17C-144 (2) -NOTE-
THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED.
BUILDING LOCATION ACCURACY IS NOT GUARANTEED
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TO: EASTHAMPTON SAVINGS BANK &
FIRST AMERICAN TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES,
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY # 250167
_ —NOTE—
SURVEYOR: �• -1- THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
AND DOES NOT CONSTITUTE A PROPERTY SURVEY
�tN OF ss —MORTGAGE LOAN INSPECTION PLAT—
NORTHAMPTON, MASSACHUSETTS
_ RWAMAN pq�E �,� PREPARED FOR
E. PRISCILLA ROSS
S IZER
135032 SCALE: I "=301 JUNE 24 , 2004
Ile, suRV HAROLD L. EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET — HADLEY — MASSACHUSETTS
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s)who seek to use
the homeowner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation/footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical, plumbing&gas)the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
`- The Commonwealth of Massachusetts
Department oflndustrialAccidents
+ Office of In vestia ations
' 600 Mashington Street
r a Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers
Applicant Information Please Print Leeibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #: ` D
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. EJ I am a general contractor and I 6 New construction
employees (full and/or part-time).* have hired the sub-contractors
2.L,E� I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
' \ship and have no employees These sub-contractors have g. 0 emolition
working for me in any capacity. employees and have workers' 9 D Building addition
[No workers' comp.insurance comp. insurance.$
required.]
5. We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.] t c. 152, §1(4),and we have no 13.7 Other
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#I 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.
*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:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation p6licy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required and ection 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
f nn.iip to$l,500 00 and/or one-year ipaT5iisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against thewflolator. Be advised that a copy of this statement may be forwarded to the Office of
Investivations of the DIA for insurance coverage verification.
I do hereby certify u er ains enalties ofperjury that the information provided above is true and correct.
Signature: Date: / -�
Phone#• Z//3 210 C7
Of use only. Do not t+,rite in this area,to be completed by city or town official
Citv or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ' J Not Applicable ❑
Name of License Holder: i �r► ' v � '" � bl/ � [/
License Number
Addres zoo Expiration Date
Signature Telephone
9.'Re isterd&H6me.Im TOVe/in&MCvntractar ,`; .., tea NotA/ppli bjle ❑_/
Company Name Registration Number
C .._0
Address Expiration Date
Telephone 7
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,,§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 uilding permit.
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Signed Affidavit Attached Yes....... No...... ❑
twlll
n Home Owner i ri u ioln
The current exemption for"homeowners"was extended to include Owner-occupied DwellinCgs of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not pos s arl�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 orywliich he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached-of 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 buildine permit.
As acting Construction Supervisor ypuf'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 refgrence to Chapter 152(Workers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries npt'resulting in Death)of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform w6rk for you under this permit.
The undersigne omeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampto rdmances, 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 17-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [ Siding[0] Other[0]
fDescription of Proposed lr J / L j`n Work '
T
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes �lo��
Plans Attached Roll -Sheet
6a. If New house and or addition to existing h`ousing, complete 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? r
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. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. o etlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or Ilar floor below finished grade
k. Will building c form to the Building and Zoning regulations? Yes No.
f. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED"WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I, -f(kc, c, (,_ A p1 as Owner of the subject
property ]
hereby authorize LOT, �et SICIL( 'lctsti
to a n my behalf, in all matters relative to work authorized by this building permit application.
If IL
�/ � v��
_Signature of Owner_- -.-_-- - —_----__—_ -- - -- -_ _- - ..___Date
as Owner/Authorized
Agent hereby eclare that the�statemkhlts 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 ppe'quu.
Print Name _
Signature of Owner/Agent Date
Section 4. ZONING Alt 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
Frontage
Setbacks Front ow
Side L::. R:._ L Tt R ,,.JAV.
Rear
Building Height •�C>' O'
Bldg.Square Footage
lib /
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location) W
A. Has a Special Permit/Variance/Finding ever been issued for/'on the site?
NO DONT KNOW YES
IF YES, date issued:Y
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
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 0
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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,ex avatioa,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• Department use onty
City of Northampton Status of F'ernt ' h
Building Department CurbfCf(Onyewayt'ermr# a
212 Main Street SewerfSep#rcArlabtlity Y
[:'-om 100 Wat f' ell*/A
ty
TO. L -
Nothampton, MA 01060 Two sets ofstrxtcturafians
phone 413-5 r—i 240 Fax 413-587-1272 P�rztt5 to t=lans 5
F
Other Speafy
APPWCATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION`1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address: ,{-
'To !�t 1/ei �' ,� Map Lot Unit
Flo re/I tic Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2.1 Owner of Record:
lq1'w a l2,o 5 s �co Keyc,� Flo E-en c'e
Name(Print) Current Mailing Address:
Telephone
Sign ture
2.2 Authorized Accent:
6:Fd 0lc r Ole r 6Ae54 d 51 Ro&,04t e
Name(Print) Current Mailing Address:
-5w bo a
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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
i
6. Total=(1 +2+3+4+,' Ch.eck Number
This Section For Official Use Only
Date
Building Permit Number: Issued'
Signature:
Building Commissioner/Inspector of Buildings Date
r
File#BP-2009-0969
APPLICANT/CONTACT PERSON EDWIN OLANDER
ADDRESS/PHONE 97 CHESTNUT ST FLORENCE (413) 695-5580 O
PROPERTY LOCATION 40 KEYES ST
MAP 17C PARCEL 144 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: REPAIR/REPLACE EXISTING PORCH(SAME FOOTPRINT)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 049348
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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*
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
Demolition Delay
Z
/,>c,d
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.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
r BP-2009-0969
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0969
Project# JS-2009-001398
Est.Cost: $20000.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EDWIN OLANDER 049348
Lot Size(sq. ft.): 10890.00 Owner: ROSS PRISCILLA M
Zoning:URB(100)/ Applicant: EDWIN OLAN D E R
AT. 40 KEYES ST
Applicant Address: Phone: Insurance:
97 CHESTNUT ST (413) 695-5580 0
FLORENCEMA01062 ISSUED ON:512112009 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR/REPLACE EXISTING PORCH (SAME
FOOTPRINT)
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 5/21/2009 0:00:00 $120.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo