38A-021 (2) -NOTE —
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
NOTE:
SUBJECT TO EASEMENTS AND
RIGHTS OF WAYS OF RECORD. �f
it
v �
'V''S' 105'±
-
i /J /) s
H ° -
BOOK 9056,
PAGE 223
• __
105'±
RUST AVENUE
TO: FREEDOM CREDIT UNION &
FIRST AMERICAN TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
1 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 LINES,
EXCEPT AS NOTED. F FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY #250167
-NOTE -
-�� THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
SURVEYOR: AND DOES NOT CONSTITUTE A PROPERTY SURVEY
S - MORTGAGE LOAN INSPECTION PLAT -
o'/ 1 � NORTHAMPTON, MASSACHUSETTS
RANDALL tic PREPARED FOR
g , 3 ZER N, „ STEPHEN S. KLOC, III
SCALE: 1"=30' AUGUST 24, 200
` 'ti r / HAROLD L. EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET - HADLEY - MASSACHUSET
HOME OWNER EXEMPTJON 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
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
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
Address of work
location
' _ _ The Commonwealth of!Vlassachuset s
—x Department of Industrial ccidents
Office of Investizarions
600 i ashina ton Street
Boston, A 02111
w?+'w.mass.; oti /dia
Workers' Compensation insurance ffldavit: Builders /Contractors /EIectricians /PI =umbers
Applicant information Please Print Legibly
Name ( Business /Orgarization;'IndividuaI): 1,)e .i ' 0 ‘ -C...,. oot C \M
Address: (� ',- bn.-M.. Vl \•..)•S
City'State /Zip: 19.a' \\A 1- 1 4 - 1 J by -- Phone Tr JS 2- 24 C /3? '1- X16
Are you an employer? Check the appropriate box:
I. Type of project (required): I
4. I 1 a.n a general contractor and I
El am a employer with 6. ❑ New construction
Ioyees (full and/or part - time).* have hired the sub contractors
2. (� I am a sole proprietor or partner- listed on the attached sheet. 7. emodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
i working for me in any capacity. employees and have workers' 9. ❑ Building addition
[i o workers' comp. insurance comp. insurance.l
required.] We are a corporation and its 10.0 Elecnical repairs or additions
3. El I am a homeowner doing all work officers have exercised their 11.1= Plumbing repairs or additions
myself. [ti o workers' comp. right of exemption per MGL 12.E Roof repairs
insurance required_] ' c. 152, §1(4), and we have no
employees. [No workers' 13. ❑ Other
I comp. insurance required.] I
*Any applicant that checks box #1 must also fill out the section beiow showing their workers' compensation policy information.
r Homeowner who submit this affidavit indicating they are doing all work and then hire outside contractor must submit a new affidavit indicating such.
-Contractor that check this box must attached an additional sheet showing the name of the sub - contractor and state whether or not those entities have
employees. If the sub - contractors have e plovees, 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 game:
Policy 4 or Self -ins. Lic. 4: 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 $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 3250.()0 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby tenth ituder- thepains [ penaltie . o perjury that the information provided above is true and correct.
Si Tr'. =ti ��L N� 7 2- �/ / Date:
Phone 4: ( ($) PGFJ' - . G 3 7 l GYC t)
✓f use only. Igo not (+write in this area, to be completed by city• or town official 11,
Ciry or Town: Permit/License 4 I
I
Issuing Authority (circle one): I
1 1. Board of Health 2. Building Department 3. City Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
i Contact Person: Phone 4: 1
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : + - � d TCV
License Number
b ao --. Glp' (i/-71° c�
address J � G u Expiratn Date
signature Telephone
Reeistered Home ImQrovement Cantsactor I Not Applicable ❑
" -J e►, �e - 13 /Go 1
:om oanv Name Registration ■ Re Number
't—>o n...M N ,v.- W A`.A► \ t 6 l bQ - 7i7-6101
.ddress
(at 3) - 1 . � Y 6 Exptrat Dat
5
Telephone 7 6S—npy
ECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G L. c. t52 § 25C(6))
+orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit. •
fined Affidavit Attached Yes ❑ No fi
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowneer to engage an individual for Lure who does not possess a license, provided that the owner acts
as supervisor. CiVIR 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 -vear 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 Hermit.
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, von may be Iiable 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
+I
SECTION DESCRIPTION OF PROPOSED WORK (check all applicable)
i I_
New House ! Addition Replacement Wii dows Alteration(s) pi Roofing
Or Doors L I I 7 .104,...44,
I
I
Accessory Eldg. _I Demolition E New Signs [0] Decks [jam Siding jG] Other ED] i
Brief : Description of Proposed
Work: _ CIpw ,E * AA-
: "U,o� Huai �o� �. Sa+.+�.1�.' 1u�� `30 ^�*�' ��- 14..u& 23.E
Alteration cf existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes Nc
Pla ^s Attached Roll - Sheet I
6a- If Nevi( house and or adciftiO -to existing h corn th foE[
a. Use of building : One Family k Twc Family Other �J�
���.�_ L�J 3�
b. Number of roans in each family unit: Number of Bathrooms 3�
c. !s there a garage attached? V b f / / / d
3Y S 7- 5 3 �y 7~ v yam. ,sue -� i o n li
d. Proposed Square footage of new construction. et ..+. l 12sr' Dimensions
e. Number of stones? Z ` 4 ..:09-1 `�
f. Method of heating? Fireplaces or Woedstoves 4 °-. ) Number of each
g. Energy Conservation Compliance. Masschecic Energy Compliance form attached?
h. Type of construction lS.lpex - -_
i. is construction within 1G0 ft of wetlands? Yes �__ No. Is construction within 100 yr. floodplain Yes -No
I. Depth of basement or cellar floor below finished grade ,5 I
K. Will building conform to the Building and Zoning regulations? Yes No .
I S ■ntic T - Ank Ci" S Private well C t r Supply �f
I : - .ry ewe, . „va e .... ,�; : �a e, ,:p y 1
SECTION 7a - OWNER AUTHORIZATION 'O 6E COMP€:ETEO WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDINGPERMIT
i
I, as Owner of the subject
property
hereby authorize '^�••e�...) i \-t\I .1'a ova- ---" , w .P
to act . ' all matters relative to work authdnzed by this building permit ap lication.
ar
I Signet ZEIME I Date t..) •.
_ I
I . as OwnerlAuthcrized
Agent h ere b y declare that the statements and information cn the foregoing application are true and accurate tc the best of my knowledge
and belief.
Signed under the pairs and penalties of penury.
i
r Nacre i
S,cn _r
ate :f C per ;Agent '\ / -ale 1
U
i ■ J
Section 4. 'ZONING i All Information Must Be Completed. Permit Can Be Denied Due Tc Incomplete Information
I Existing I Proposed Required by Zoning
This column to be filled in by
Buildin Department
Lot Size I _..... __,. , ....._,. ,_.., _...._., _._.. .. _....
Frontage _„ .... ._._.. ___...
Setbacks Front �1
i
Side L: _ -.,. R:'
Rear _._
Building Height
Bldg. Square Footage % __.. __.
Open Space Footage _ °/
(Lot area minus bldg & paved :— ..--
caning)
# of Parking Spaces ._ ""
(volume & Location) - ----- — ._" w_'.` w _ ._- .-- - -.---
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 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
IF YES enter Bock ` Page' and /or Document #.
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 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO •
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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 0 NO
!F YES, then - a - Northampton Storm Water from the DPW is required.
CI Department use only
City of Northampton status of Permit_
Building Department Curb Cut/Driveway Permit
' Ca 1 ,. A � ` 'I 212 Main Street Sewer/Sepfic.Availability
1 Room 100 Water/Well Availab
JUL - 7 2008 Northampton, MA 01060 Two Sets of Structural Plans
phone 41'"i 87 -1240 Fax 413 -587 -1272 PiottSite Plans .
Other Specify
1. LtPLIAT1GNsT(t!LIrO T, ALTER, R RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
a:-
I SECTION 1 - SITE_, INFORMATION l
1.1 Propert Address: This section to be completed by office I
35 1 V $A- S)4J"e__ - Map Lot Unit
CC2. -\ (" ) t'W 0 106 Zone Overlay District
Eini St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
r i 'ch J _.) 35 KV to vi
Name (Print) C urrent Mailing Address:
i 3. Cto.25
Telephone
Signature ((/ //
2.2 Authorizec1!#'gent:
v
Name (Print) Current Mailing Address:
Signature 4 Telephone
SECTION 3 - 'ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollars) to be I Official Use Only
omoleted by permit applicant
1. Building 1(a) (a) Budding Permit Fee
1, I
2. Electrical _____, (b) Estimated Total Cost of
Construction from (6)
3. Plumbing I �--_ Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) I 1 v Check Number 3Ji5
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building, Commissioner[Inspector ort Date
File # BP- 2009 -0023
APPLICANT /CONTACT PERSON R DEAN ACHESON
ADDRESS/PHONE P 0 BOX 1052 WILLIAMSBURG (413) 268 -0246
PROPERTY LOCATION 35 RUST AVE
MAP 38A PARCEL 021 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: EXTEND MUDROOM W /ROOF ONLY(3 X 4 & 3 X 3)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 83968
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON qq
INFORMATION PRESENTED: l 1 f lara'
L.. pproved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§ ilk 4t- Lt?t7. St
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan �p
ZONING BOARD PERMIT REQUIRED UNDER: § p--13-1r
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
/ 07 11Y/01(
Signature of Building Official Date
g g
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.
1 $
BP- 2009 -0023
GIS #: COMMONWEALTH OF MASSACHUSETTS
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- 2009 -0023
Project # JS- 2009 - 000030
Est. Cost: $1800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: R DEAN ACHESON 83968
Lot Size(sq. ft.): 7884.36 Owner: PENGELLY FRITHA
Zoning: URB Applicant: R DEAN ACHESON
AT: 35 RUST AVE
Applicant Address: Phone: Insurance:
P 0 BOX 1052 (413) 268 -0246
WILLIAMSBURGMA01096 ISSUED ON: 7/14/2008 0:00:00
TO PERFORM THE FOLLOWING WORK: EXTEND MUDROOM W /ROOF ONLY(3 X 4 & 3
X 3)
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 7/14/2008 0:00:00 $50.003045
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo