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35-271 R; ' SEP27 !t Ll LN a R i • cs °Y1 t ( +, w.. t, 4' C� l LA } .h i VI ......... 4 Ito `.�' .. 'M'•�Ii� �� y rye R.7 •? ~,_.�) � .r + A Jp ,� V r n + Ir T0 'd ZGLS bLL ETb T sN3aiinS ' ININtk w Wks 9S: T T 2ni 00—ZT—d38 Az 0,?� ( 1t, of ��n> fl��ltt�tolt g � E ;2ta�aachnctlla = DEPnRTME14T OP BUILDrNG INSPECTIONS — 212 ?lain Street ' Municipal Building Northampton, Mass. 01060 WORKER'S CO\fI'ENSA-nON INSURA-NCE A17,II)AVIT I ---�- --- (liccus:clperrnittcc) with a principal place of businesshcsidcncc at: j x.16 - -- ---- (Sn-c lcity/stalerTip) do hereby ccrdi;, under tic pains and penalties of perjury, t1231 ( ) I am an employer providing the following worker's colnot ns iol; cove eye for In1' eluplovccs worlQng on tins job ([nsur�G Corsrw) (P0Lc; N imirr) --- - (-D.piruor, Date) I am a sole proprietor, general contractor or homeowner(ci cic onc) and have hired the contractors listed below who have the iOUo%VinQ worker's comnensanon policies: (Name of Contractor! (Inn nncc Co oan}'rPoucr . tun^ ;) (i:>:a r,eo Date) - (Name of Coatraciw) --- Ojis-dra=c ComoanyiPolic), Nu-mbcr) ��oir lion Date) (Name of Contractor) (Insuranc; Compa-oy Pot.'c} Nambu) (E\pimaoo Datc) (Name of Contractor) (Insumc-- Company/Pohcy Number) (L-xpir-atioo Datc) (eaacit adii�ocil nc�d if acCCii:,to !u�informx5oa pcste.inans to.n oca'in�.o'y) I am a sole proprietor and have no one worming for me. ( ) I am,a home owner performing all the work myself. NOTE:plcsc be-crate tL, { Jc hcc-rowc, Y Who cnploy pczonl w w r--mi•-,•Kt?= -,:uK3 r M, U- js as t d..cll�i aC nAl @OCC Ih_.a Lt7cY l."_lftf In tt LL:Ch ItX uvilx�/."DU ICS]dC]OC OO r�CSUl11Y:]ZapulYC[3.11 u/_u✓LT ooe�e :12y ar�:d.--cd to be employers uaic theµvdk 'i o=qc:mziioa Act(GL152"1(5)�afVLiatioo by a homeow=for:bczv—_a permit n•:y c T3cncc the legal etaaat of cn mvloyx under dw Wockoe,cocap""Lioa A\ i- I u—i—t rid the>ooyy of thi.�mty be foc mtrd.ed to tbo Department of Jc>dzxtrid Amdmtl Ofrioo of tr—foe tho covens-vcrif cauoc nad th t L•iJmm to ccaue coverts,tsndcr soetion 23A of htoL 152 an lad to the LM4 on of cri ni pen (t s 0001i-'a m of•fine of ttp to S 1 302.00 andle)(-i$pruoaman of up to ooc year end ci it pcnattio n Cx fo m of n stop Work Order end a fim c(S 100.00 a day.EainA me ( Foe dcp„trz,vl u,e«ply Permit Number ot '� i`4ap;; L t�natun:of LitznsccJPcrmiucc SECTION!8•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION IQ-,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...... ❑ 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 It"!QN AACACRIPTION '011 'licable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. Demolition❑ New Signs [ j Decks Siding[ ] Other[ ] Brief Description of Proposed Work: ,o&d <-cc Cle dc f- ro < i v e �� S 'c!tiv� Alteration of existing bedroom Yes No Adding new bedroom Yes No �,i�y��G� Attached Narrative❑ Renovating unfinished basement Yes No / Plans Attached Roll o - Sheet o 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. Mascheck 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 SEC`Clt)N 7a•'CWNER;AUTHORI�ATIt1N TO BE COMPLETED WHEN OWNE SAGER t? t CONTRACTOR APPLIES 0 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 dec re that the statemen s 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 Z GCG Signature of Owner/Agent Date n n SI,cL� r`� ic Section 4. ALL INFORMATION MIDST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by �j Building Departmentr�� Lot Size Frontage Setbacks Front /Icc 7`�-t Side L: R: L: R: /D Rear / D Building Height d1 Bldg.Squire Footage % bCir l�C- i-f;Z'St" Ycc, bU S/it. 0�� q �. f� 5/�� l� f yo Open Space Footage , % (Lot area minus bldg&paved , Q��L 70 3 —) 6 parking) #of Parking Spaces Fill: -T volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO >�, DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? 0 DON'T KNOW YES X -511-7,'11 -�'- / S G. PZ7�Y) ./'Xf//(/r/L� S 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: Pr �' i� City Of Northampton 1J . Building Department $EP 2 7 2000 2 42 Main Street R Room 100 ,FlqWa MA 01060 5 '1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION SITE INFpRMATICIN b 1.1 PropertyA Address: � y Rd { , ..yy�, r 'SECTION, Pi12t3PER7"Y OWNERSHIPlAUTHORIZE©AGENT 2.1 Owner of Record: Name P nt) Current Mailing Address: Ct/7 Telephone Sig ture 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3�EST(MAT,tou ONATRUCTIOWOOSTS Item Estimated Cost(Dollars)to be Official Use Only com leted by ermit applicant !c cfL (a) Building Permit Free 1. Building ;� 'U' ?ccC S1fL!) 2. Electrical (b) Estimated Total Obst of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2 + 3+4+ 5) J G'C'C Check Number 3 This Section For Official Use Only Building Kermit Number: Gate Issued: Sgrieture: Building Commissioner/Inspector-of Buildings Date File#BP-2001-0323 APPLICANT/CONTACT PERSON OMASTA JOHN P&FAYE AMBRFE ADDRESS/PHONE 165 WEST FARMS RD (413)586-0031 Q PROPERTY LOCATION 165 WEST FARMS RD MAP 35 PARCEL 271 ZONE RR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Bu Permit Filled out Fee Paid Typeof Construction: CONSTRUCT 10 X 18 DETACHED DECK& 10 X 14 SHED 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 ALLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION: Approved as presented/based on information presented. Denied as presented: Special Permit and/or Site Plan Required under: § PLANNING BOARD ZONING BOARD Received&Recorded at Registry of Deeds Proof Enclosed Finding Required under: § —w/ZONING BOARD OF APPEALS Received&Recorded at Registry of Deeds Proof Enclosed Variance Required under: § w/ZONING BOARD OF APPEALS 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 Co alsion Permit from CB Arc:ectur Committee Signature bf1luilding O cial 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. 165 WEST FARMS RD BP-2001-0323 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35-271 CITY OF NORTHAMPTON Lot:-001 Permit: Buildin Category:ADDITION BUILDING PERMIT Permit# BP-2001-0323 Project# JS-2001-0536 Est. Cost: $500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Lot Sizes .ft. : 165092.40 Owner: OMASTA JOHN P&FAYE AMBRFE Zoning:RR Applicant. OMASTA JOHN P & FAYE AMBRFE AT. 165 WEST FARMS RD Applicant Address: Phone: Insurance: 165 WEST FARMS RD (413) 586-0031 0 FLORENCEMA01062 ISSUED ON.1013100 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 10 X 18 DETACHED DECK & 10 X 14 SHED POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings Underground: Service: Meter: Footings: Rough: Rough: House# Foundation: 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: Fee Type: Receipt No: Date Paid: Check No: Amount: Building 10/3/00 0:00:00 763 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo