07-018 (2) �N� v o1C aC(1"
File e BP-2017-0241 � p fa `L
APPLICANT/CONTACT PERSON WARNER, GARY
Iva\ r
ADDRESS/PHONE DeV`d" coo�� � _
PROPERTY LOCATION 332 NORTH FARMS RD Qµ..
MAP 07 PARCEL 018 001 ZONE RR(I00)/WSP(100)/WP(12)/ �+
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TvpeofConstruction: Change the rear section into a legal accessory appartment
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 BASED ON
IN 1 MATION 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
��
I-127-/‘
Sie e of Bu mg 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 the Office of
Planning&Development for more information.
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pi.�rre 13-587-12410 Fax 413-587-1272
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I APPLICATION TO CONSTRUCT,ALTER,Fa FAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Prcoerh.,Pddress. J - i nis ection tc be-campleeed by office
3 a A/ Furs S f21/ Map ------- ---_ -;----a=Lct — Unt
Zane OverlayDis District -1
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I SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
1 2.1 Owner of Record:
1 Gary WaF- n -er '{O 6N Farsen_5 24 Kereinc.aatti9
1 Name(Frin° Curren]+�iaiili Aik.d.ress 3 p i
i
W ca...),--k-Liz--,1/4 _ -elephoce b 3 6
Slgnature` �
12.2 Authorized Agent:
Name(Fdnt) Current Mailing Andress:
Slanarere Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars;to be II Official Use Only
completed by o=mit apollcan:
1. Building a 500, I.(a)Building Permit Fee
2. Decthoal I Ib)Estimated Total Cost c`
Construction from(5)
3. Plumbing 1 Building Permit Fee
4. Mechanical N✓AC/ D
5Fi6 T Pmt ao"I _
- Total=( 3+q.o1 l7 �� 0 iChesk Number ���
This Section For Oricial Use Only
1 Bcgdino Permit Number: Dare
saved:
Slynarre:
5-iiciag Comm!ssioner/Ins?ecioroi edlaings tate
E , aIe -
e
1 Section 4, ZO KF 6 11 gin lnfor cenus_oeCBeea nameded n_e ac inocrarefe hfcr .acon
E 1 ProposedRequgoiProposed by Zoning 1 :01.
1 This Pei by
Builders Oepzirrecr
Lot Size
Frontage _
Setbacks Front
Rear -- __ -.
s pr, e hr D N�
D l
3 +g Square Footage 'l _ 0 11_..._. s
1 Open Space-Rootage o f _ - _
?of ateaLtninS bldg&paved ----_
e
I -c reg Spaces — 1 -------
FEL ,I(vola-e(volame& o[enset
A. .Has a,Special Permit/Var�a !-ceFinding ever been issued for/on the site?
NO 4 DON KNOW 0 YES 0
IF YES, date issued:.
IF YES: Was the permit recorded at the .Reaiste;of Deeds?
NO 0 DONT KNOW O YES 0 1 .
IF YES: enter Book ! Page and;cr Document
B. Does the site contain a brook, body of water or wetlands? NO is 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 0 , Cate Issued: ; . _.
C. Do any signs exist on the property? YES Q NO i
IF YES, describe size, type and location:
C. Are there any proposed changes too: additions of signs intended for the property f YES 0 NO 0
IF YES: describe size, tyre and location:
_. Will the onstructior activity datum(clearing, grai.na excavator, or filling)over 1 acre ois it ran of a common plan
tat mil disturb over 1 acre? REE 0 NO 0
LE YES then a Norh rasion Storm WaterV an tent Pernt from one CPA ieg:tined
SECTION 5-DESCRIPTION OF PROPOSED WORK lchack all aaciicable_)
Newhouse n Addition ❑ I Paptacentent Windows 1 Altera-ion;s) n I Roofing I I
Cr Doors C
Accessory Eidg_ RI Demolition rel New Sim-ns [C] Becks L. Siding LC] Other[C)
Brief Description of Proofped D //fes_
`sJcrk. Rea r1� ire £ kr S1-IeL bur (d ni MY /n specjzo41
Alteration of existing bedroom Yes No Adding new bedroom ./ Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga. If NiW house and or addition ro eexistuera housfr'.ci-crAting,ste the folloWRrod.
a Use of buuaing ' 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
a Number of stories'
f Metros of heating? Fireplaces or V✓oodstoves Number of each
g. Energy Conservation Compliance Masscheck Energy Compliance form attached% F
h. Type of construction
construction within 10C t of mean s? Yes No Is construction within 100 yr floodplain Yes No
J_ Dept of basement o.r cellar floor below tinisned grade
k Will building conform to the Building and Zoning regulations? Yes No_
I. 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
YI, c{ ✓ PCZ ✓ v-� as Owner ofthe subject
property
hereby authorize 1
to act on my behalf,in all matters reiative to work authorized by this building permit application.
C-� et 1Z1 (IL
$l 1
ona a of Owner tl Cate
pyo ^' "},_sx�.£'.- .. >:.-4Ip
, as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing tepi dcation are true and accurate, to the best of my knowledge
and belief.
Signed under pains and penalties of perjury.
Prof Name
Signature of OwnevFgent Data
SECTION S-CONSTRUCTION SER`VIC'E$ I
a.i Licensee Conedm s Ian Suiessiis_,;: 1 Not Ap,^iiemb:e c
same ca Livers,4oker'�,,,
License NJmber
Address BrErviitm Dore
Signature Telephone
I
9. Reaisiered Hnmelmprov.m nrGor,:zdoY' t Not Fp„Jcsbie 2
Conran Name Resistration Number
�Address Eir 'ion P_t=
Teleahore
I
SECTION 10-WORKERS'COMPENSATION INSURANCE AFF(OAVIT(fL.O L. c. 152, Q 29C(6fl •
Worker Compensation Insurance affidavit must be comp-;eted end submitted'Mtn this appricat or. Failure to pr ld tis acfdavit' ll result I
id the denial of the issuance of the building permit.
Signed Affidavit Attached Yee_...., @ No E i
V 11 game Owner -scam; n
The current exempt on for"homeowners"was extended to include O tner n c cried Dweilinss of one(1) or two(2) Families
and to allow such homeowner to engage an Lndivid al for hire who does not nooses a license,provided that the owner acts
assunervisoe CMR 780. Stith Edition Section 1953(1. I
Definition of Homeowner:Person(a)who own a parcel of land on which heishe resides or intends to reside,on winch there
is,or is intended to he,a one or two family dwelling,attached on detached structures accessory to such use and'or farm
structtures. A person who constructs more than one home in a two-yea;period shall not be considered a homeowner_
Suchhomeowner"shall submit to the Building Canal,on a form acceptable to the Building Oficial.that he/she shall be
resoonsibk for all such work performed under the building ntnnit
As acting Construction Supervisor year presence on the job site vi,l be required from veto time,doting and n,on
completion of the work for which this permits issued
Also he advised that with reference erenc o Chapter 152(Workers' Compensation) and Chapter 153 Bilaiiincy of Employers to
Employees fat in w..s not resulting in Death)of the Massachusetts G n al Laws Annotated,von mas be liable for person(s)
you hire to perform work for you under this persi?.
The undersigned"homeowner"certt'ies and assumes responsibility for corup5=noe with the Stats Building Code,City of
Nothnmpton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
=Homeowner Shensi-are
d..} The il. Ytj .v+i4;'JC'h'. 9j, ✓'n6:JJfwch ar'etts
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iic.it— ✓ep^✓1.✓.ers ef� L .""da35 h ..,
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_ , Office cf Thv o .. 'c.ns
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4. rr ', 560 ./7e5 ina,en Steed."'�si Roston,, /LJ ow
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v ,;_keens° Compensaltfon Eaturnontra A r_.aasia d,uider /Controctore lr-,leetrecinas,dFlclnebers
Aronffcant Ln ormat on Please i rdect dreaflbP-v
Name (Business/Organization/Individual): Clair(1 U✓a r Q542.r
Address: 40 (/ hi FQ2.r wtc, Rd
City/State/Zip: Fier enc C M e4 Phone P: Y ( 3 563 3 8 k b
Are you an employer? Check the appropriate box: I
Type of project(required):
1.❑ I am a employer with 4. E I am a general contractor and I _
employees (fail and/or part-time).* have hired the sub-contractors 6. U New eonstmenon
listed on the attached sheet, 7. 7 Remodeling
2.U I am a sole proprietor or pa,-trier-
ship and have no employees These sub-contactors have S. ❑ Demolition
worldng fox me in any capacity. employees end have workers'.insurance.t 9. BuIlhing addition
comp.
[No workers' comp. insurance p
required.] 5. E We are a corporation and its 10.H Electrical repairs or additions
3.® I am a homeowner doing all work officers have exercised their 114 ? Plumbing repairs or addition;
myself. [No workers' coma. right of exemption per MGL
12.E Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.11 Other
comp. insurance required.] .I
*Amy applicant that cheeks box g1 must also fill out the sector below showing their workers'compensation policy infornation.
'Ho meowners who submit this of davt indicating they are doing all work and then hire outside contractors must submit a new afIrdavlt v:dicalang such.
=Contractor=_that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not then entities have
employeesIf the sub-connectors 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. Lie. :: Expiration Date:
Rob Site Address: City/State/Zip:
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 11,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Sionamre: w CL-`^ '-.J Date: 9 `(.p( f CO
Phone r: 41(3c (0) 3g( 8
1 Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phoney:
II
City or Northampton
- Kees aizOILLs et Ss
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rea; . _ _ ^t+a ;tai2
4x res :4• 211122c:1.221 --d='`' "s:c
c_ h .pt,_, f' eL.,6e
= ECTCR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOKE OWNER E:takik rTZO:N ACKNOWLEDGEMENT
i The Stare of Massacnueetts allows the bomagmrner the right under 78OCMR 108 3.4 to act as his/her I
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:ivied lin, 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 any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state buffding codes and teaulacfons. The inspection
process requires that the building department be called to inspect work at various stapes. which include
foundation/footines tbefore backfill). sonotube holes (before pour). a roach bui@dinc inspection
(before work is concealed). insulation inspection (if reouired) and a final buildine insneciion.
The building department requires these inspections bafore 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. (1., understand the above.
'
one owns /resident's signature requesting exemption)
I will call to schedule aUI required building inspections necessary for the building permit issued to me.
Date 'Z" /27 / /0
Address of work location
City of Northampton 212 Main Street, Northampton, MA. 01060
Solid waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 332 N rk5'tej
The debris will be transported by c_c,, //rs ‘.7-.4-03 ALS',
The debris will be received by:
Building permit number:
Name of Permit Applicant Qcv'i L)aF- hek-
Date Signature of Permit Applicant
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Affected Premises: II I II I I II Al 1111 I II I II
332 North Farms Road
Northampton, Massachusetts
2016 00017688
Bk: 12384P9::242 Page: 1 011
Recorded: 08/26/2016 10:05 AM
RESTRICTIVE COVENANT
I, Gary M. Warner of 406 North Farms Road, Northampton, Massachusetts owner of
residential property known as 332 North Farms Road, Northampton, Massachusetts ("the
Premises"), more particularly described in a deed recorded in the Hampshire Registry of Deeds
Book 2278, Page 226, hereby covenant and agree that the accessory apartment attached to the
main house located on the Premises will not be used as a separate dwelling unit or sleeping space
without first obtaining a building permit for an accessory apartment from the Northampton Building
Department.
Each subsequent owner shall within 30 days of the sale, submit a notarized letter to the
Building Commissioner stating that they will occupy one of the dwelling units on the Premises as
their primary residence. nn
In WITNESS WHEREOF, I have hereunto set my hand and seal. tlrwct 06 Zot b
tat._ diary*
J� uaz- - k
itnes tdry M. W er
COMMONWEALTH OF MASSACHUSETTS
HAMPSHIRE,77 ��ss. //��
On thisnday of AVSJ1 2016, before me,the undersigned notary public,personally appeared
Qn1 H,6t Ar&F-e and proved to me through satisfactory evidence of identification which was
po rs nyeA 1lW.1 (P.f� t to be the person whose name is signed on the preceding or attached
dbcument, and acknowledged to me that s/he signed it voluntarily for its stated purpose.
/4 ELIZABETHWROBUCKA , Notary Public
Notary Public My Commission Expires: 9(0 I q
—%.. lAy AUPrs I ra
•
ATTEST: EiAMs SE.^ii "^., (/=1•4!2114itc i�,,p , REGISTER
MARY,,0 LBERD°T T