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<� COMMONWrEALTH OF MASSACHUSETTS
by EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
j DEPARTMENT OF ENVIRONMENTAL PROTECTION
.'� ONE WINTER STREET. BOSTON. AtA 02108 617-292.5$00
W'ILLIAV F WELD
Govcmor
ARGEO PAUL CELLUCCI I
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION�ti C
Property Address: mss' � �'! r �I CI Address of Owner:
Date of Inspection: �% �� J (If different)
Name of Inspector: r,3
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: L J fa- /`. -5 Fc- j? T( c
Mailing Address: 4 ' y r� C— < L V
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported bel
and complete as of the time of inspection. The inspection was performed based on my training and experience in the p
maintenance of on-site sewage disposal systems. The system:
asses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:
The Svstem Inspector shal submit a copy of this inspection report to the Approving Authority within thirty(30) days
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the syst
the report to the appropriate regional office of the Department of Environmental Protection. The original should be
and copies sent to the buyer, if applicable, and the approving authority.
,ei _
INSPECTION SUMMARY Chec Ay $, C, or D:
f Af j SYSTEM PASSES:
V I have not found any information which indicates that the system violates any of the failure criteria as de
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSESt
One or more system components as described in the"Conditional Pass" section need to be replaced c
completion of the replacement or repair, as approved by the Board of Health,will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not del
The septic tank is metal, unless the owner or operator has provided the system inspector wi
Compliance (attached) indicating that the tank was installed within twenty(20)years prior t
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial it
failure is imminent. The system will pass inspection if the existing septic tank is replaced i
as approved by the Board of Health.
(revised 04/25/97) page 1 of 10
DEP on the World Wide Wet. http:/mww.ma9rtst.statr.ma.u3rd*p
Printed on Recycled Paper
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Zoning
Miscellaneous Additions,Repairs,Alterations,etc. '' Tel.No. -5 ' L J� Alterations
s
NORTHAMPTON, MASS. �f - 19 Additions
'
' APPLICATION FOR PERMIT TO ALTER Repair
/ J f/ Garage
1. Location �( /l/ir i/-fir°/rte/- /.n.��' Lot No.
2. Owner's name Address WX,11, I`F� rof
3. Builder's name cXe- ��'�,.r fr%,r Address " F' r—'/'
Mass.Construction Supervisor's License No. Expiration Date X//%'X 'f
4. Addition
..7
5. Alteration / °%a c,7ak i���`� 7 �i�r./n.r �` � r�L 'r�cv d t✓ �'r�i: /r�,u� �'�' r�.
6. New Porch'
7. Is existing building to be demolished?
8. Repair after the fire
9. Garage No.of cars Size
10. Method of heating Zi,/ LJG1�r�
11. Distance to lot lines
12. Type of roof rt �
13. Siding house C el�-I c
i
14. Estimated COSL%il
The undersigned certifies that the above statcments are true to the best of his.
knowledge and belief.
Signature of responsible appicant
Remarks
(5 +
XT
2 6 � Y.;, �aaaarflnsrtts
EPY OF SUtLDING IA; EPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building '
Northampton, Mass. 01060
WORKEWS COMPENSATION INSURANCE AFFIDAVIT
(licensa./permittee)
with a principal place of business/residence at:
, , ; }/�%�� ,; (phone#)
(street/ci staiehip)
do hereby certify, under the pains and pen ties of perjury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Policy Number) (Fxpiration Date)
(--Yf am a sole proprietor, general contractor or homeowner(circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
time of ontractor) (Insurance Co /Policy Number) (Expiration Date)
(Name of Contractor) ere mparry/Policy Number) (E iration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(atta.dt addidocal rfioa if necmuy to wchu information pertaining to all coatmcc )
(Ia a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:pie=be avr=that whilo homeowners who employ persons to do maiauaaace oonshvctioa or repair work on a dwelling of
not mode than throe unite m which the homeowner resides or oa the grounds appurtenant tbereto an not geowaily comidcred to be
employers under the vas compensation Act(GL152.=1(5))�application by a homomw far a license or permit may evidence the
legal atahu of an employer under the Wockeen Compa ndion Ad
I understand that a copy of this uatemcid may be forwarded to the Deput me t of in&ntrial Accidra&Offioc of Imunaoe for the
coverage verification and that failure to aoratro eoveragu under section 25A of MGL 152 can lead to tbo imposition of criminal penaltics
oombemg of a fine ofup to$1,500.00 andler mtpruonmerd of up to one year and civil penalties in the form of a Stop Work Order and a
fine of S 100.00 a day against tae
For drysrtmMul lino only
Permit Number
/ Maps Lot#
1�s Signature of ucenseeJ mittce
^•ali��71[ko-.+i+'iifirSidiarit�ilor. .
10. Do any signs ebst on the property? YES NO
IF YES,describe size,type and location:
Are there any proposed changes to or additions of signs intended for the property?YES NO
IF YES,describe size,type and location:
21v ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO
LACK OF INFORMATION.
This colu= to bs filled in
by the Bcilding Department
Required
Existing Proposed By Zoning
Lot size
Frontage
Setbacks
- side L• R: L: R:
- rear
Building height
Bldg Square footage
%Open Space:
(Lot area minus bldg
&paved parking)
# of "Parking spaces
f of Loading Docks
Fill:
(vol-ume--& location)
13 . Certification: I hereby certify that the information contained herein
is true and accurate to the best of my knowledge.
APPLICANT'S SIGNATURE '''
fr�Lr ,� �' r� `f
NOTE: Issuanoe of a zoning permit does not relieve an appiioanra burden to oomply witt�701l
Czoning requirements and obtain all required permits from the Board of Health. Conservation
ommission. Department of Publio Works and other applionbie permit granting authorities.
FILE if
i
a ocr 2 6 :1
I
DEPT SttILDIILOtNG 1" ' Fi 1 e No ��,5
ZONING PERMIT APPLICATION (§I0 . 2)
PLEASE TYPE OR PRINT ALL INFORMATION
1. Name of Applicant: f���``��,;
Telephone: . J
1
2. Owner of 4- )z
Address: `�` ���ln f��, f'i< V ./i' , Z� Telephone:
3. Status of Applicant: Owner Contract Purchaser Lessee
Other(exxplain):��;�
4. Job Location: � -.ej1?('_
Parcel Id: Zoning Map# Parcel# �a District(s): /�-
(TO BE FILLED IN BY THE BUILDING DEPARTMENT)
5. Existing Use of Structure/Property
6. Description of Proposed Upe/Work/Project/O cupation: (Use additional sheets if necessary):
'�/ 1 wen ( r IV
40 tlk Attached Plans:Sketch Plan Site Plan Engineered/Surveyed Plans
Answers to the following 2 questions may be obtained by checking with the Building Dept or Planning Department Files.
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 DONT KNOW YES
IF YES: enter Book Page and/or Document#
Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ,date issued:
(FORM CONTINUES ON OTHER SIDE)
File#BP-2000-0445
APPLICANT/CONTACT PERSON Richard Constant
ADDRESS/PHONE 3 Blueberry Bend (413)532-5654
PROPERTY LOCATION 48 WINTERBERRY LANE
MAP 36 PARCEL 228 ZONE SR
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:_REMODEL KITCHEN,BATH&ENTRY WAY AREA&SPACE ABOVE GARAGE FOR
FAMILY ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 057246
3 sets of Plans/Plot Plan
THE OLLOWING 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 Comm' n
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.
48 WINTERBERRY LANE BP-2000-0445
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 36-228 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinq
Category:renovation BUILDING PERMIT
Permit# BP-2000-0445
Project# JS-2000-0771
Est.Cost: $62648.00
Fee: $313.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: S -6 Contractor: License:
Use Group: R-d-1 Richard Constant 057246
Lot Size(s9. 1): 75358.80 Owner: MATRONI AMI&BOB MARMOR
Zoning_SR Applicant: Richard Constant
AT. 48 WINTERBERRY LANE
Applicant Address: Phone: Insurance:
3 Blueberry Bend (413) 532-5654
SOUTH HADLEY 01075 ISSUED ON.1112199 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN,BATH & ENTRY WAY
AREA & SPACE ABOVE GARAGE FOR FAMILY ROOM
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 11/2/99 0:00:00 $313.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
L
M
4a WINTERBERRY LANE BP-2000-0445
GIs#: COMM ,LTH OF MASSACHUSETTS
a :B lock:36-2281 1 OF NORTHATON
Lot:-0Q1
Permit: Building
Categggy;reno�ion
BUY.DING PEMIT
Permit# BP-20110-0445 -
ProiW# I I IS-2000-0771
Est-.Corti 92-648.00
Fee.$311 00 PERMISSION IS HEREBY GRANTED TO:
Coast.Class; Contractor Licenser
Use Groin Richard Constant 057246
Lot Size(sq. ft.): 75358-80 , Owner: MATRONI AMI&BOB MARMOR
AtUIfciM Rrcha a
2rori}Ig:S1lt tc3 can t:ar,:. _
AL. 48 WINTEfIBERRY LANE
i ,I(gant Adds: Ph�one: Insurance:
3 Blueberry Bend (413) 532-5t;A-
SOUTH HADLEY 01075 ISSUED ON.-ILY 99 0:40.011
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN BATH & ENTRY WAY
AREA &' SPACE ABOVE GARAGE FOR FAMILY ROOM
P T MS C SO IT IS YI&IBLE FROM THE§TMET
Inspector of Plumbing Inspector of Wiring D.P.W. Inspector of Buildings
Underground: Service: ' Meter:
�/
Footings-
Rough: Rou h• -2 ' House# Foundation.
Final: ,�"{��71 �--
�' . ( Rough France: p 1'C la 01
Gas dire Depagglent Fireplace/Chimney:
�Tiougfi: - - - _ :_ �• - _ .: __ Insutatioe[. � ,���
Final; Smoke: Final:
-
77 PERM`MAY RE REVOKED BY THE CITY OF ORTHAMPTON UPON VIOL TION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occuoancy i tore:
Fee Tyne: Receigt No: Date Paid: Check No: Amount:
Building 11/21990:00:00 $313.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
sow
r.