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To: MokiARCH MoRTGAGE 4 LAWYERS TITLE INS•co
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES, AND BASED ON EXISTING MONUMENTATION, ALL EASEMENTS, ENCROACHMENTS
AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES. I FURTHER
REPORT THAT THE PROPERTY IS NOT LOCATED IN A FLOOD PRONE AREA AS SHOWN ON FEDERAL INSURANCE MAPS FOR COMMUNITY
NUMBER "CDC! 40 7
DATED: 2-22-99
NOTE
THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES
SURVEYOR: (r . , , _ r ... _ . _ -1 0 , • NOT CONSTITUTE A PROPERTY SURVEY. 4 .
die MORTGAGE LOAN INSPECTION PLAT
tiNDi
1 4 11* N O RTH AM PTO N , MA SS .
J. \ OWNER
LABARGE, SR
134605 DE5OR AH L. RoBE:RT J ,DE5AU'TE LS
.4 ° SLAY 4 ScAL.E' 1 " = 2.0'
Richard J. LaBarge, Sr., Registered Professional Land Surveyor
110 IGng Street, Northampton, Massachusetts 01060
•
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
iermits 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 J J ,( Zest0
Address of work
location
-,
, • 4 ,
-
The Commonwealth of Massachusetts
Department of Industrial Acciderzts
Office of Investigations .
600 Washington Street
Boston, MA 02111
,..•,.. ...=,..- -- ..:".
--
www.mass.gov/dia
• .
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
A • • licant Information Please Print L — 11
Name (Business/Organizzion/Individnal): t- l'i fi Ea
• Address: Ze, 6..t (4._ ". 1/4.1 C 0 0 tot- Vkto"'L-- , • - .
City/State/Zip: 0 04U. ‘Nl-114.-i Phone.#: (f 5-----ez, 31 0
Are you an employer? Check the appropriate box: Type of project (required): 11'
1.0 I am a employer with 4. 0 I am a general contractor and I
6. 0 New co ' 'on
have hired the sub-contractors
employees (fill and/or part-time).*
listed on the attached sheet. 7. 0 Remodeling
/ 0 I am a sole proprietor or partner-
ship and have no employees These sub-contractors have. 8• 0 Demoliti on
k
and have loye es ave worers '
working for me in any capacity. emp 9. Ei Banding addition
_ comp.inspranr,e_t .
[No workers' comp. insurance ---- - - - - -
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
4: 3 I am a homeowner doing all work officers havetxercisecl their . 11.0 Plumbing repairs or additions
t
m - No workers' comp. right of exemption per MGL
12.0 Wrepairs
insurance required.] t c. 152, §1(4), and we have no
13. iWi Other 4i 44_44 isJ
employees. [No workers'
comp. insurance required-1 •
*Any applicant that checks box #1 must also fill out the section below showing their vvorkers' 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.
IC.ontracmrs that chreqr 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.
lam 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. #: 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 Da for insurance coverage Veifficalicin.
I da herabycertini under the pains and penaldes ofperjury that the mformalwnprovidedithoviie an4orr I
1.4- t K zo t 0
Signature: .I Dair: A ,
Phone #: t-i i 5 5 ift, ; .c s o - •
Official use only. Do not write in thrls area, lb be completed by city a r town officiaL
City or Town:
Issuing Authority (circle one): ' Permit/License #
1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
. 1
6. Other
Contact Person:
Phone #: f •
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
S, Re tifiteted. ti itieinibi4iremilitearttract(fr w c = n ; E ff ° $ .., 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 ❑
wtiWrieraMixeMMOU
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [El Siding [0] Other [D]
Brief Description of Proposed ( p Jrc �� /� _L � A ttes5 • Z St
.GK
Work: � 2 Xt S� �►� v r °,c^ 1 'c
Alteration of existing bedroom Yes Adding new bedroom Yes "'"
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
liil�draidiir� fioii� male. tC+np:
sa 1fJ��vi � •:.
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? ,p 2.1-0
d. Proposed Square footage of new construction. G 1 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
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
I , as Owner /, thorized
Agen ereby declare that the statements and information on the foregoing application are true and accurate, to the • • my knowledge
and belief.
Signed under the pains and penalties of perjury.
61 `
ldarfl :j1
Rent e
Signature of Owner /Agent Date
r
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 I i i .
Frontage - -• I ' i
Setbacks Front
Side L:1 i R:' 1 L: _�... R:'
I
Rear I
Building Height
[ _
Bldg. Square Footage 1 I F-1 % I 1 1
Open Space Footage % :
(Lot area minus bldg & paved 1 i a M . ? ��� , --�-
parking)
# of Parking Spaces
Fill: _—... — .. . .---... ,.-- .. —,—,_ _---
P 1£
(volume & Location)
A. Has a Sp l Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book I Pager a d /or Document tt. TV
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Iss d:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location: i
E. Will the construction activity disturb (clearing, grading, ex tion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton .,
Building Department 7 ' ' T ,� ;,i
212 Main Street d • - f i
Room 100 9 .
Northampton, MA 01060 €� � ' 3
phone 413- 587 -1240 Fax 413- 587 -1272 �
.r ` ''. tea , 1 x ?C°A , d III#% ` e <. ,.,,?i '. �� APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLIN
i J UN 1 5 2010
SECTION 1 - SITE INFORMATION
1.1 Property Address:
Th i1s'section to bs completed by gffice
R V C LETJOO A �� map , , h L _ i Un
� - 1 1 • x ` Zane, Overlay District
( ' �1 A ' l P r t) " Elm St Diatrlct D istrict
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: -
e t t3 ....t, 2 v I � Zv � l c . V •l� � c /� 60 - e... O t U G O
Name (Print) Current Mailing Address: 9/ 3 � S-3 It)
.�. Telephone
Signature
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 q 1
2. Electrical .r (a) Building Permit Fee
t Eat ed To
Constr uction from (6) of
3. Plumbing
Build (b) ing P ermit Fetal Cost e
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number �7 5
This Section For frcial Use Only
Date
Building Permit Number: Issued
Signature:
Building Comm /Inspector of Buildings Date
File # BP- 2010 -1143 • '
APPLICANT /CONTACT PERSON ERVIN ERINN R
ADDRESS/PHONE 20 GLENWOOD AVE NORTHAMPTON O 586 -5370 0
PROPERTY LOCATION 20 GLENWOOD AVE
MAP 25A PARCEL 137 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 30-3 �,�.t,
Fee Paid �J
Typeof Construction: EXTEND PORCH & ADD ACCESS RAMP
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THELOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
A pproved 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
Signature of Building Of ici /0/(0
al 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.
BP- 2010 -1143
GIS #: COMMONWEALTH OF MASSACHUSETTS
;gig , :' y 0 = 25A - 137 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 -1143
Project # JS- 2010- 001677
Est. Cost: $1750.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 9844.56 Owner: ERVIN ERINN R
Zoning: URB(100)/ Applicant: ERVIN E R I N N R
AT: 20 GLENWOOD AVE
Applicant Address: Phone: Insurance:
20 GLENWOOD AVE 0 586 -5370 0
NORTHAMPTONMAO1060 ISSUED ON:6/18/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: EXTEND PORCH & ADD ACCESS RAMP
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 6/18/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo