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:Driveway. 5 bedroom
3 car
House
Garage
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gallon septic tank "C' •— Pumping manhole ("C")
0
AS—BUILT DIMENSIONS
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4" pvc solid pipe
"A" to "D" = 136' — 0"
"B" to "C" = 23' — 0"
"B" to "D" = 131' — 6"
Existing
distribution box ("D")
401f of 4" pvc perf pipe
\111 As—built plan
White Oaks Woods
Lot # 1 — Dunphy Drive
Existing SAS "D" Northampton, Massachusetts
Dionne Mgt. Team
PO Box 294
Sunderland, MA. 01375
( 219 — 2799
* No expressed or implied warranty *
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The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
--111f=' °�`'� Office of Investigations
.1 ® 1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Please Print Legibly
Name (Business/Organization/Individual): �(0^3(-c:� 0[.4,e y fi86,z.Gt�tf /et.s "9,-9 I�igt G-CrL
Address: 3 cis $s7-,5 Ali tc.S
City/State/Zip: 4--(car-Yotc "-f1 O (046 Phone #: r
Are you an employer?Check the appropriate bo Type of project(required):
1.n I am a employer with 4. I am a general contractor and I
employees (full and/or part-time).* have hired the sub contractors 6. n New construction
2.n I am a sole proprietor or partner- listed on the attached sheet. 7. [' Remodeling ship and have no employees These sub-contractors have 8. n Demolition
working for me in any capacity. employees and have workers'
g y p y 9. n Building addition
[No workers' comp. insurance mp. insurance.
required.] 5. We are a corporation and its 10.n Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.1B/Other face.. Apia S�A
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'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.
tC:ontractors that check 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.
I am 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 DIA for insurance coverage verification.
I do hereby certif nder the .ains and enalties o .er'ury that the in ormation provided above is true and correct.
Signature: ee� Date: 3 /0.7
Phone#: X772 Z Z( 835!3
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �i Not Applicable l
Name of License Holder: 44R-6%i C v t — 06 !siv
License Number
Address .0/ 0 Expiration ate
943 L2.! 83Si/
Signature Telephone
9. Registered Home Improvement Contractor Not Applicable ❑
G' ito e∎S c— /c4'-f /}l3 2-3 3
Company Name Registration Number
w GS
64244 ,'c.s /C 4(2 /sl
Address Expirati(n Date
H6(--Y Telephone 403 22.! 9378
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 buildin ermit.
Signed Affidavit Attached Yes No ❑
11. - Home Owner Exemption A-ffrr
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 n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [E] Siding [0] Other[
Brief Description of Proposed T�
Work: ��S;,e/cc1:,cs.3 oF .2":JGj2ourk k /a6 0 C./5 44 f 6x ,e
Alteration of existing bedroom Yes No Adding new bedroom Yes 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
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. Masschsck 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
I, 2-7Strf o�L44 v4 1 , as Owner of the subject
property
hereby authorize et.j.cyz Ar c. /41YE
to act , Behalf, in al(m ters relative to work authorized by this building permit application.
\(, Signature. er Date
I, C—G. & -Jc cS / o 'ci , 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
.A,- _ ‘5.-- 3
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
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L/ R: LO_C
Rear bO
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Spe 'al Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was th ermit recorded at the Registry of Deeds?
NO DON'T KNOW (3 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO (3 DONT KNOW QYYES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO 0 (1)//,-1/4y8L
IF YES, describe size, type and location: iv/ ✓fat= I� f % .47_ � R.,6 i3 r 2
y /ems X�AY
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, exc ation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
,ECEIVED City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
2013 212 Main Street Sewer/SepticAvailabiy
Room 100 Water/Well}vatlability:' .
Northampton, MA 01060 Two Sets of Structural Plans
DEPT.or BUILDING INSPECTIOJ Plot/Site Rians
NORTHAMPTON MA�1060 413-587-1240 Fax 413-587-1272
T ,
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: \\ This section to be completed by office
�Vz .CJ Clet//Gif �� Map Lot Unit
'f-14 D/O,E, Z. Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
—6 f /e, c4)c..gd,b /V Z d u ///ec -
V Nam ) ' Current Mailing Address: 7 l 3 3 /fe�o (
Telephone
J Signature
2.2 Authorized Agent:
eG.f>1•Zcci'(Cv /64 y 3 et.)FSsE,2d✓,C..r,1)(2 /f 4 / t /-
Name(Print) Current Mailing Address:
9/-y ZZ
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 5e. -A/0 poey,.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6) 37, ?D S'. CC)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 +2+3+4+5) Check Number //9 —
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
0I`
File#BP-2013-1110
APPLICANT/CONTACT PERSON CLARENCE KAYE
ADDRESS/PHONE 3 WESTERNVIEW RD HOLYOKE (413)221-8358
PROPERTY LOCATION 142 DUNPHY DR
MAP 36 PARCEL 347 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out !� ��
Fee Paid �1 9 `
Typeof Construction: CONSTRUCT 14 X 30 INGROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 064314
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOJRMATION 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
s/ i,
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.
142 DUNPHY DR BP-2013-1110
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-347 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Inground Pool BUILDING PERMIT
Permit# BP-2013-1110
Project# JS-2013-001831
Est. Cost: $37908.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CLARENCE KAYE 064314
Lot Size(sq. ft.): 77798.16 Owner: AM TRUST BANK C/O JEFFREY J ROWLAND
Zoning: Applicant: CLARENCE KAYE
AT: 142 DUNPHY DR
Applicant Address: Phone: Insurance:
3 WESTERNVIEW RD (413) 221-8358 WC
HOLYOKEMA01040 ISSUED ON:5/24/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 14 X 30 INGROUND POOL
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 5/24/2013 0:00:00 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner