31C-040 (3) Page 1 of 1
Darryl McKenney
From:
Date: - IIIIIIIIIIIIIIIIIIIIIIIIIII
IIIIIIIIIIIIIIII
IVIIIIIIIIIIIIIVIII(IIIIVIII
To: _ 2014 00011017
Subject: Bk: 11681 Pg:47 Page: 1 of 1
Recorded: 06/30/2014 11:15 AM
Know All Men By these Presents
That Sherry H. McKenney and A. Darryl McKenney, owners of the real estate at 16 Ford
Crossing, Northampton, Ma. 01060 more particularly shown as Date: March 3, 2014; Hampshire
Registry of Deeds at Book 11595, Page 192-signed March 5, 2014, hereby Covenant and Agree
that the basement space at address 16 Ford Crossing, Northampton, Ma. 01060 will be used as
storage, office, studio or recreation. It will not be used as a sleeping space without first
obtaining a building permit and meeting all the requirements of the Massachusetts State
Building and Health Code for a newly created bedroom.
Executed as a sealed instrument this June 30, 2014
A. Darryl McKenney
Sherry H. McKenney
ATTEST: HAMPS13IRE
22?--Lc f f
REGIS`T'ER
MciT LBED,Tt 6/29/2014
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The Commonwealth of Massachusetts
- Department ofludiistrialAccidents
1"1:11�ei r •'
Office of Investigations
rr 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ��'jop
Address: to �Jor\�tr� a.1• _ . �, �'�e�-f G
a O Q
City/State/Zip: ` Lw Phone #: 1/1 j 3 7 c�
Are youan employer?Check the appropria a box: Type of project(required):
1.21-am a.employer with 4 4. ❑ I am a general contractor and I
employees (full.and/or part-time).* have hired the sub-contractors 6. New construction
2.❑,I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g_ ❑Demolition
working for me in any capacity. employees and have workers'
comp. insurance.$ 9. ❑Building addition
[No workers' comp. insurance P•
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers'. 13.❑ Other
comp.insurance required.]
*Any applicant thatchecks box#1 must also fill out 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 anew affidavit indicating such.
*Contractors 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: j _`%_3c�.vfAAQ_�v-I
Policy#or Self--ins.Lic. #:_C>-�C SGU C0 t- 7 I ZJ t (Expiration Date: 16 f�-
Job Site Address:
1 to f�'�` �°_1tPiSs t � = --City/State/Zip: , �/� OIOQ
T—
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 or an erification.
I do hereby c ti Up a d penalties ff th at the information provided above is true and correct.
Sian re: Date: Z
Phone#:
Eonly. Do not write in this area, to be completed by city or town official
n: Permit/License#
hority(circle one):
Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
rson: Phone#:
Versionl.7 Commercial Building Permit May 15,2000
4
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110 11) .
Independent Structural Engineering Structural Peer Review Required Yes No
SECTION 11 OWNER:AUTHORIZATION-TO;BE COMPLETED:';;WHEN''
OWNERS AGENT OR CONTRACTOR APPLIESFOR BUILDING!PERMIT
as Owner of the subject property
.._. .._ .,__ .. ._...._ _ ._.
...... ._.
hereby authorize` _. �C.�l�C ..h'y to
act on y b half, in all matters elative to work authorized by this building permit application.
Signature of Owner Date
� •�� �'_ �'", � _� -�CCr±'' .__,._.._. ._w._._._.' 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,Penury- ,....._—_.._...—..�_.-,..-._..—,.---...,. —.,_,,.,--,-..--.---I _..._
Print Name _
Signs ner gent Date
SECTION 12-CONSTRUCTION.SERVICES -
10.1 Licensed Construction Supervisor: Not Applicable ❑ _
Name of License Holder: ��./��'' � '" � ... _.
License Number
Addres Expiration Date
Signs ure Telephone
SECTION 13-WORKERS."CCMPENSATIQN 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 0
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS-AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL.PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENSLOSED SPACE)
9.1 Registered Architect:
...,....._.._.__......_.W__..__..__,.,__.�.__.___......�..._....._�___�..�. ___._._.__......�...�............__.___._._._., Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
Signature Telephone v-
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
i
_._
_:... . _..:._ .I
Address Registration Number
Signature Telephone Expiration Date
w...___.._ __. .........
_. _....__
Name Area of Responsibility
Address R29,istration
Signature Telephone Expiration Date
_.. _,__
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
__...., . ......._.
Name Area of Responsibility
Address Registration Number
Signature Telephone w Expiration Date
9.3 General Contractor
.. .._. .......
..._.
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
_.._
Address_ _ p!�
P.. ,
Si Tele hone
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column tb re filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
Fill: T
'
.
A. Has a Special Permit/Variance/Finding ever been issued for on the site?
- A@0& x-� �-\
— NO ��y DONTKNO0/ �~� YES �_�
°—
IF,YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds �
�
NO ~�
DONT KNOW 0 YES
IF YES: enter Book Pa and/or Document# �
----------~ --------------
m�&
O. Does the�tecunt�nabrook, body uf water nrwpt�n�J NO DON7KNOV � 'ES 0
IF YES, has a permit been or need to be obtained fmm the Conservation Commission?
Needs tobeobtained �-��-\ Obtained ��` Date�-� ' .
��
C. Du any�gnsedstnn the proper� �� �N�� YES Y_� NO
IFYES, describe size, type and location: ..._............................................___.............___ ........._........_ ____. ......
______J
'
O. Are there any proposed changes toor additions 0
i
— '
IF YES, describe size, type and location:
E Will the construction activity disturb grading,excavation, ur filling)over 1 acre orisb part ofa common plan
that will disturb over I acre? YES ��� ) NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
'
'
��
Version 1.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs 5 Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other❑
Brief Description ;Enter a brief description here.
Of Proposed Work:
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑
A-4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ -- - 3A ❑
Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:'�� _..�...�,...M....� ......_.._.._......,._._..___._..____.____..__..._.. _.__._ ._
M Mixed Use F-1 Specify:
S Special Use El Specify:
COMPLETETHIS SECTION IF EXISTING:BUILDI.NG UNDERGOING.RENOVATIONS,ADDI-TIONSAND/OR CHANGEIN USE
Existing Use Group Proposed Use Group.
Existing Hazard Index 780 CMR 34) _ ; Proposed Hazard Index 780 CMR 34)
SECTION.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE'USE ONLY
Floor Area per Floor(so
S,
1 St
1St
nd
2
2 ----_....___..._.._...__.._.__...._...1
3rd 3rd
4th .,_.._. .. M ___,._._,. _..__ ., 4
th ..............._.,._._.._...�...�.....� -
Total Area(sf) Total Proposed New Construction(sf)
.........
Total Height(ft)
- Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood_Zone„Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone[-] Municipal ❑ On site disposal system E]
Versionl. mmercial Building Permit Ma y 15,2000
r� Departure t use,onfy
f Northampton stags of'Perm�t
it ng Department Curb CUt/Qnvevuay Permit a
JUN 2 Q 2011 i?yh2 Main Street Sewer/SepticAvaifabrlrty
lROom 100 WateNVVelI Avaifabifity
--- NWha pton, MA 01060 Two Sets of Structural Plans
a.
.
6he�4�'-1=3 -1240 Fax 413-587-1272 _ Plot/Stte Plans
--
Ott
erSpeclfy:'.. '
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address
/ This section to be completed by office
cx-2Q 5 S.) Map Lot Unit
i
Q+5 G t1� -.►.���e r 1 —CJ l O 4 G Zone Overlay District
i
-....,.....,--.... »-n•• EIm.St:District`, CB District'
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address
t Signature `( Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing AddressL
w..,...
Signat Telephone ?j 7j�
SECTION 3-(ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building l G (a)Building Permit Fee
2. Electrical ! (b)Estimated*TM61 Cost of
I Construction from- 6 _ _-----
_ .,..._,.._
3. Plumbing
Build ing Permitfee
4. Mechanical(HVAC)
5. Fire Protection d �d __..._...... ._M
6. Total=0 +2+3+4+5) Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-1376
APPLICANT/CONTACT PERSON R DEAN ACHESON
ADDRESS/PHONE 6 NORTH MAIN ST WILLIAMSBURG (413)268-0246
PROPERTY LOCATION 16 FORD CROSSING
MAP 31 C PARCEL 040 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildine Permit Filled out AQA
Fee Paid
Typeof Construction: FINISH BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildine Plans Included:
Owner/Statement or License 83968
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOVArATION 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
e elay
Signature of Building O ficial 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.
16 FORD CROSSING BP-2014-1376
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 3 1 C-040 CITY OF NORTHAMPTON
Lot:- PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-1376
Project# JS-2014-002326
Est.Cost: $15100.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: R DEAN ACHESON 83968
Lot Size(sg. ft.): 8021.00 Owner: MCKENNEY ALBERT
Zonine: Applicant: R DEAN ACHESON
AT. 16 FORD CROSSING
Applicant Address: Phone: Insurance:
6 NORTH MAIN ST (413) 268-0246
WILLIAMSBURGMA01096 ISSUED ON.6/30/2014 0:00:00
TO PERFORM THE FOLLOWING WORK.FINISH BASEMENT
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 6/30/2014 0:00:00 $90.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner