35-271 (2) �O ---
R ti GXt� of Po rillalliploll
A 6 a5sachnsrtts — —
DEPARTMENT OF BUILD0\1C INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, Mass. 01060
WORIC R'S CONUENSAUON INSURANCE A t A'VIT
with a principal place of businesslresidence at:
—(mgt/ci ty/statc,zip)
do hereby certify, under the pe.irLs and penalties of penury, ,hat
( ) t am an empiove, providing the following wori;crs compensation coverage for In)'
emplovecs worlsng oll tl:is job.
(Las=nc.-2 Cor zp=---v) (Polio Nu_mhcr) (T—xpiradon Dann)
I am a sole prop:,etoi, general conic-actor or homeowner (clicie one) and have hired
h contractors !isle; below who have the folloW ing worker's compen-sation policies
�etnctN-L
Me ri c!� - ✓ ib/oo
��
(Nnne of Con tos) (lnsuranc C moan}vPclic, Numi�:) (r_�:pinnaon Date)
1Z6 f 4 I
(Name of Con rac or) (lnsurancc CompanyiPotic; Numc-2r) (L\Du-zuon D2te)
(Name of Contractor) Rasuanc2 Compuy/PoOc} iiairtxr) Expirtion Date)
(Name of Contractor) ansuranc—c Company/Policy Number) (Expiration Date)
(aaach additia::il�'cci ifc�-••^r to a�ct„d<iafocnnuoa perta;uing to rill ooau cn o:�)
( ) I am a sole proprietor and have no one worming for me.
( ) I am a home owner performing all the work myself.
NOTE:plc 5c be aware ths;wtnlo homcoxvcra who cznplay pc-L=to do„-•:•.• -,•�corj�-.:Cioa cr rcyau wort on a dwctliag of
ant more than throw units is w W ch the homoow ocr resides or oc the gou,, s appur�•M tbccw a,aot coasidcrcd to be
employm under the woeka s o�tien Act(GL152-=t(5)�appliciiion by s bc,=oa3r fer a ticease or permit May evidcn«the
Ie921 etahaa of an amployx under tho Wor{tda Conxpa=.XJ- n Aa-
1 und& r d thid a copy of thin ctal--t my bo forwarded to the Dcpartmrn of tf]d13Y d Amdcah'Ofhoo of lazvrinca for the
coves -&t vcrifieatioo and that f-il=w acauc covcrnsc under section 25A of?,{GL 152 can lend to tha unposiiioa of MMM--1 pca&W-
oomisting of a fine of up to S 1,300.00 and/or mluisoonxai of up to one year and civil pmaltia in the form of a Stop W ofk Order and a
flim c(S 100,00 a dzy igpinzt ter
Foe d={;.=rtz>rsY.al use only
/ l-CT4llt 1`llu t _
_ v/�� - M ip ------Lot n
gnaturc of LiccnsocJ crnuttcc- --iii e
_7 TT�
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9: Re isere _ . 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...... ❑
tf-kl lrfin � E}-wirer 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 Icense,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 buildinZ 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 ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: Sc J ;,t,�,y7 '` —�y?JUL� /1 d1 SX 3-3
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet o
60FROW, [o "s and or adci`rtror tc a Asti"ng hatr Ong com fef t(ie°folydi i
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
SECTION'7X,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
I, as Owner/Authorized Agent
hereby dec are tha the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and be ief.
Signed under the pains and penalties of perjury.
Print Narp e
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
�
Lot Size 3` kcre S 3,�4 Aztec,
Frontage
ISM rT I z FT
Setbacks Front WZ T51— 02
Side L: R: L:o R: g� /
Rear lc (o a
Building Height g U
Bldg. Square Footage 1009
%
d1%�(5 t�eL.
Open Space Footage %
(Lot area minus bldg&paved
parking) }` oco
#of Parking Spaces
Fill:
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? NO DON'T KNOW
YES _ .5yviai( loyo&— off. ISM
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:
N
D tyt rthampton
'Department
21 i n Street
720 100
DEPT
Northa pt *n, MA 01062
0
�
lo���� �,� y12 0 Fax 413-587.1272
olcse
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to becom�I�tedby offrceti
1.1 Property Address: /
rnS L�
Ito 1�
Map Lot u �I 4 eu n F
d�-7-7-{A-M FTV A/ �!Q 6 Z- Zo�ie Overlay�D�strEC��
Elm St D►str�ct'° CB Disfrict
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2.1 Owner of Record:
�b e mas f�- !6 S GIJ� !-- �a�►,Ag s a2� 0 06 Z
Name(Pant) Current Mailin 63 s� r� DD /
JL Telephone QQ
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 ermit applicant
1. Building �v (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 =(1 + 2 + 3 +4 + 5) Check Number 35— _
This Section Official Use Onl
Building Permit Number: M� 7� Date Issued:
Signature:.
Building Commissioner/Inspector of Buildings Date
File#BP-2000-0793
APPLICANT/CONTACT PERSON OMASTA JOHN P&FAYE AMBRFE
ADDRESS/PHONE 165 WEST FARMS RD
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
Buildinp,Permit Filled out
Fee Paid / 5
Typeof Construction: INSTALL 18 X 33 ABOVE GROUND POOL
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:
Approved as presentedibased 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 on Permit from CB Architecture Committee
Z Z L aoZ�
Signature of Building al 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-2000-0793
1S#: COMMONWEALTH OF MASSACHUSETTS
lap:Block: 35 -271 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Above ground pool BUILDING PERMIT
Permit# BP-2000-0793
Project# JS-2000-1489
Est.Cost: $11000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO
Const.Class: Contractor: License:
Use Group:
Lot Size(sg. 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.•3122100 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 18 X 33 ABOVE GROUND POOL
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
,ominspector 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 siEnature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 3/22/00 0:00:00 135 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo