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28-079 (3) NOV-22-2006 03 :27 AM P. 01 Howard Laboratories 62 Main Street - Hatfield, MA 01036 Tel. (413) 247-5533 Fax (413) 247-9599 WATER ANALYSIS REPORT Henshaw Well Drilling Invoice Number: 12761C Sample Location: 377 Sylvester Road, Well Head. Client: Melissa Seymore Sampled By: HWD Date Sampled: 10-11-06 Date Received: 10-13-06 Parameter Results Limits Comments Total Collform Bacteria 0 colonies/ 100ml 0 colonies/ 100ml OK Color 25 PtCo Color Units 15 PtCo Color Units Iron 0.28 mg/l 0.3 mg/I OK Manganese 0.019 mg/I 0.05 mg/1 OK Nitrate 0.34 mg/l 10 mg/I OK Nitrite 0.006 mg/I 1 mg/I OK pH 7.90 pH Units 6.5 - 8.5 Ph Units OK Sodium 3 mg/I 28 mg/I OK Conductivity 0.24 mS/cm No Standard No Standard Turbidity 9.16 NTU No Standard No Standard Chloride 60 mg/I 250 mg/I OK Hardness 101 mg/I No Standard <50 soft >100 hard ND = None Detected Recommendations: This sample meets acceptable standards of potability. The parameters with an asterisk which are over the limit should go down after a few weeks as the water and materials floating In the well settle. Analyst: SL Date: 10/19/06 MA Certification: M-00851 Massachusetts Department of Conservation and Recreation Office of Water Resources 148195 TYPE OR PRINT ONLY Well Completion Report 1.WELL LOCATION GPS (Required) North— — — — West — Address at Weil Location: Property Owner/Client: Subdivision Name: Mailing Address: ' % City/Town: vt4,� :tom ^`a.. .` �' '� e- t_ " s `a . CitylTown: Assessors Map Assessors Lot#: NOTE: Assessors Map and Lot# mandatory if no street address available Board of Health permit obtained: Yes 0 Not Required [ Permit Number Date Issued` 2.WORK PERFORMED &,WELL TYPE 4.DRILLING METHOD­ 6.CASING Overburden Bedrock From (ft) To (ft) Type ,: Thickness Diameter 2E F-W 5.WELL LOG OVERBURDEN Water Loss or Drop in Extra ❑ El�❑ LITHOLOGY Bearing Addition Drill Fast or Zone of Fluid Stem Blow T.SCREEN From(ft) To(ft) Code Color Comment Drill Rate Y I N Y ✓ N F I S From(ft) To(ft) Type Slot Size Diameter YIN Y F ❑❑❑ - - - Y > N Y ✓ N F ✓ S ❑❑❑ — — — Y ✓ N Y / N F / S 8.ANNULAR SEALIFILTER PACKIABANDONMENT MTL. Y ✓ N Y I N F ✓ S'` From{8) To (ft) Material Description Purpose YIN YIN FI`S` ❑❑ ❑❑ Y / NY / N PI"S ,. ❑❑ E]El Y YIN F I S"",� ❑❑ E]1:1 Y / N Y I,N '/'S El El ❑❑ .r , kWELI LOG, BEDROCK Extaa 9.STTE SKETCH Water Drop in Extra Visible Loss or #of Fast'or LITHOLOGY Bearing Drill Large Slow Rust Addition Fracture To(ft) Code Comment Zone Stem gips ri11 Rate Staining of Fluid per foot ': a � Y1NY'/ AlF,✓ SY ✓ NY ✓ N r l A. YINY, INF / S Y / N YIN Y ✓ NY /N F / S Y / N Y / N Y I I, Y N F I S Y / N Y I N id i `.` Vl �4�`��� �"' ti Y / NYINFISYINYIN WI'NY / N'f-)✓ SYINYIN Y1NY / N F I S Y / N YIN v . r Y I N Y I N F ✓ S Y ✓ N YIN 5-7-- 'LtC ; Y I N Y I N F I S Y I NY / N Y ✓ N 10.WELL TEST DATA(ALL SECTIONS MANDATORY FOR PRODUCTION WELLS) 11.STATIC WATER LEVEL(ALL WELLS) Yield Time Pummel Pumping Level Time to Recover Recovery Depth Below Date Method (GPM) (hrs&min) (Ft BGS) (hrs&min) (Ft.BSS)w. Date Measured Ground Surface (ft) t i.+ UL i ) S { ~ 12.PERMANENT PUMP(IF AVAILABLE) 13.ADDMONAL WELL INFORMATION Pump Description Horsepower Developed'Y�/ N Fracture Enhancement Y'= '/ N Pump Intake Depth (ft) Nominal Pump Capacity (gpm) Disinfected Z/ N Surface Seal Type r `) 14. COMMENTS S Total Well Depth Depth to Bedrock 15.WELL DRILLER'S STATEMENT IThis well was drilled, altered,and/or abandoned under my supervision,according to applicable rules and regulations, and this report is complete and correct to the best of my knowledge. ► ! 1 A41 Duller. y`' A" �° Supervising Driller Signature: `°f jl�` xr ` ' ' Registration #:1 1 �� 1�t I '"I �, �R^.-'•,.,s.,_: ti E�„y _'`v �..`. `,� Lt�` Firm: ' Y r` Date Complete: ` " Rig Permit#: NOTE: 1Wll Completion Reports mzw he filed by the registered►veil driller within 30 days of well completion. BOARD OF HEALTH COPY owl I ■■ararrtia\■■.rar...aa..■aaraaararaa a.r■■rats r■r■aa■■rarrrrr..aria■aaa■■.■aa ■ . ■ a City of Northampton fj NUMBER FEE $ 6 BOARD OF HEALTH jd, This is to certify that �C/ NAME ADDRESS Is hereby granted a Permit For °7 ■ This license is granted ' conformity with the Statutes and ordinances relating : thereto and expires -unless sooner suspended or revoked. , 20 6� Board of Health : r..............■..........■........■.......■.■.■........■■■.■....■■.■■...■ DEPP.P,TMcNT OF BUIL.DI)I�C lNSPcCTlOhS € I I':SP[C7Q2 212 Afain SLrccL - A'lunicipl Building � i NorlhnnfpLo„, lkltin. 01060 1 Squares(Fo�/otage Pmount SBasement @ $_IS � r 1 ! (� 1st Floor @ - 2nd Floor @ $-30 1/2 Floors, Attic. Garage Deck Porches $_I:; (7 ` 05� - TG; i (SUBJECT TO ATTACHED CONDITION 1 & 2) Permit No. D09-07 Conditions: Driveway Permit In lieu of plan approved by City Engineer I agree to the following added conditions: I. I will contact the Department of Public Works and have an inspector check and approve the graded gravel base prior to paving to insure compliance with slope and location; 2. 1 further agree that if in the inspections any of the permit conditions are not met that I will at no expense to the City remove and replace the driveway as directed by the City Engineer. By: Petitioner Melissa Seymour 45 Vernon Street, Greenfield, Ma 01301 413-773-0342 Note: The Public Works Department recommends that you provide a plan showing the proposed driveway with grades and location in the future to avoid possible expense which you will incur by not getting approval of actual plans in advance. For commercial and industrial applicants, a plan showing the proposed driveway with grades and location is required. cc: Building Inspector Permit No. D09-07 CITY OF NORTHAMPTON, MA DRIVEWAY PERMIT Date: 9/21/06 FEE: $25.00 CHECK#: 5824 THE BOARD OF PUBLIC WORKS Driveway must be staked and house & lot number posted The undersigned respectfully petitions your honorable body for: Permission to install a driveway at 377 Sylvester Road, Florence, Ma 01062.New Construction Fifteen (15) foot maximum width at the street line. Gutter drainage not to be disturbed. All drainage shall be directed off the driveway surface to adjacent land and not on the existing roadway. Driveway surface to be paved as soon as possible if the grade of the proposed driveway exceeds 3% or more. Homeowners will be held responsible for any cost to the City of Northampton in the event of a washout of this driveway. By: Melidsa Seymour Telephone #: 413-773-0342 Proposed Location Inspected By: Gravel Base Grade Inspected By: Final Approval THE BOARD OF PUBLIC WORKS voted that petition be granted. Edward Huntley Director of Public Works EXHIBIT "A" The land in Northampton, Hampshire County, Massachusetts being Parcel 2, containing 1.870 acres, as shown on a plan of land entitled"Plan of Land in Northampton, Massachusetts for Irene Szymanski," dated October 6, 2005,by Heritage Surveyors, Inc., recorded at the Hampshire County Registry of Deeds Plan Book , Page Also, the grantor herein hereby grants an easement to the grantees herein as shown on said plan, said easement being shown as "Proposed acres easement for the benefits of parcel 2", said easement is for purposes of grantees constructing and maintaining a driveway the land of Grantor as shown on said Plan. By accepting title, the grantees, their heirs, successors, and assigns herein agree to maintain the easement at their own expense, to use it as a driveway access to parcel 2 only, and hold Grantor harmless from all claims arising out of the use of proposed easement including any action for personal injuries or property damage incurred by the grantees or their invitees. QUITCLAIM DEED KNOW ALL BY THESE PRESENTS I, IRENE SZYMANSKI, of 361 Sylvester Road, Northampton, Massachusetts for consideration of LESS THAN ONE HUNDRED AND 00/100 DOLLARS ($100 . 00) grant to MELISSA SEYMOUR and TIMOTHY SEYMOUR, husband and wife, tenants by the entirety, both of 45 Vernon Street, Greenfield, Massachusetts 0 with QUITCLAIM COVENANTS the land in Northampton, Hampshire County, Massachusetts, bounded and described as follows : See Exhibit A, attached hereto and made a part hereof . Being a portion premises conveyed to the grantor herein by deed dated q 6 (fzv and recorded in Hampshire County Registry of Deeds in `Book j�j o3 Page q Witness my hand and s al this 6th day of July, 2006 . Witness Irene Sz ski UCOMMONWEALTH OF MASSACHUSETTS Hampshire, SS . July 6, 2006 On this 6th day of July, 2006 , before me, the undersigned notary public, personally appeared Irene Szymanski, proved to me through satisfactory evidence of identification, which was a Massachusetts Driver' s License, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purp i Notary Public C, BERNARD J.WHALEN,JR. Notary Public My Commission xpires t� 0mmmweatth of Massachuwft My Commission mires on February 28.2008 CITY OF NORTHAMPTON, MASSACHUSETTS J, DEPARTMENT OF PUBLIC WORKS 125 Locust Street i Northampton, MA 01060 413-587-1570 Fax 413-587-1576 Ned Huntley, P.E. Director ASSIGNMENT OF HOUSE NUMBER(S) Street: Sylvester Road Assessors Map: Portion of Sheet 28 Lot 010 House Number: #377 Sylvester Road Date: August 15, 2006 Remarks: Reference is made to Plan of Land in Northampton, Massachusetts Surveyed for Irene Szymanski by Heritage Surveys, Inc. dated October 6, 2005. House Number 377 Sylvester Road is assigned to Parcel 2 on said plan containing 1.870 Acres. This new lot has been recorded in Plan Book 211 Page 46. House number was requested by the Applicant for permitting purposes. (No new parcel ID had been assigned to this lot at the time of inquiry). Ned Huntley, P.E. City Engineer/Director of Public Works cc: Central Dispatch Water Division Tax Collector Sewer Division Massachusetts Electric Streets Division Verizon Telephone Inspectors Comcast Assessors Bay State Gas Police Department Post Office (Northampton) James Thompson(GIS Coordinator) Post Office(Easthampton) Applicant: Melissa Seymour 45 Vernon Street Greenfield, MA 01301 K:\House Numbers\ -----------------------------------------------* Official Receipt for Recording in: Hampshire County Registry of Deeds 33 King St. Northampton, Massachusetts 01060 Issued To: WHALEN & WHALEN Recording Fees ---------------------------------------------- Document Recording Description Number Book/Page Amount w----------------------------------------------r PL 00018590 211 46 $75.00 SZYMANSKI DEED 00018591 8789 117 $125.00 SEYMOUR EXCISE $.00 $200.00 Collected Amounts ----------------------------------------------* Payment Type Amount *----------------------------------------------* Check 7118 $125.00 Check 4493 $75.00 $200.00 Total Received $200.00 Less Total Recordings: $200.00 Change Due $.00 Thank You MARIANNE DONOHUE - Register of Deeds By: Marilyn H Receipt# Date Time 0153603 07/11/2006 10:12a EXHIBIT "A" The land in Northampton, Hampshire County, Massachusetts being Parcel 2, containing 1.870 acres, as shown on a plan of land entitled "Plan of Land in Northampton, Massachusetts for Irene Szymanski," dated October 6, 2005,by Heritage Surveyors, Inc., recorded at the Hampshire County Registry of Deeds Plan Book , Page Also,the grantor herein hereby grants an easement to the grantees herein as shown on said plan, said easement being shown as "Proposed acres easement for the benefits of parcel 2", said easement is for purposes of grantees constructing and maintaining a driveway the land of Grantor as shown on said Plan. By accepting title, the grantees, their heirs, successors, and assigns herein agree to maintain the easement at their own expense, to use it as a driveway access to parcel 2 only, and hold Grantor harmless from all claims arising out of the use of proposed easement including any action for personal injuries or property damage incurred by the grantees or their invitees. QUITCLAIM DEED KNOW ALL BY THESE PRESENTS I, IRENE SZYMANSKI, of 361 Sylvester Road, Northampton, Massachusetts for consideration of LESS THAN ONE HUNDRED AND 00/100 DOLLARS ($100 . 00) grant to MELISSA SEYMOUR and TIMOTHY SEYMOUR, husband and wife, tenants by the entirety, both of 45 Vernon Street, Greenfield, Massachusetts with QUITCLAIM COVENANTS the land in Northampton, Hampshire County, Massachusetts, bounded and described as follows : See Exhibit A, attached hereto and made a part hereof . Being a portion premises conveyed to the grantor herein by deed dated and recorded in Hampshire County Registry of Deeds in Book /,,,D3 , Page q Witness my hand and s al this 6"' day of July, 2006 . Witness Irene Szogyifski COMMONWEALTH OF MASSACHUSETTS Hampshire, SS. July 6, 2006 On this 6th day of July, 2006, before me, the undersigned notary public, personally appeared Irene Szymanski, proved to me through satisfactory evidence of identification, which was a Massachusetts Driver' s License, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purp BERNARD J.WHALEN,JR. Notary Public Notary Public My Commission xpires : G;mmonwealth of Massachusetts My Commission axpires on February 26.2008 CERTIFICATE OF LIABILITY INSURANCE 6a%zs%2-066" PRODUCER (413)549-4971 FAX (4135549-4974 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Blair Cutting & Smith ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE A Div of Neighborhood Ins LLC HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 25 University Drive Amherst, MA 01002 INSURERS AFFORDING COVERAGE NAIC# INSURED The Home Store Inc. INSURERA: Peerless Insurance 24198 P.O. Box 300 INSURERS: American Intl Group Whatel y, MA 01093-0300 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY CBP9625143 08/01/2006 0810112007 EACH OCCURRENCE $ 100000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 10000 CLAIMS MADE ®OCCUR MED EXP(Any one person) $ 500 A PERSONAL&ADV INJURY $ 100000 GENERAL AGGREGATE $ 200000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 200000 POLICY n PRO JECT n LOC AUTOMOBILE LIABILITY BA9625601 08/01/2006 08/01/2007 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY A SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY CU9624146 08/01/2006 0810112007 EACH OCCURRENCE $ 200000 OCCUR CLAIMS MADE AGGREGATE $ A $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND WC ST EEL X OTH- EMPLOYERS'LIABILITY WC9300481 08/01/2006 08/01/2007 E.L.EACH ACCIDENT $ 500,000 B ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE9 $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1 $ 500,000 OTHER ESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE pp __ �JJ William Dowd, Acct Exec./NOw t .'� ,ORD 25(2001/08) ©ACORD CORPORATION 1981 _V Nm uA mk I avoa 83ls3AIAS lend �� ---- C0•Y l C— - •g0/C oc 35.6)• i' ooao NOS'JO'!3• � �$� c �o Z ' E3, V imp �AmJ�li � Ilan y V C,r C — 1 0741'34'W— allo _ m �,o1z - 3suAy N (A °mz aA _ z i mo ° �n yAKAA m I s� lDmy OOmD'I � � OOO An 8 � II A� m " � I c9�, ° y a V °> y �m I - PLAN BOOk O-AN OP I a e In igg �+OU 11 loll F YDC-CATALOG SALCS Fax:413-665-8321 Dec b 1UUb unowAas ° cG721W+43aroN a�rvw4n3 AP SN018W]a 3tW M1Ytl w i��f fl>io noa 0110 H4� �ppp aQyC_ei.z.i`8 aotn.vi X"6'4 I rn J W $ 7 2 �3 Y N =3 - , gel r "n C 325 xr r 1 I w g 2 Y -- � iif p er ` M 4 ry �� In Office of Investigations 600 Washington Street Boston,MA 02111 ,. SY•�,. www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly I�aI21e (Busmess�Orgaruzation/Indw�dual):---- ��i)'b12C.- - - ------- Address: 3 SA'T'E rc_v City/State/Zip: W (j J v93 Phone #: Are ou an employer? Check the appropriate box: Type of project(required): 1. I am a employer with _ 3S, 4. ❑ I am a general contractor and I 6. few construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # ❑ Remodeling ship and have no employees . These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions e 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.0 Other 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. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: T-�- C64-VYi > . L-44 �tm2 Gv{tl i SMlM- Policy#or Self-ins. Lic. #: WC, 71 '755 G13 Expiration Date: ell 1c)(. Job Site Address: City/State/Zip: �Royf ae, Ivy 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 certify under the pains and penalties of perjwy that the Information provided abo a is true and correct Signatur �/� Date: Phony-t- q t 3 (oS f 2 Of .ciat use only. no not wr1Je!In this area, to be completed by clry or town erf)?e W. 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#: �� fnan2anivrrcuaalt�z �, lla�J.,T� BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 051933 Birthdate: 12/16/1949 Expires: 12/16/2006 Tr.no: 5971.0 Restricted: 00 THOMAS O RYAN 340 N MAIN ST SUNDERLAND, MA 01375 G' � e, Commissioner SECTION 8'-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /+, Not Applicable ❑ Name of License Holder: I k O rywVgQ,VI D Nl�(i 6F � -nd eta�� ��� License Num er Add res Expiration Date ia) - q� Signature —Telephone 9.Rnrt stnred�Homii"iiiioroveii 4nt,Contractiir 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....... V, No...... ❑ 1 ­Honie Uvrn& 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 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 E] Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks Siding[p] Other[ Brief Description of Proppsett �%� Work: '=V)55w 1 �'DI�.�` oyl 4 LA)4y) q,tiL. aq Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. It N @W house and or addition 10 exisflng'hous np, comoke-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 �`7 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 21 Y k. Will building conform to the Building and Zoning regulations? �\ Yes No. I. Septic Tank City Sewer Private well x City water Supply SECTION is-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Tim M W Me k SScl as Owner of the subject property hereby authorize , to act 91Lmy Vehalf, in all matters relative to work uthorized by this building permit application. Signature Own r bate Y s 0•'`""a U as Owner/Authorized Agent hereby declare that the statbfnents 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. �S Print Name 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 l �. ��ov CD Frontage ... . .`�.. Setbacks Front (�br+ Side L d) R: ,�OP+ L: . R:- /.57 Rear Building Height Bldg. Square Footage Open Space Footage ry % (Lot area minus bldg&paved 1af /� parking) #of Parking Spaces Fill: volume&Location - m A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW 0 YES IF YES, date issued: f�pp� �i/atr „qtr , IF YES: Was the perniit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 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 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES NO 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 NO KA IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i � BM City of Northampton Building Department 212 Main Street Room 100 '} ' Northampton MA 01060 phone 413-587-1240 Fax 413-587-1272 P, Sk, y .MVA APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE I OR TWO FAMILY DWELLING 'SECTION 1 -SITE INFORMATION ` u ndc&n On I (�rmr� 1.1 Property Address: This section to be co�gleted by office �r(1 �I��S`hX �vc�G�. Map Lot Unit �Flove.vi e e , I�� Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: m G 112 kI Asa X15 ��rl�tNt �veen- 'e,1d MA D t Name P int Current Mailing Ac 1�f)dr !- t1l 3_ 0.34a Aff Telephone Signatu 2.2 Authorized Agent: p n. �x 300 W il o 011i'l Name(Print alb i� Current Mailing Address: a C7 J41.3— 53'1 — q(0 4 ) Signs u Telephone re SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant �;,,,viaorh.a n 4 1�1 Qp (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number G + This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings'' Date File#BP-2007-0622 APPLICANT/CONTACT PERSON THOMAS O RYAN ADDRESS/PHONE 340 NORTH MAIN ST SUNDERLAND (413)537-9640 PROPERTY LOCATION 377 SYLVESTER RD MAP 28 PARCEL 079 001 ZONE RR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid l Typeof Construction: CONSTRUCT FOUNDATION ONLY FOR SFH WITH ATT GARAGE 1,547 SQ FT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 051933 3 sets of Plans/Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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* 6A/L 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 Commi 2 140 Signature uilding Offrcial 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. 377 SYLVESTER RD BP-2007-0622 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 28-079 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: FOUNDATION BUILDING PERMIT Permit# BP-2007-0622 Project# JS-2007-000931 Est.Cost: $15700.00 Fee: $232.05 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS O RYAN 051933 Lot Size sc. ft.►: Owner: SEYMOUR TIM&MELISSA Zoning RR Applicant. THOMAS O RYAN AT- 377 SY1.VF=STF1- RD Applicant Address: - Phone: Insurance: X 340 NORTH MAIN ST 413) 537-9640 . _ WC SUNDERLANDMA01375 ISSUED ON:12/13/2006 0:00:00 TO PERFORM THE FOLLOWING WORK CONSTRUCT FOUNDATION ONLY FOR SFH WITH ATT GARAGE 1,547 SQ FT 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:C/h Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Gil. Insulation: Final: Smoke: Final: l9 rr 3- 'j ?.a 7 THIS PERMIT MAY BE REVOKED BY TH 0TY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULA I PONS� , Certificate of Occupancy - Sienature: FeeType: _ Date Paid: Amount: Building 12/13/2006 0:00:00 $232.055868 212 Main Street, Phone(4 0)587-1240,Fax:(413)587-1272 Building Conunissioner-Anthony Patillo