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25C-002
CITY OF NORTHAMPTON Construction Debris Affidavit In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work covered by a Building Permit shall be disposed of in a properly licensed disposal facility, as defined by M.G.L. c. 111 § 150A. Address of Work: 118 to oRTu s-ra e`T' T'p The debris will be transported by: MAO. $rrLzwIu The debris will be received at: 04)/et/ Re .t Liu q A Signature of Permit Applicant v� /y1- 9 /Glef..._1114,.,__ Datel .TUAIS ZO /) Building Permit Number: ?P Zol/ - to11 LARKIN &SAMOLEWIC2 TEL :1 � Mar 15,9b V:( NO.UUI r.Ul _ M 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. • 0 T D 7 1 _ T d A . t__.. ■ f 3 rd 0 1 ' , 0 A 1/4. "�? ,..... � .L 4". -- R - c- a,.a. ' A TO: CITIZENS MORTGAGE CORPORATION & LAWYERS TITLE INSURANCE CORPORATION 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 NE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, EXCEPT AS NOTED, I FURTHER REPORT THAT THE PROPERTY IS. NOT LOCATED WITHIN A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY ' 50.117 SURVEYOR NOTE- - THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY - MORTGAGE LOAN INSPECTION PLAT- - ( watt. ' ,M• . NORTHAMPTON, MASSACHUSETTS WM GAIL A. BOURDON • ,;� .;� SCALE: 1" FEBRUARY 20, 199 r. ±i . 1 • .'i . i ' � ` HAROLD L. EATON AND ASSOCIATES, INC. ,,.� REGISTERED PROFESSIONAL LAND SURVEYORS •fit. 235 RUSSELL STREET — HADLEY -- MASSACHUSET ' .. 1:49 . X 40 .0-0- "*" ..-..**"b' '' "1 C,) ts,, 1 . Q:4 C. ki 4 1,z i Ile kft 4 2" 4 0 ,,\"\ •• '1 \ i*NIC' . VII ...\\ q \ 4 • . 1 % , o wr± O a' 3 y �Q 0- o A VT : to 4 3,..._:•_•...--Sw V1/4 .1;:4P N• Ili ,, .....- -,,,,,, ,,,--,, -4 . 0t.suTh r N Pi i C 1 , % . 1 1.0 o I p_pv, 0 ("al e cro.501, o,ht ! • i 1 , cr . 1 Iii ) .-.1 0 i .. I- 4. is....______ ,,o_.s —.I ).; o y u if a 6u-ows \i .9 \ 1 9 hlls►X 4mt.-+oels Q r o - tv� 7A loll ;' 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, 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 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 tome. Date Address of work location ■ ' • - ' , . . . . , • • •L The Commonwealth of Massachuse Department of Industria I Acidents Office of Investigations • =••=10 1 600 Washington Street • Boston, MA 02111 • www.mass.gov/dia .... -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/plumbers ,.., Applicant Information - Please Print Legibly • :: ,..!.:: Name (BusinesS/Organina , ion/Individual): W )(Nit") ....] . TriArNp4 sl . .1 ,. • Address: "--, 0 • ' 114 ) City/State/Zip: LEEDS NA (1) I AK? Phone.#: iii3 .52b lir,6" - p Are you an employer? Check the appropriate'box: • •Type of project (required): ' 1. 0 I am a employer with 4. 0 I am a general contractor and I • 6. RNew corisiniCticm have hired the sub-contractors employees (fall and/or part-time).* listed on the attac,hed sheet: 7. 0 Remodeling • 2_ g I ani a Sole proprietor or partner- These sub-contractors have ship and. have no rapployees. 8. Q Deniolition - working for me Many capacity . elmloyees__andliaye wOrkers' : - - - -. • . 1 . 9: m Bad:* alldidiiii [Ne workers' comp ip su i ance • __ conip.inturmce_, . •. 10. ID Electrical repairs or additions required.] , . 5. 0 We are a ccapor-ation and its 3. 0 I am a homeowner doing all work officers hav xercised their • 11.0 Plumbing repairs or additions myself [No workers' corop. right of exemption per MGL 1---7•:, 12.0 ic.00r repans . • insurance required.] t • : ,c. 152, §1(4), and we have no • employees. [No workers' 13 -0 Other r ' . COIDP• insurance =Tilted-1 . • • *Any applicant that checks box #1 must also fill out the section belovishovvilig their %Tit:aims compassation policy information. -:.. . t Homeownere who submit this affidaVitincficating they are doingall wink and then hire outside contraCtors must subtaitaaew affidavit indicating such. Contractors that check this box raustattached an additional sheet showing the name of the sub:conttactors and state whether or not thoscentities have employees If the sub-contractors have employees, they must provide their workers' comp policy number. • lain an employer that isprovidkrg workers' compensation insurance for my employees.. Below is the policy and job information. . Insurance Company Name: V ia.t.) Liii e_s . . , • • ' ' • Policy # or Self-ins. Lic. #: 1- i'ZIA & I- L/E? g 5 1 0 1 Expiration Date: - 2 6 ZWei ZOIZ. • . 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 requif6 SeCtibif25A 152 can lead to the iiiiiioiiiibri ofnai lienahies of a fine up to $1,500.00 and/or oiae irrquisonment, 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 yiolator. Be advised that a copy of this statement may be forwarded to the Office of , - afeifikaficolscif the DIA for iiiiiiiin' ce doviii4e verification. ' . _ Ida Itere th c under the pains and penalties ofperjury that the itiformatiOnprovd_above.lxinse.arldiorTprt„ _ ,--.—.... Signature: ,0 . _ /ogeov51,,,, • ' - Date: t b7 12 . —7 Phone*: 'ill S 74, Vet, 6 - - . :- - . : ' . . - • . - Offidal use only. .Do not write in this area, to be completed by city or town'officiai • City or Town: '• Permit/License # • ._.. _ Issuing Authority (circle one): - .1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical,In 5. Plumbing Inspector 6. Other , Contact Person: Phone #:. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 611 1110U `T• 'LlRopns. K C S 51 License Number €e Ff2tattrr s razz L - ? ag„ct4, elms AuLslis 15 featut.A2q 2c./ 2 Address Expiration Date 4 Signature Telephone S :Re iistered=H iiiri'e mgro e`tnent; ortt ot« r•n _. i . 2 q& , , .41t, Not Applicable ❑ h im S l u2omsP ES16ug t'_o1:1SilP.l eTiciA) I a1 zz. Company Name Registration Number O • Box 141, 21- am.te . Ze.i z Address Expiration Date LE F.)06 Mfg 6) 0,4.3 Telephones3 - 4 /05b 1- 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 ❑ o wner .� em ` mit 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. ffij Demolition © New Signs [0] Decks [D Siding [0] Other [0] Brief Description of Proposed be-K.6 4` 111 o r 6cJu sr iu7 45 A QAfI . Work: COUSTatier J/er, Zr " 24" Two ciarii GA SEE FLAN Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet skew h`ous�� _ dit to exists pl i ins co l e the o na: 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. 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 Ta OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT WI %Pain W B Cd tk , as Owner of the subject property hereby authorize WI laAdf S• l U R o . 6kA to act on my behalf, 'n all atters r- ati ' to , o : uthorized by this building pe it ap lication. 6 5 " • >1 Signature of Owner Da Will /fun �• 1 4A , 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. W.Iiii n 7• T `j,titgenzi Print Name 17 7- G • S - Signature of Owner gent Date • p m 4 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete I orm tion Existing Proposed Required by Z. ing 4 _, 1 This column to be Iled ' , by 44, ° Building Depa • t — ''.°4' `" , r O.- , . /, C4- rt iCtO,SD,_ cY ] Lot Size I 1 L _ . _�. ' ,u� Frontage 70 LAI 1. . ' L3Tt._.4C, _...--_z i Setbacks Front 18_6 l'u 1557 Side L o R:Z /.ail L:' -o ff " R: / S . a2' i„--1 Rear 1 3Y I� �-- -- Building Height ( ii 12'0 Bldg. Square Footage S oY j 1 I% r] 1 Open Space Footage % _ ; (Lot area minus bldg & paved t_ L . ,_ parking) # of Parking Spaces L 1 , °- -: Fill: � ,,.,._ � o_ � -. � (volume & Location) L A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO e DONT KNOW 0 YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book r Page ! and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0.1 DONT KNOW Q YES Q 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 •, IF YES, describe size, type and location: s" D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO 0 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 k 1 NO e IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . — AE CE City of Northampton Building Department v . - 212 Main Street � �� g�,� �� 41 ..614" Room 100 .E..e , 4 • rthampton, MA 01060 ® v _^ - T `' - 587 -1240 Fax 413- 587 -1272 A ,` Z. 4.- . te 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: \‘$ WoR`clS STGE E T Map Lot - Unit 1J ° r4.'x ts&R- Zone Overlay, District Elm St. District' ''` CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Wi H 1 N M WELL U 25 MEAJOOw BR.o�ok RD Lo►.t� µiC,w�aor.J MA Name (Pri t� Current Mailing Address: 01 \Otr Telephone ijJ3_ 585.08 Signature 2.2 Authorized Agent: 1111AIA 3 . e2.onnsW ,A ?.O . Box )q l L6 t=ns Mlp 01053 Name (Pri t) 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 39, oca . 00 2. Electrical (b) Estimated Total Cost of I piles • oe Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection j r 6. Total = (1 + 2 + 3 + 4 + 5) /d, o0a Che Numbe This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -101,1 APPLICANT /CONTACT PERSON WILLIAM TUROMSHA ADDRESS/PHONE P 0 Box 141 LEEDS (413) 586 -4005 PROPERTY LOCATION 118 NORTH ST MAP 25C PARCEL 002 001 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 `3 fr j f d) Fee Paid •l Typeof Construction: ZPA - DEMO & BUILD NEW GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 000515 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay r► 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. 118 NORTH ST d , BP- 2011 -1011 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 002 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS ' Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: GARAGE BUILDING PERMIT Permit # BP-2011-1011 Project # JS-2011-000804 Est. Cost: $40000.00 Fee: $115.20 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WILLIAM TUROMSHA 000515 Lot Size(sq. ft.): 10149.48 Owner: WELCH WILLIAM M II Zoning: URB(100)/ Applicant: WILLIAM TUROMSHA AT: 118 NORTH ST Applicant Address: Phone: Insurance: P O Box 141 (413) 586 -4005 LEEDSMA01053 ISSUED ON:6/9/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:ZPA - DEMO & BUILD NEW GARAGE 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: D ^'z -13 C Rough: Rough: House # Foundation: Driveway Final: . Final: Final: _ -3 / _ ( t J'',.., Rough Frame: ok17— 2—/( OV -''L -' Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: (j ? —( J // C THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE . ' /, f Certificate of Occupant"..,_ ature: FeeType: Date Paid: Amount: Building 6/9/2011 0:00:00 $115.20 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner