30A-088 (2) 10. All disturbed areas shall be graded, loamed and seeded, or stabilized with erosion control
blankets or netting, and a covering of straw mulch prior to November 30, of each year. No
disturbed areas or stockpiled materials will be left unprotected or without erosion control
after this date.
11. No disposal of soils or other materials shall be allowed within: a 100 -year floodplain; 40
feet of the 100 -year floodplain elevation; any wetland; or any area within 100 -feet of a
wetland, unless such areas are specifically approved by the Commission, in accordance
with 310 CM . 10.00, and City of Northampton Ordinances - Chapter 337.
12. Upon completion of the work covered by this Order, the applicant shall notify the
Conservation Commission.
"ATTACHMENT A"
1. Prior to the initiation of any work, the applicant/owner shall submit a letter of
understanding to the Commission stating that he /she has received, read, understands and
shall comply with these conditions. The applicant, and, his or her contractor, foreman
and/or construction manager shall sign the letter of understanding.
2. The applicant shall notify the Conservation Commission after silt fence is installed and
before work begins for inspection.
3. The limit of work line shall be set by hay bales or silt fence proceeding from the northwest
comer of the garage to the back yard until it meets the beginning of the restricted area, as
shown in project plans.
4. All required permits must be obtained from applicable federal, state and local agencies and
departments prior to the start of any project.
5. A copy of these conditions and associated plans shall remain on site during all construction
and/or building activities. The project manager and all equipment operators shall be
familiar with the approved plans, and shall be informed of their location on the site. This
location shall be accessible to all contractors whenever work is occurring on site.
6. All revised plans shall be approved by the Conservation Commission and incorporated into
the permit by reference and shall be followed during the course of construction.
7. The areas of construction shall remain in a stable condition at the close of each construction
day. Erosion control measures shall be inspected at this time, and maintained or reinforced
as necessary. All such devices shall be inspected, cleaned or replaced during construction
and shall remain in place until such time as stabilization of all areas that may impact
resource areas is permanent. These devices shall also be inspected to assure that the
maximum control has been provided. Any entrapped silt shall be removed to an area
outside the buffer zone and resource areas, and maintained or reinforced as necessary.
Erosion controls shall be inspected after every rainfall to assure that maximum control has
been provided.
8. An adequate stockpile of erosion control materials shall be on site at all times for
emergency or routine replacement and shall include materials to repair or replace silt
fences, straw bales, erosion control blankets, riprap, filter berms or other devices planned
for use during construction.
9. Soils exposed for periods greater than two months shall be stabilized with erosion control
blankets and netting, a covering of straw mulch, or a temporary cover of rye or other grass
to prevent erosion and sedimentation. Drainage ditches shall be stabilized and seeded with
a native perennial grass mixture. Any stabilization materials such as jute netting shall be
firmly anchored to prevent them from being washed from slopes by rain or flooding.
Preference should be given to biodegradable materials.
1
Massachusetts Department of Environmental Protection
L, Bureau of Resource Protection - Wetlands
. . . WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection - Act - M.G.L. c. -131, §40 -
B. Determination (cont.)
❑ 5. The area described in the Request is subject to protection under the Act. Since the work
described therein meets the requirements for the following exemption, as specified in the Act and
the regulations, no Notice of Intent is required:
Exempt Activity (site applicable statuatory/regulatory provisions)
❑ 6. The area andlor work described in the Request is not subject to review and approval by:
Name of Municipality
Pursuant to a municipal wetlands ordinance or bylaw.
Name Ordinance or Bylaw Citation
C. Authorization
This Determination is issued to the applicant and delivered as follows:
iy/Pby hand delivery on ❑ by certified mail, retum receipt requested on
31c9o1I
D/alltiCt Y / Date
This Determination is valid for three years from the date of issuance (except Determinations for
Vegetation Management Plans which are valid for the duration of the Plan). This Determination does not
relieve the applicant from complying with all other applicable federal, state, or local statutes, ordinances,
bylaws, or regulations.
This Determination must be signed by a majority of the Conservation Commission. A copy must be sent to
the appropriate DEP Regional Office (see http: / /www.mass.Qov /der /about/region.findyour.htm) and the
property owner (if different from the applicant).
S' • natures
w
D 7------ r
4r r a ' ...
Date 4a011 Y
wpaform2.doc • Determination of Applicablity • rev. 10/8/04 Page 4 of 5
,,
L 1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
V1/PA F 2 _D etermination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Determination (cont.)
❑ 6. The following area and/or work, if any, is subject to a municipal ordinance or bylaw but not
subject to the Massachusetts Wetlands Protection Act:
❑ 7. If a Notice of Intent is filed for the work in the Riverfront Area described on referenced plan(s)
and document(s), which includes all or part of the work described in the Request, the applicant
must consider the following alternatives. (Refer to the wetland regulations at 10.58(4)c. for more
information about the scope of alternatives requirements):
❑ Alternatives limited to the lot on which the project is located.
❑ Alternatives limited to the lot on which the project is located, the subdivided lots, and any
adjacent lots formerly or presently owned by the same owner.
❑ Alternatives limited to the original parcel on which the project is located, the subdivided
parcels, any adjacent parcels, and any other land which can reasonably be obtained within
the municipality.
❑ Alternatives extend to any sites which can reasonably be obtained within the appropriate
region of the state.
Negative Determination
Note: No further action under the Wetlands Protection Act is required by the applicant. However, if the
Department is requested to issue a Superseding Determination of Applicability, work may not proceed
on this project unless the Department fails to act on such request within 35 days of the date the
request is post- marked for certified mail or hand delivered to the Department. Work may then proceed
at the owner's risk only upon notice to the Department and to the Conservation Commission.
Requirements for requests for Superseding Determinations are listed at the end of this document.
❑ 1. The area described in the Request is not an area subject to protection under the Act or the
Buffer Zone.
® 2. The work described in the Request is within an area subject to protection under the Act, but will
not remove, fill, dredge, or alter that area. Therefore, said work does not require the filing of a
Notice of Intent, subject to the following conditions (if any).
Please see Attachement A.
❑ 3. The work described in the Request is within the Buffer Zone, as defined in the regulations, but
will not alter an Area subject to protection under the Act. Therefore, said work does not require
❑ 4. The work described in the Request is not within an Area subject to protection under the Act
(including the Buffer Zone). Therefore, said work does not require the filing of a Notice of Intent,
unless and until said work alters an Area subject to protection under the Act.
wpaform2.doc • Determination of Applicability • rev. 10004 Page 3 of 5
1
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 2 - Determination of Applicability
Massachusetts- Wetlands Protection Act - M.G.L. c, 131, §40
B. Determination (cont.)
The following Determination(s) is /are applicable to the proposed site and /or project relative to the Wetlands
Protection Act and regulations:
Positive Determination
Note: No work within the jurisdiction of the Wetlands Protection Act may proceed until a final Order of
Conditions (issued following submittal of a Notice of Intent or Abbreviated Notice of Intent) or Order of
Resource Area Delineation (issued following submittal of Simplified Review ANRAD) has been received
from the issuing authority (Le., Conservation Commission or the Department of Environmental Protection).
❑ 1. The area described on the referenced plan(s) is an area subject to protection under the Act.
Removing, filling, dredging, or altering of the area requires the filing of a Notice of Intent.
❑ 2a. The boundary delineations of the following resource areas described on the referenced plan(s) are
confirmed as accurate. Therefore, the resource area boundaries confirmed in this Determination are
binding as to all decisions rendered pursuant to the Wetlands Protection Act and its regulations regarding
such boundaries for as long as this Determination is valid.
❑ 2b. The boundaries of resource areas listed below are not confirmed by this Determination,
regardless of whether such boundaries are contained on the plans attached to this Determination or
to the Request for Determination.
❑ 3. The work described on referenced plan(s) and document(s) is within an area subject to
protection under the Act and will remove, fill, dredge, or alter that area. Therefore, said work
requires the filing of a Notice of Intent.
❑ 4. The work described on referenced plan(s) and document(s) is within the Buffer Zone and will
alter an Area subject to protection under the Act. Therefore, said work requires the filing of a
Notice of Intent or ANRAD Simplified Review (if work is limited to the Buffer Zone).
❑ 5. The area and /or work described on referenced plan(s) and document(s) is subject to review
and approval by:
Name of Municipality
Pursuant to the following municipal wetland ordinance or bylaw:
Name Ordinance or Bylaw Citation
wpaform2.doc • Determination of Applicability • rev. 10 /6/04 Page 2 of 5
Massachusetts Department of Environmental Protection
L Bureau of Resource Protection - Wetlands
1
WPA F o r m 2 — D etermination of Applicability
- Massachusetts Wetlands Protection Act M.G.L. c..1 31, §
A. General Information
Important:
When filling out From:
forms on the Northampton
computer, use Conservation Commission
only the tab
key to move To: Applicant Property Owner (if different from applicant):
your cursor -
do not use the Thomas Kelly
return key. Name Name
25 Clement Street
� Mailing Address Mailing Address
Northampton MA 01060
..:=X: City/Town State Zip Code City/Town State Zip Code
sem
1. Title and Date (or Revised Date if applicable) of Final Plans and Other Documents:
Mortgage Loan Inspection, as modified in application packet 4/14/2011
Title Date
Title Date
I I
Title Date
2. Date Request Filed:
April 14, 2011 i
l
B. Determination l
Pursuant to the authority of M.G.L. c. 131, § 40, the Conservation Commission considered your
Request for Determination of Applicability, with its supporting documentation, and made the following
Determination.
Project Description (if applicable):
Construction of a 26' by 11' single story addition to a SFH within the footprint of an existing deck, to
be removed
Project Location:
25 Clement Street Florence
Street Address City/Town
30A 088
Assessors Map /Plat Number ParceVLot Number
wpaforrn2.doc • Determination of Applicablily • rev. 10/6104 Page 1 of 5
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SURVEY DEPICTING RESTRICTIVE AREAS 1, 2, AND 3.
THOMAS F . KF.i .T Y
DATED: DECEMBER 7, 2010
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Massachusetts Department of Environmental Protection
,?�--
Bureau of Resource Protection - Wetlands
;' ��
I l WPA Form I 1- Request for Determination of Applicability City/Town
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
D. Signatures and Submittal Requirements
I hereby certify under the penalties of perjury that the foregoing Request for Determination of Applicability
and accompanying plans, documents, and supporting data are true and complete to the best of my
knowledge.
I further certify that the property owner, if different from the applicant, and the appropriate DEP Regional
Office were sent a complete copy of this Request (including all appropriate
documentation) simultaneously with the submittal of this Request to the Conservation Commission.
Failure by the applicant to send copies in a timely manner may result in dismissal of the Request for
Determination of Applicability.
Name and address of the property owner:
THo r.& M M k a--Y
Name
Z5 ( L6ME Arr sr
Mailing Address
Ft,orLf.NGE i Mob a4e
City/Town
State Zip Code
Signatures:
I also understand that notification of this Request will be placed in a local newspaper at my expense
in accordance with Section 10. g� 2 ! � 0 � 5(3)(b)(1) of the Wetlands Protection Act regulations.
! " it -@ X / 2 - nZ a 1
Signature of Applicant to
Signature of Representative (if any) Date
wpafonn1.doc Page 4 of 4
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 1- Request for Determination of Applicability City/Town
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
C. Project Description (cont.)
b. Identify provisions of the Wetlands Protection Act or regulations which may exempt the applicant
from having to file a Notice of Intent for all or part of the described work (use additional paper, if
necessary).
3. a. If this application is a Request for Determination of Scope of Alternatives for work in the
Riverfront Area, indicate the one classification below that best describes the project.
RJ Single family house on a lot recorded on or before 8/1/96
❑ Single family house on a lot recorded after 8/1/96
El Expansion of an existing structure on a lot recorded after 8/1/96
❑ Project, other than a single family house or public project, where the applicant owned the lot
before 8/7/96
❑ New agriculture or aquaculture project
❑ Public project where funds were appropriated prior to 8/7/96
❑ Project on a lot shown on an approved, definitive subdivision plan where there is a recorded deed
restriction limiting total alteration of the Riverfront Area for the entire subdivision
❑ Residential subdivision; institutional, industrial, or commercial project
❑ Municipal project
❑ District, county, state, or federal government project
❑ Project required to evaluate off-site alternatives in more than one municipality in an
Environmental Impact Report under MEPA or in an alternatives analysis pursuant to an
application for a 404 permit from the U.S. Army Corps of Engineers or 401 Water Quality
Certification from the Department of Environmental Protection.
b. Provide evidence (e.g., record of date subdivision lot was recorded) supporting the classification
above (use additional paper and /or attach appropriate documents, if necessary.)
. D1)
wpaforml .doc Page 3 of 4
Massachusetts Department of Environmental Protection
L - Bureau of Resource Protection - Wetlands � VLt2T � I City/Town WPA Form 1- Request for Determination of Applicability ° Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
C. Project Description
1. a. Project Location (use maps and plans to identify the location of the area subject to this request):
2s• a, M &JJ r ST' -K?- G 141 rt,o Yl. / ' J a'
Street Address City/Town
Assessors Map /Plat Number Parcel /Lot Number
b. Area Description (use additional paper, if necessary):
S i >u ate FA (44. t (...4 4(6 u SE 6 N LoT gczcoriaEA
Pzt,to(2- - g t 9 4,
c. Plan and /or Map Reference(s):
Title Date
Title Date
Title Date
2. a. Work Description (use additional paper and /or provide plan(s) of work, if necessary):
1St.A1.ui) t SL Abp11t6N b J./
Ex(S 13 Eoo7PIZ1 r) t,
(iv ail l N a.00 t of ft P.Av - erzAAN t
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wpafonnl.doc Page 2 of 4
I Massachusetts Department of Environmental Protection
i` r�- -- -� Bureau of Resource Protection - Wetlands
r
I i WPA Form 1- Request for Determination of Applicability City/Town
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. General Information
Important:
When filling out 1. Applicant:
forms on the - nom As K
computer, use Name E -Mail Address
only the tab key
to move your 2 5 Ct,f ° Akfrott S EET
cursor - do not Mailing Address
use the return F Lo QC N GE ,M, A 0 io ,g Z
key. City/Town � t � � 0-) � ` (� State Zip Code
itit Phone Number J ' Fax Number (if applicable)
MIL 2. Representative (if any):
Aim. Awn.
Firm
Contact Name E -Mail Address
Mailing Address
City/Town State Zip Code
Phone Number Fax Number (if applicable)
B. Determinations
1. - I request the make the following determination(s). Check any that apply:
Conservation Commission
• whether the area depicted on plan(s) and /or map(s) referenced below is an area subject to
jurisdiction of the Wetlands Protection Act.
❑ b. whether the boundaries of resource area(s) depicted on plan(s) and /or map(s) referenced .
below are accurately delineated.
l2 c• whether the work depicted on plan(s) referenced below is subject to the Wetlands Protection Act.
whether the area and /or work depicted on plan(s) referenced below is subject to the jurisdiction
of any municipal wetlands ordinance or bylaw of:
Iv 0 raltA mp o /J M. A SSA CH u.SFrrS
Name of Municipality )
❑ e. whether the following scope of alternatives is adequate for work in the Riverfront Area as
depicted on referenced plan(s).
wpaforrnl .doc Page 1 of 4
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permitted in said Area 3 without first obtaining the prior written consent of the owner of
Lot B, which consent shall be entirely at the discretion of said owner.
Being the same premises conveyed by deed of Robert Kurnit and Kathy Reep to Lourdes
M. Tallet and Florence W. Campanile dated July 5, 1994 and recorded in the Hampshire
County Registry of Deeds in Book 4514, Page 272.
ATTEST. EL':, �PVI?IT-2, MVIAW c
MARIANNE L. DONOR Lila
.E"
— — EXHIBIT A
A certain tract or parcel of land on the northwesterly side of Clement Street,
Northampton, Hampshire County, Massachusetts, shown as Parcel B on a plan entitled,
"Plan of Land in Northampton, Massachusetts, surveyed for Warren S. Hall, Jr." dated
January 8, 1987, by Almer Huntley, Jr., & Associates, Inc., recorded in the Hampshire
County Registry of Deeds Plan Book 151, Page 56, more particularly bounded and
described as follows:
Beginning at an iron pin to be set on the northwesterly side of said Clement Street at the
southwesterly corner of Parcel A as shown on said plan;
Thence S. 55° 52' 29" W. along the northwesterly side of said Clement Street 125.00 feet
to an iron pin at Northampton Coordinate System N: 12,993.434, E: 20,563.791;
Thence N. 38° 40' 38" W. 90.00 feet to an iron pin;
Thence N. 09° 37' 54" W. 80.00 feet to an iron pin;
Thence N. 55° 51' 42" E. 173.16 feet to an iron pin;
Thence S. 38° 49' 25" E. 132.00 feet to an iron pin;
Thence S. 55° 52' 29" W. 85.00 feet to an iron pin;
Thence S. 34° 07' 31" E. 31.00 feet to an iron pin on the northwesterly side of Clement
Street at the place of beginning.
Containing 30,419 square feet, more or less.
Subject to a right of way and easement for the benefit of Lot A 20 feet wide to pass and
repass on foot and with motor vehicles and for the installation, maintenance, and repair of
utilities over the driveway leading from Clement Street across Lot B to Lot A, more
particularly shown on a Plan recorded in said Registry at Plan Book 131, Page 58.
Subject to easements for the benefit of Lot A over Restrictive Areas Number 1 and 2 on
Lot B as shown on the aforementioned plan, which require that no improvements of any
kind or additions or alterations thereto shall be made, erected, placed or allowed to stand
in said Easement Restrictive Areas. Said areas shall be left entirely in their natural state,
and only storm damaged trees or shrubs may be removed. No improvements or alteration
of any kind shall be permitted in said Areas 1 and 2 without first obtaining the prior
written consent of the owner of Lot A, which consent shall be entirely at the discretion of
said owner of Lot A.
Together with an easement over Restrictive Area No. 3 as shown on said plan for the
benefit of Lot B that no improvements of any kind or additions or alterations thereto shall
be made, erected, placed or allowed to stand in said Restrictive Area No. 3. Said
Restrictive Area No. 3 shall be left entirely in its natural state, and only storm damaged
trees or shrubs may be removed. No improvement or alteration of any kind shall be
.,
___- - CIO TGAGE_LOAN INSPECTION
THIS PLAT IS FOR IDENTIFICATION PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY
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'' / �` � SUBJECT TO AND /OR
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� 1 TOGETHER WITH THE
� 1 -7 - 5 1 Sb BENEFITS OF ANY AND ALL
0 t AGREEMENTS, CONDITIONS,
0 2' ' COVENANTS, EASEMENTS,
�� RESERVATIONS,
RESTRICTIONS, RIGHTS, AND
TAKINGS OF RECORD.
I HEREBY ACKNOWLEDGE RECEIPT OF A COPY OF MORTGAGE-LOAN INSPECTION
SURVEY DEPICTING RES FICTIVE AREAS 1, 2, AND 3.
_1.1.+41• !a- 4W a � � .�,
THOMAS F. KELLY
DATED: DECEMBER 7, 2010
Doc: 940016130 OR /4514/0274 07/11/1994 14:15
shall be entirely at the discretion of said owner of Lot A.
Together with an easement over Restrictive Area No. 3 as shown on
said plan for the benefit of Lot B that no improvements of any kind
or additions or alternations thereto shall be made, erected, placed
or allowed to stand in said Restrictive Area No. 3. Said
Restrictive Area No. 3 shall be left entirely in its natural state,
and only storm damaged trees or shrubs may be removed. No
improvement or alteration of any kind shall be permitted in said
Area 3 without first obtaining the prior written consent of the
owner of Lot B, which consent shall be entirely at the discretion
of said owner.
Being the same premises described in the deed of Warren S. Hall,
Jr., to Robert Kurnit and Kathy Reep, dated mq RC H a 7 ,
19 lb , and recorded with the Hampshire County Registry of Deeds,
in Book 3537, Page 197.
ATTEST: HAMPSHIRE, AoREGISTER
MARIANNE L. DONOHUE
flat; 90Q1fi13Q QR l4514iO713 n7111n9° 19.5
EXHIBIT A
25 Clement Street
Northampton, MA 01060
A certain tract or parcel of land on the northwesterly side of
Clement Street, Northampton, Hampshire County, Massachusetts, shown
as Parcel B on a plan entitled, "Plan of Land in Northampton,
Massachusetts, surveyed for Warren S. Hall, Jr." dated January 8,
1987, by Almer Huntley, Jr., & Associates, Inc., recorded in the
Hampshire County Registry of Deeds Plan Book 151, page 56, more
particularly bounded and described as follows:
Beginning at an iron pin to be set on the northwesterly side of
said Clement Street at the southwesterly corner of Parcel A as
shown on said plan;
Thence S. 55° 52' 29" W. along the northwesterly side of said
Clement Street 125.00 feet to an iron pin at Northampton Coordinate
System N: 12,993.434, E: 20,563.791;
Thence N. 38° 40' 38" W. 90.00 feet to an iron pin;
Thence N. 09° 37' 54" W. 80.00 feet to an iron pin;
Thence N. 55° 51' 42" E. 173.16 feet to an iron pin;
Thence S. 38° 49' 25" E. 132.00 feet to an iron pin;
Thence S. 55° 52' 29" W. 85.00 feet to an iron pin;
Thence S. 34° 07' 31" E. 31.00 feet to an iron pin on the
northwesterly side of Clement Street at the place of beginning.
Containing 30,419 square feet, more or less.
Subject to a right of way and easement for the benefit of Lot A
20 feet wide to pass and repass on foot and with motor vehicles and
for the installation, maintenance, and repair of utilities over the
driveway leading from Clement Street across Lot B to Lot A, more
particularly shown on a Plan recorded in said Registry at Plan
Book 131, Page 58.
Subject to easements for the benefit of Lot A over Restrictive
Areas Number 1 and 2 on Lot B as shown on the aforementioned plan,
which require that no improvements of any kind or additions or
alternations thereto shall be made, erected, placed or allowed to
stand in said Easement Restrictive Areas. Said areas shall be left
entirely in their natural state, and only storm damaged trees or
shrubs may be removed. No improvements or alternation of any kind
shall be permitted in said Areas 1 and 2 without first obtaining
the prior written consent of the owner of Lot A, which consent
. Doc: 961613D OR /451414212 07/11,./1994 11:1$
KNOW ALL PEOPLE BY THESE PRESENTS THAT
WE, Robert Kurnit and Kathy Reep
of 129 Upper Byrdcliffe Road, Woodstock, New York,
being married, for consideration paid and in full consideration of
One Hundred Three Thousand ($103,000.00) Dollars, paid this day
grant to Lourdes M. Tallet and Florence W. Campanile, as joint
tenants with rights of survivorship
of 62 Main Street, Hatfield, Massachusetts, with quitclaim
covenants
the land located at 25 Clement Street in Northampton, Hampshire
County, Massachusetts, bounded and described as follows:
For a complete description, see Exhibit A attached hereto
and incorporated by reference herein.
Witness our hands and seals this -S day of , / J 7/ / /1994.
oft b rt Kurnit
� So d7.� -C cm-)
(0 n-
Kathy Reep
THE STATE OF NEW YORK
, ss. • Jiz S , 1994
Then personally appeared the above named Robert Kurnit and
acknowledged the foregoing instrument to be his free act and deed,
Before me, (e
. , Notary Public
My commission expiE. IERINE ANDERSON
/ rr0(ery Public, State of New York
Rep. 44987297
TEE STATE OF NEW YORK Qualified in Ulster County i
/ Commission Expires October 7, 194)
, ss. \/(L/ S , 1994
Then personally appeared the above named Kathy Reep and
acknowledged the foregoing instrument to be her free act and deed,
CO •-"• ,=,.. . •
e1 . M _:,�• . :� 4' x ;
II , `'. ':, Q. Q . s�aT Before me
IIi___-
w '�iiiin�,�l , ; d ' 3 ..0 L , Notary Public
a i c ! �4t
� I r�`k��I4fl ry' i 1 . r, F, '' My commission expires:
� 4
�4I S ., , KATHERINE ANDERSON
' �; ,"S i r i c - a l . ,.:!' Notary Public. State of New York
`
fx - .x Rep. 44987297
apiliiiii, : — t' e� Qualified 1n Ulster County
° o ' Commission Expires October 7,19.E
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 faini&
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 construiion 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 rou=h building inspection (before work is
concealed), insulation inspection (if reauired) 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
jermits 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
�� urry. �n hp �J understand the above.
(Home owner /resident's s'lgnature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date
Address of work
location
T
. The Commonwealth ofMassachusetts
Department of Industrial Accidents •
, }�ti,� - • Office oflnvestigations
� � N y
. = 600 Washington Street
c. _ Boston, MA 02111
Y `a„ sue' • www.mass gov /dia - •
-Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/Plumbers
Applicant Information - Please Print Legibly
Name ganizat ion/Individnai): r : n,— ril .V
- - Address: �� -- •
City/State/Zip:--F-_,1 , , , f r A , o ja(- Phone. #: 1 //) C 5p- 7 — `3 l L7 • - .
Are you an employer? Check the appropriate•bos _ /
I am a employer with 7),R tu, - 4.. CI I am a general contractor and I 6 �New
emQ 1oyees (full and/or part time).: have hired the sub- contractors
2. I ant a sole proprietor or partner- . listed on the.atlached sheet 7. Remodeling
• ship and have no errployecs These sub - contractors have. .8. Deaolit<on - . • -
working forme m � � i em�Ioyees an 114 -7.e workers' . a&dtfioii
orktag any capacity. • �
[Na workers' coup- insurance- . .
required ] 5. 0 We are a corporation and its 10.D Electncai repairs or additions
3. I am a homeowner doing an work officers brief xerc their . 11.❑ Plumbing repairs or additions .
myself o workers co Of exemption per MGL
3's ' comp. 12.0 Roof repairs .
insurance required.] t • c: 152, §1(4), and we have no - • .
esuployees -o 13. Other
Any applicant that checks .box #1 must.also fin out the section blow showing ir i'ol s'- compmsatien policy tufaamafiaai: •
t Homeowner* vho subiat this davit:iadu mI they are doing alt work and then hire outside connaitois trust subnut a new-a$ davit indicating such.
TCon tractors that check this box mustattached an additional sheet showing the name of the sub-contractors and statcwhedier•or aotthose•entides have •
employees. lithe sub- contracoors have cmp /eye:4 they raus provide dick workers' cony. poky amnber. .
• Jam an employer that is providing workers' compensation insurance for ray employees Below is the policy and job
information.
• Insurance Company Name:. - • -
•
Policy # or Self ivs. Lic. #: • Expiration Date:
Job Site Address: C' fS •
. rt3' tatelZi .
• Attach a copy of the workers'" compensation policy declaration page the policy number and expiration date).
Failure to secure covera as ... . � tinder Secttr n "25A of 1VIGL "c. - 152 can lead to i ie imp osition of cum t pc aaIttes of a
ge, requui�" --
fine up to $1,500.00 and/or one- year as well as civil .penalties in the form of :a STOP WORK- O12DEIt and a fine
of up to 525000 a-day against the violator Be that a copy of this statem may forwarded:to the Oceof
1 vestiaations ofthe IDIA for`°mst ce coverage v eiific on: :_
Ii herebj cei fr under the p pen f perjury that the information provided ab aadrorre'Y
aims and alr5ies o . .
si> e: a ivIL,n �,- ,� 2,t i • _ b ate =* .� a -_ 26 / { _.
Phone it: - -. . . .. . . - -
Official use only. Do not write in this area, to be completed by city-Or town officiaL
City or Town: . _ PermTit(LIcense #
Issuing Authority (circle one):
:1. Board of Health 2. Bolding Department 3. City/Town Clerk . 4. Electrical 5. Plumbing Inspector
6. Other .
•
Contact Person: Phone #:
•
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: 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 ❑
11. - Home Owner Exemption
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 10835.1.
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 Signatur__. �..., . - ►_ 1 �
eT . _ ` t 1__. ft)3 2c) 11_
�
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition N Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding ID] Other [Q]
sO/✓ ✓ � ,.. , et s! '�u ,,t✓'inz / d S ,V��i e (- ?((s4r ' 9
Brief Description of Proposed /km r' / t I f1 't ( C t o � \ v tS 1 , !� 1 / r' e41
Work: ' ) + ) /� /
Alteration of existing bedroom Yes No Adding new bedroom ,rYes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family
� unit: Number of Bathrooms ove-
c. Is there a garage attached? 1
d. Proposed Square footage of new construction. ` C Dimensions L X L
e. Number of stories? 0
f. Method of heating? el/Me � � {D1 i NI G c'') Fireplaces or Woodstoves / Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction l/lZ//V
i. Is construction within 100 ft. of wetlands? Yes K 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? /V 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
I, , 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
✓ k j-y-m,c-vo r Q Le t t� .Q 3- �v f I
Signature of Owner /Agent / Date
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
r � Building Department
Lot Size / 1`5
Frontage
Setbacks Front c u /!
/
Side L: ` R: 7 L: R:
Rear j( • S` . a
Building Height / /
Bldg. Square Footage r' !�
Open Space Footage `�
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DON'T KNOW k t ' 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES Q
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO q) DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q ,Date Issued:
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 ec?
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 Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
s snit
GQ \
City of Northampton Status of Permit: Department use only
Building Department Curb Cut/Driveway Permit
Z, 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
0 ,00r, Northampton, MA 01060 Two Sets of Structural Plans
�� " phone 413 -587 1 240 Fax 413- 587 -1272 Plot/Site Plans
Other Specify
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 Pronertv Address:
Map L30 ? Lot ? Unit
Zone SR/10P Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
F C 11 a5
Name (Print) Current Mailing Address:
�I X 3( 2 5 - 7
, , ..i .o F
K. oi 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 GUS LSD (a) Building Permit Fee
2. Electrical 4 - o U0 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) r 6 0C v ,
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) C )- (, • 60f f../ 0 Check Number 5ea `,1 go O b "a 0
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0691
APPLICANT /CONTACT PERSON KELLY THOMAS
ADDRESS /PHONE 25 CLEMENT ST FLORENCE (413) 587 -3117 0
PROPERTY LOCATION 25 CLEMENT ST
MAP 30A PARCEL 088 001 ZONE SR(100) / /WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Paid
Typeof Construction: CONSTRUCT 26 X11 BEDROOM ADDITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON p 6 I'
INFORMATION PJ` SENTED: O - 1
proved V Additional permits required (see below) t 1
PLANNING BOARD PERMIT REQUIRED UNDER: § 4 W
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
V Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay � ��"`� "� - 1 /
-/ il_S (
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.
25 CLEMENT ST BP- 2011 -0691
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A - 088 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP- 2011 -0691
Project # JS- 2011- 001133
Est. Cost: $26500.00
Fee: $200.20 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq ft.): 30404.88 Owner: KELLY THOMAS
Zoning: SR(100) //WP Applicant: KELLY THOMAS
AT: 25 CLEMENT ST
Applicant Address: Phone: Insurance:
25 CLEMENT ST (413) 587 -3117 0
FLORENCEMA01062 ISSUED ON: 6/1/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 26 X11 BEDROOM ADDITION
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 6/1/2011 0:00:00 $200.20
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner