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THIS PLAT IS' COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED.
BUILDING LOCATION ACCURACY IS NOT GUARANTEED
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TO: MORTGAGE SERVICE CENTER &
COMMONWEALTH LAND TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT UNES,
EXCEPT AS NOTED. 1 FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY 1 250167
—NOTE —
SURVEYOR:. THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
of v,s — MORTGAGE LOAN I SPECTIO N
NORTHAMPTON, MASSACHUSETTS
i?AN0I LL ' PREPARED FOR
E. MARTIN J. & KATHLEEN M. SULLIVAN
a X35032
SCALE: 1 " =30' MAY 14, 2004
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„ HAROLD L EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET — HADLEY — MASSACHUSETTS
TOTAL P.01
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DEPARTMENT OF BUILDING INSPECTIONS ,, = `•: _ ` I - /
INSPECTOR 212 Main Street • Municipal Building 'r'4'1 y S`,
Northampton, MA 01060 .
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction supcc:.Hsor. 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.
(Ho ow /resident's signature requesting exemption)
I will call to sc edule all required building inspections necessary for the building permit
issued to me.
Date /tiAuT 6 :4004
Address of work
location IA tiOl 11 tLR t
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DEPARTMENT OF BUILDING NSPECTIONS
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212 Main Street • Municipal Building
Northampton, Mass. 01060
WORKER'S COiYTTENSA'110N INSUIZANCE Aielel_DANFIT
I
(liccrist clpo7inittc&
with a principal place of business/residence at:
(phonei;:)
(strccticity!:..(7...1p)
do hereby certify, under ains and penaltier, or perjury, :hat.
( ) I am an employer providing the follovv worker's compensation coverage or :fly
employees working on this job:
- (Ingaranc.. Company) (Pclic Number) CE...): Dare)
( ) I am a sole proprietor, zentral con , ,T. , : - homeowner (circle one) and have hired
the contractors listed below who have the folic • workers cornnensation polioles:
(Ne of Contractor) Cinstlrancc Colatt 1\larnbcr) tT-L.):trat:on Date)
(Name of Contraclori (liisurance. CoraparryiPotio Nurnbcr) (Er:ill D-ate)
(Name of Contractor) ( las Fano:: Co rriTan 1- (Exration Date)
--- ---
(Name of Contractor) (las Coalt=y7Policy Number) (Iiy.t:t7t1tion Date)
(att.lcit
( ) I I1-111 ii. sole proprieior an:l. have no one - •. , ..)1 4 kiri for inc.
( ) 1 am a home owner Derforrninq all the wo:k in '''''
NOTE plc 1 z. 1 - 1 :z!• w'alle 1 % crnploy ; 1.0 C.'..) .., c....::-..x c-4- ::-.;.v.itr . :.:wc.111: c:
not more 111.:o throo Unit, In - d111 - , 1 ,,: c., 0,, :.1,..: E .-::,-,..arttr.2..rd 1.1 ,....re. no( c-c) cK.c.::.:::::::2
cznployc-.3 urd.cr the orkte: cr. ALI (G1_152,=1(5.1), :..r.;-.1:::::ion by a. hot:1:70+,1x( for t ticc-- cK - p..7.rmi: : ,-.--,....:r•cc th-:
legal rtanss of r.1.2 c=rployor under the Worker's Cornper.s.-r.tic.n /..ct..
I understand that a copy of this statcr-uet may b.. folv.-nrsiod to 11., Itr nerst. of in.:his:sir-I A.0c Oflic"" of l''''''''' for II '
C°‘'Cri VC rin l i C ' Cl 4111:1 that ilurt 10 ! 00 ut sz.: 251. of MOL 152 can Itui to the imposition 6f crtmir_t1 pcitallits
ononisti of ,,. fin. of up to $1.2,00.00 ,or impr of up tn c-,-. yr.: !tr. civil tia in ::4 form of a Sk Wcfk. Or !Ind
firo or S100.00 a thy tg.?..in.-.1 r:1::..
For dq.:a.ltrvele.3. Imo Gni y
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SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
.iiRe ' ea " ome; tri : Vern en ;. on fa c- o , : ; ' 04 .4,11 Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE,AFFIDAVIT (M:G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ❑ No ❑
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 Zo O Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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SECTIONS DES ., R P, TtI.ONiOF RROPOSED WORK (check ail applicab - le)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ .
Or Doors ❑
Accessory Bldg. ❑ Demolition[' New Signs [ ] Decks [ ] Siding [ ] Other [ ]
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Brief Description of Proposed Work: P?0 ")- = " � f '° f C P w ° orP I ' p df*) Sal; q, 7
y.Pc `1.i 10n r L f,5 . caur^, - - t
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D - Sheet 0
61 "ew ous ° . " rigor act li of to,.exittin tfousif ggrco rfS e a `heffol tT ing:
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?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck 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 Nc
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
SECTIOPl7aOWNER AUTHORIZATION TO' BE COMPLETED WHEN
OWNERSTAGENTAO*CONTRACTOR APPLI FOR°BUILDING PERMIT'
I, , as Owner of the subject property
hereby authorize _ to ac; or
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
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Signature of Owner /Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage (O /
Setbacks Front V g "
Side L:;) 1r' R: L: R:
Rear --
Building Height % ,o , i
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved j
parking)
# of Parking Spaces # ' {
Fill:
(volume & Location)
A. Has a Special Permit/Variance /Finding ever been issued for /on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regis try of Deeds? 1 NO DONT KNOW +� YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT 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 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:
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of Northampton � ' � � t
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ing Department , . t "
AUG 2004 1r Main Street _ . = a 4=
• oom 100 rk� - o
M A 01060
O Bu1u ,G►NSPEC � �. rtha pton, �� -�� � � �� � � � � F � � ���
DE N0RZNPA1 P 1 0 ;, ;t: ' -06 -1240 Fax 413 - 587 -1272 °¢ P � `
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
Th�sasectron be completed by office
1.1 Property Address: 5
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SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
phPRTr v� S.� i ttuP YJ t o F 'c rrk Ro
Nam Print) Current Mailing AdryeisA. oerki ui t 1' IM o 1o37
Telephone i�-jj 11 Ifni_
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Signatu *� a' Fa {f?
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone •
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit, Fee
2. Electrical_ (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) "r
5. Fire Protection LI C O �-
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6. Total = (1 + 2 + 3 + 4 + 5) - Check Number '` Z Zj
This Section For Officiall Use Only
Building Permit Number: Date Issued: 6/004
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Signature: t rc. sue"'
Building Commiss of Buildings Date
12 WINTER ST BP- 2005 -0172
GIS #: COMMONWEALTH OF MASSACHUSETTS
IvilpIllock: 24D - 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: BUILDING PERMIT
Permit # BP- 2005 -0172
Project # JS- 2005 -0189
Est. Cost: $23900.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 5793.48 Owner: SULLIVAN MARTIN J
Zoning: URB Applicant: SULLIVAN MARTIN J
AT: 12 WINTER ST
Applicant Address: Phone: Insurance:
12 FORT HILL RD (413) 268 -3664 ()
HAYDENVILLEMA01039 - 9736 ISSUED ON: 8/12/04 0:00:00
TO PERFORM THE FOLLOWING WORK: DEMO EXISTING GARAGE, JACK UP HOUSE &
NEW HOUSE FOUNDATION
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: Receipt No: Date Paid: Check No: Amount:
Building 8/12/04 0:00:00 3228 $120.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo