: C 7 . 3/ /fi Gravel Base Grade Inspected By: Final Approval: THE BOARD OF PUBLIC WORKS voted that petition be granted. Edward S. Huntley, P.E. Director of Public Works Cc: Building Inspector (SUBJECT TO ATTACHED CONDITION 1 & 2) u Y ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR ONE- AND TWO - FAMILY DETACHED RESIDENTIAL CONSTRUCTION (780 CMR 61.00) Applicant Name: P 4.4 Oevelepie,vr a Site Address: a3 i,oup j , //c jC print Town: i t11 }9 �, � �/� /' l 1 LJL✓ ,' Applicant Phone: if/ 3. ± 7- 3 97 S Applicant Signature: ' 4 .1/ Date of Application: P. /f 0C NEW CONSTRUCTION: (choose ONfrof the following two options) 780 CMR TABLE 6107.1 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR NEW ONE - AND TWO - FAMILY BUILDINGS MAXIlVruM MINIMUM D Ceiling or Option I: Slab Basement Fenestration exposed wall Floor p Perimeter AFUE HSPF SFFR U- factor floors R -Value R -Value R -Value R -Value R-- Value and Depth 1 National Appliance Energy P. -10, Conservation Act (NAECA) of .35 R -38 R -19 R -19 R -10 Aft 1987 as amended minimums or greater as applicable Note: This form is not required if you choose either of the two versions oT c neck as listed a Option 2: REScheck Version 4.1.2 or later variant software analysis must be completed (780 CMR 6107.3.2) I REScheck —Web which can be accessed at httpJ /www.ener_wcodes_aov /rescheck/ ADDITIONS OR. TL.L IO S,TO E7cCTINGBUILDINGS OVER ARS OLD *Buildings under 5 years old must use option ri l or #2 in New Construction section above. Complete the following formula to determine the % of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b _ a) SF 100 x — _ % of glazing (b) Glazing area equals SF b a Hazing is #0 %,'use the! ahart.be ow ' . g h 'i g is. ?.40 = '%1 proceed to ` SU NROOM" ' ' . n 780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTI LOW -RISE RESIDENTIAL BUILDINGS MAXIMUM 1MINIIMTUM ®, Ceiling and Slab Perimeter Fenestration w all Floor Basement wail U- factor Exposed floors R -Value R -value R -Value R -Value R -Value and Depth 39 _ R -37 a R -13 R -19 R -10 R-10. 4 -feet a R -30 ceiling insulation may be used in place of R -37 if the insulation achieves the full R- value over the entire ceiling area (i.e. not compressed over exterior walls, and including any access openings). SUNROOM — An addition or alteration to an existing building/dwelling unit where the total glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the addition. Note: Owner to fill out Consumer Information Form (found in Appendix 120.P) , a R1 HAMp CITY OF NORTHAMPTON, MASSACHUSETTS ?� "; DEPARTMENT OF PUBLIC WORKS ' �� . t` 125 Locust Street III 3 � t!R ,�. � oo ( Northampton, MA 01060 ^. 413- 587 -1570 Fax 413 - 587 -1576 Edward S. Huntley, P.E. Director ASSIGNMENT OF HOUSE NUMBER(S) Street: Loudville Road Assessors Map: Sheet 41 Lot 075 House Number: #23 Loudville Road Date: March 17, 2008 Remarks: Reference is made to Wetland Delineation Plan of Land in Northampton and Westhampton, Massachusetts Surveyed for Tom Bacis by Heritage Surveys, Inc. bearing a date of July 21, 2006. House #23 is assigned to Parcel 5 (containing 1.92 Acres ±) on said plan. Numbering of this lot was requested by the applicant for permitting purposes. i. i , Ai Jam: fa rila, P. City gineer cc: Central Dispatch Board of Health Water Division Tax Collector Sewer Division National Grid Streets Division Verizon Telephone Inspectors Comcast Assessors Bay State Gas Police Department Post Office (Northampton) James Thompson (GIS Coordinator) Post Office (Easthampton) Registrar of Voters Applicant: Tom Bacis 67 Division Street Easthampton, MA 01027 K: \House Numbers\ ffi (i D arz1 ant n , ^ � `' = - -- : ; _ E assac4ttsetfs % 1 " — 5 e '"' DEPARTMENT OF BUZI DWG INSPECTIONS '_ -- INSPECTOR 212 Main Street P •Municipal Building t/ 1y S ! " ' Northampton, MA 01060 LOCATION 93 kc,„JCu,/"C l«ts' SQUARE FOOTAGE AMOUNT BASEMENT @ .20 / I d 9g' • vo r ST FLOOR @.50 /Y90 il 7'62 vo • 2 FLR @ 0 • V36 l r3©:_ f7 FLOORS, FINISH Al 11C, GARAGE @ _20 j 7t k //5 • .R6 DECK/PORCHES @ - :20 90 0 7 CP- J 0 TOTAL. 4 /3 (09.00 2007 1ECC Energy I Efficiency Certificate > Ceiling / Roof 38.00 Wall 19.00 Floor / Foundation 19.00 Ductwork (unconditioned spaces): � Cler >s >H# .............................. ............................... Window 0.31 0.30 Door 0.15 NA i i:::: ``:: � <i ` ?i:i i >` #? Forced Hot Air Furnace 92 AFUE Water Heater: t Name: Date: Comments: ` Heating and Cooling Piping Insulation: ❑ HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R - 2. Certificate: A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R- values; window U- factors; type and efficiency of space- conditioning and water heating equipment. The certificate does not cover or obstruct the visibility of the circuit directory label, service disconnect label or other required labels. NOTES TO FIELD: (Building Department Use Only) Project Title: Dave Lapine Report date: 12/16/09 Data filename: C: \Program Files \Check \REScheck \Energy Audits \Lapine Dave \Loudville Rd Spec.rck Page 4 of 4 Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Heating and Cooling Equipment: ❑ Furnace 1: Forced Hot Air: 92 AFUE or higher Make and Model Number: Air Leakage: ❑ Joints, attic access openings, and all other such openings in the building envelope that are sources of air leakage are sealed. ❑ Recessed lights in the building thermal envelope are 1) type IC rated and ASTM E283 labeled and 2) sealed with a gasket or caulk between the housing and the interior wall or ceiling covering. ❑ Access doors separating conditioned from unconditioned space are weather - stripped and insulated (without insulation compression or damage) to at least the level of insulation on the surrounding surfaces. Where loose fill insulation exists, a baffle or retainer is installed to maintain insulation application. ❑ Wood - burning fireplaces have gasketed doors and outdoor combustion air. Sunrooms: ❑ Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U- factor of 0.50 and the maximum skylight U- factor of 0.75. New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Vapor Retarder: ❑ A minimum of Class II (1.0 perm) vapor retarder is installed on the interior side of above -grade framed walls or it has been determined that moisture or its freezing will not damage the materials. Exceptions: Class III (10 perm or less) vapor retarder is permitted for vented cladding over OSB, plywood, fiberboard, gypsum, or for sheathing over 2x4 framing having insulation of R -5 or better, or for sheathing over 2x6 framing having insulation of R -7.5 or better. Materials Identification and Installation: ❑ Materials and equipment are installed in accordance with the manufacturer's installation instructions. ❑ Insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R- value. ❑ Materials and equipment are identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. ❑ Insulation R- values, glazing U- factors, and heating equipment efficiency are clearly marked on the building plans or specifications. Duct Insulation: ❑ Supply ducts in attics are insulated to a minimum of R -8. All other ducts in unconditioned spaces or outside the building envelope are insulated to at least R -6. Duct Construction: ❑ Air handlers, filter boxes, and duct connections to flanges of air distribution system equipment or sheet metal fittings are sealed and mechanically fastened. ❑ All joints, seams, and connections are made substantially airtight with tapes, gasketing, mastics (adhesives) or other approved closure systems. Tapes and mastics are rated UL 181A or UL 181B. ❑ Building framing cavities are not used as supply ducts. ❑ Automatic or gravity dampers are installed on all outdoor air intakes and exhausts. ❑ Additional requirements for tape sealing and metal duct crimping are included by an inspection for compliance with the International Mechanical Code. Temperature Controls: ❑ Thermostats exist for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and /or cooling input to each zone or floor is provided. Heating and Cooling Equipment Sizing: ❑ Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code. ❑ For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2006 IECC Commercial Building Mechanical and /or Service Water Heating (Sections 503 and 504). Circulating Service Hot Water Systems: ❑ Circulating service hot water pipes are insulated to R -2. ❑ Circulating service hot water systems include an automatic or accessible manual switch to turn off the circulating pump when the system is not in use. Project Title Dave Lapine Report date: 12/16/09 Data filename: C: \Program Files \Check \REScheck \Energy Audits \Lapine Dave \Loudville Rd Spec.rck Page 3 of 4 REScheck Software Version 4.3.0 Inspection Checklist Ceilings: ❑ Ceiling 1: Raised or Energy Truss, R -38.0 cavity insulation Comments: Insulation must achieve full height over the plate lines of exterior walls. Above -Grade Walls: ❑ Wall 1: Wood Frame, 16" o.c., R -19.0 cavity insulation Comments: ❑ Wall 2: Wood Frame, 16" o.c., R -19.0 cavity insulation Comments: ❑ Wall 3: Wood Frame, 16" o.c., R -19.0 cavity insulation Comments: ❑ Wall 4: Wood Frame, 16" o.c., R -19.0 cavity insulation Comments: Windows: ❑ Window 4: Vinyl Frame:Double Pane with Low -E, U- factor: 0.310 For windows without labeled U- factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: ❑ Window 3: Vinyl Frame:Double Pane with Low -E, U- factor: 0.310 For windows without labeled U- factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: ❑ Window 2: Vinyl Frame:Double Pane with Low -E, U- factor: 0.310 For windows without labeled U- factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: ❑ Window 1: Vinyl Frame:Double Pane with Low -E, U- factor: 0.310 For windows without labeled U- factors, describe features: #Panes Frame Type Thermal Break? Yes No Comments: Note: Up to 15 sq.ft. of glazed fenestration per dwelling is exempt from U- factor and SHGC requirements. Doors: ❑ Door 1: Solid, U- factor: 0.150 Comments: ❑ Door 2: Solid, U- factor: 0.380 Comments: This door is exempt from the U- factor requirement. ❑ Door 3: Solid, U- factor: 0.150 Comments: Floors: ❑ Floor 1: All -Wood Joist/Truss:Over Unconditioned Space, R -19.0 cavity insulation Project Title: Dave Lapine Report date: 12/16/09 Data filename: C: \Program Files \Check \REScheck \Energy Audits \Lapine Dave \Loudville Rd Spec.rck Page 2 of 4 • REScheck Software Version 4.3.0 Compliance Certificate Project Title: Dave Lapine Energy Code: 2007 IECC Location: Northampton, Massachusetts Construction Type: Single Family Building Orientation: Bldg. faces 180 deg. from North Conditioned Floor Area: 1495 ft2 Glazing Area Percentage: 21% Heating Degree Days: 6404 Climate Zone: 5 Construction Site: Owner /Agent: Designer /Contractor: Loudville Rd. Dave Lapine Dave Lapine Northampton, MA Northampton, MA :gip : ��s��. ��.�� �����►.;:.;:.;;:.... .... ............................... :;;:.::.;:.:;.:;.;::.;:.;:. Compliance: Maximum UA: 337 Your UA: 328 Gross :; Cauity Cont Glazing UA • Assembly Area;or R Va1ua R.Vatue or Door Pe rsmstir 11 Factor Wall 1: Wood Frame, 16" o.c. 597 19.0 0.0 27 Orientation: Front Window 4: Vinyl Frame:Double Pane with Low -E 96 0.310 30 SHGC: 0.30 Orientation: Front Door 1: Solid 22 0.150 3 Orientation: Front Door 2: Solid ? 1 8 0.380 3 Orientation: Front Door 3: Solid 20 0.150 3 Orientation: Front Wall 2: Wood Frame, 16" o.c. 604 19.0 0.0 23 Orientation: Back Window 3: Vinyl Frame:Double Pane with Low -E 221 0.310 69 SHGC: 0.30 Orientation: Back Wall 3: Wood Frame, 16" o.c. 512 19.0 0.0 28 Orientation: Right Side Window 2: Vinyl Frame:Double Pane with Low -E 45 0.310 14 SHGC: 0.30 Orientation: Right Side Wall 4: Wood Frame, 16" o.c. 114 19.0 0.0 5 Orientation: Left Side Window 1: Vinyl Frame:Double Pane with Low -E 24 0.310 7 SHGC: 0.30 Orientation: Left Side Ceiling 1: Raised or Energy Truss 1545 38.0 0.0 46 Floor 1: All -Wood Joist/Truss:Over Unconditioned Space 1495 19.0 0.0 70 Furnace 1: Forced Hot Air 92 AFUE Compliance Statement: The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the 2007 IECC requirements in REScheck Version 4.3.0 and to comply with the mandatory requirements listed in tt ee #217 R e k Inspection Checklist. la /4. AFAte ESch Name - Title Signature Date Project Title: Dave Lapine Report date: 12/16/09 Data filename: C:1Program Files \Check \REScheck \Energy Audits\Lapine Dave \Loudville Rd Spec.rck Page 1 of 4 Q 7-C c--15i Q11-2_, e , 2 t 9 .5b1_.70 e 1-., 1) . ) ..)9 0 ,1 c at,,.. ,, .. ogn 01) .5c; 0€233 2.)-4m ')LiF..-.,C1 1201/)002y ) (?ut")) d (.7,--C_-17 0.91-vorii,olor,-7(-0 / ''' IV cfni-favi ai-ct- s Ab/c7An..“)0e C7C i Ql ) d. Q/ I/ -> -U./ - 18Z CiS ) 91 Iyarc $ r-ro.ot74-cvz 1 , tt sli il - DJ , Di-Al-IL? 47,fiv'?) ,1?A'fid) I - I - I 40/c)(61'iwoahl 0 g N jt , 20- -- Ytmki 0/ Q 4 c: t`-1 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 - - -- per- mits- i-n- 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. Address of work location 4 The Commonwealth of Massachusetts -- Department of Industrial Accidents ; 1 — P Office of Investigations • w.� : - l_ ....rr�� 600 Washington Street =e1 Z Boston, MA 02111 ' www mass g /dia - Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Apnlicant Information Please Print Legibly Name ( Business /organization/Individual): V. A1.. De i ; e10 pwl e,..r i cL??:e • Address: (v E,-j S City /State/Zip: F'A57 AM Phone #: 9/ 3- 57 -- 3 ci 75 Are you an employer? Check the appropriate bog: 1. Type of project (required): / 4.. I am a general contractor and I 6. Type New construction 0 I am a employer with ❑ W � 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 shin . anA have o. P .:ale; ees These sub - contractors have 8. ❑ Demo; on working for me in any capacity. employees and have workers' g Y ca P ac ty. 9. 0 Building addition [No workers' comp. insurance _ comp. insurance.t required:] 5. 06 We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I -am a- iomeowne -ding- ll- work o_ er eras _.theiz- -- —_1-1 lmnbing 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' 13.0 Other comp. insurance required.] *Any applicant that checks boa #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 contactors must submit a new affidavit indicating such. tContractors 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: A / J y/ /4104 / --7 ti� L o Policy # or Self -ins. Lic. #: tA) L j 3 15 - .3 7 3 7Q (o - o I S Expiration Date: 7- 9 ^ /0 Job Site Address: hci'\)c Lj i I ' Ci ty /State /Zip : AAA 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 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: 13e 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 u der the p s • and penalties of perjury that the information provided _ above istrue_and correct. _- __ - ., �� ,S pate; / — / , /L3' Phone #: c k 3- S() - 7, -- Official use only. Do not write in fl area, to be completed by city Or town offlciaL City or Town: Permit/License # Issuing Authority (circle one): I_ Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. PIumbing Inspector _ ___ _ 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /1 Not Applicable ❑ Name of License Holder : - PAJ I vO ,4 1. r_ P/A - 6 0 g License Number r 0 (4 :3 I Ayr 6 j E'Asryg &J ,441 Qic.) 7 /-/8— .;v /, Address ..- �,-, Expiration Date e'''' ..„7„. j �� 9/3 -- 5$7- 3(7,5" Signature Telephone 9. Registered Heme':Improvebient Contractor , , . , .., x . N�. , . 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 re No ❑ _ The_current_exemption for "homeowners" was extended to include Owner 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, a e • n. • - . ` • . ,, ° r - . • - . s- General Laws- Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ® Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [0] Brief Description of Proposed Work: COUSTRuc-r► aF /-)e S t yk TAcii /4)/Ye. Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative . Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa tf..t ew.hOUSe and aT:a dition5#o eXistinq - Housinci `'- complete ttie.follouinn a. Use of building : One Family X Two Family Other b. Number of rooms in each family unit: 7 Number of Bathrooms 0- C c. Is there a garage attached? d / d. Proposed Square footage of new construction. 0(c & Dimensions S 7 X 59 e. Number of stories? a f. Method of heating? 0 /A. ffyO,to .4t/2 SySTel Fireplaces or Woodstoves / ;rZ7■<� 19 Number of each / g. Energy Conservation Compliance. >v5 Masscheck Energy Compliance form attached? h. Type of construction 6 , � tT ! lcaJ ie s/r`/va u rn / S 7/C 4 F .r4 i. Is construction within 100 ft. of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes aC No j. Depth of basement or cellar floor below finished grade $ 7 - /Q f k. Will building conform to the Building and Zoning regulations? '( Yes No . I. Septic Tank X City Sewer Private well X City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , 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 , 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 Name Signature of Owner /Agent Date 1 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 g yis 51 Pt 3,4-'1 _ Lot Size % aA .M�__ .___ ._S9M E_..m... _ __.a _.. ,_. PO © ___ Frontage=_ _ N_ ___...�.... . _......., _ ____ ........... ....I.„.. ..._•. _ . ,__ _ . Setbacks Front Side L. R.w'S3. L: L R t z Rear i f 7 0 r ` /7b r Building Height Bldg. Square Footage i % a0to1 1 * ? / Open Space Footage (Lot area minus bldg & paved „ __, �/ ,1 parking) ' — "O ✓ 7 fr `S '4 o # of Parking Spaces "' Fill: (volume & Location) f __ — �•_. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 4i YES IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW ® YES IF YES: enter Book i a Page' I and /or Document #'µ� _ Y 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 Obtained 0 , Date Issued C. Do any signs exist on the property? YES 0 NO 02$ IF YES, describe size, type and location: t Ir — fhere any pro posed changes to or ad rtlod` ns` oTslgns infen ed or tee 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 0 NO CO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Building Department =walk 212 Main Street Room 100 Northampton, MA 01060 pie 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: . .3 3 LC,)(041Q rZce Map Lot Unit /OA Ail0 -AA Zone Overlay District Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Er Name (Pi Current Mailing Address: S/3 5a7- Pe2..few Telephone Signature 2.2 Authorized Anent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1/ / SO. 0 00. go (a) Building Permit Fee 2. Electrical //, e". o (b) Estimated Total Cost of Constniction from (6) 3. Plumbing /V.Cdc2. 0 e:• Building Permit Fee 4. Mechanical (HVAC) / 1O�C o 0 5. Fire Protection 34100 . o o I* 6. Total = (1 + + + 5) q 2C,7<2, 0 00. 0 0 Check Number _ - 4('° Section Faidfri Use Wig • 4: Date B ding Permit Nu 'er • Issued: Signature: _ Building Commissionerthspector of Buildings: File # BP- 2010 -0669 APPLICANT /CONTACT PERSON DAVID LEPINE ADDRESS /PHONE 262 EAST STREET EASTHAMPTON (413) 527 -3975 PROPERTY LOCATION 23 LOUDVILLE RD MAP 41 PARCEL 075 001 ZONE RR(100) / /WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 00/ 347 Fee Paid ) Typeof Construction: CONSTRUCT 2 STORY SFH W /ATT GARAGE /DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 044188 �4 3 sets of Plans / Plot Plan THE FALLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 Pennit from CB Architecture Committee Permit from Elm Street Commission _ Permit DPW Storm Water Management Demolition Delay ..d-. j 2 l/ c Signature of Building fficial 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. 23 LOUDVILLE RD BP -2010 -0669 GIS #: COMMONWEALTH OF MASSACHUSETTS Iap:Block: 41 - 075 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 -0669 Project # JS- 2010 - 000978 Est. Cost: $226000.00 Fee: $1369.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: 5B Contractor: License: Use Group: R4 DAVID LEPINE 044188 Lot Size(sq. ft.): 83417.40 Owner: DML DEVELOPMENT CORP Zoning: RR(100) / /WP Applicant: DAVID LEPINE 7-- AT: 23 LOUDVILLE RD �1 � Applicant Address: Phone: Insurance: 262 EAST STREET (413) 527 -3975 Workers Compensation EASTHAM PTO N MA01027 ISSUED ON :2/25/2010 0:00:00 TO PERFORM THE FOLLOWING WORK :CONSTRUCT 2 STORY SFH W /ATT GARAGE /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 2/25/2010 0:00:00 $1369.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo