38D-060 (5) 53 REVELL AVE MBP-2018-00198
GIs#: COMMONWEALTH OF MASSACHUSETTS
MJS-2018-000253 CITY OF NORTHAMPTON
Map:Block:Lot PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit:Building DO NOT HAVE ACCESS TO THE GUARANTY FUND(MGL c.142A)
BUILDING PERMIT
Permit# MBP-2018-00198
Project# MJS-2018-000253
Est. Cost: 17000
Fee:110.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MARK SARAFIN CS - 053434
Lot Size(sq. ft.): Owner: CAMP O S EO JOSEPH O JR
Zoning•URB Applicant: MARK SARAFIN
AT. 53 REVELL AVE
Applicant Address: Phone: Insurance:
42 Pomeroy Meadow Road (413) 527-7812
SOUTHAMPTON, MA 01073 ISSUED ON. 08/21/2017
TO PERFORM THE FOLLOWING WORK: REMOVE/REPLACE CEILINGS TO
LIVINGROOM/HALLTO REMOVE KNOB &TUBE
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 ofOccupancy Signature:
FeeType: Date Paid: Amount: Check Number:
Alteration 08/18/2017 110 104995
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#MBP-2018-00198
APPLICANT/CONTACT PERSON: MARK SARAFIN
42 Pomeroy Meadow Road SOUTHAMPTON,MA 01073 (413)527-7812
PROPERTY LOCATION
MAP:LOT ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid $110.00
Building Permit Filled out
Fee Paid $110.00
Typeof Construction: REMOVE/RE ACE INGS TO LIVINGROOM/HALL TO REMOVE KNOB&
TUBE t\.)( fi E lO K6 co DFTECTOXY Wqa((ECTvi
New Construction P 1
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildine Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF MATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intennediate 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
Pennit from Elm Street Commission Pen-nit DPW Storm Water Management
Demolition Delay
R -7
Signature of Buil 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 Office of
Planning&Development for more information.
4
i r "
18
Department use only
City of Northampton Status of Permit:
h, Building Department Curb CU00tiveway,Permit
212 Main Street SeweNSepticAvallability
�►` Room 100 WaterNVeltAvailability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PlotfSite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION M6
r }
1.1 Property Address: This section to be completed by office
e-eo�I ( lUe
Map Lot Unit
J J
1 Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of R Ord:
Name( ri ) Current Mailing Address:
Telephone
Signal
2.2 Authorized Agent: 1f / (?
Name ' t Current Mailing Address: ol(A
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Q-1.00 i (a)Building Permit Fee
2. Electrical wo r. (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) o CDC) , Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Mint 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
Side L: R:^ L: R
Rear
Building Height �'J
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW /7\ YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O 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 O YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
'P
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,ex nation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YEF 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all awlicable)
New House F-1 Addition Replacement Windows Alteration(s) Roofing F-1
Or Doors 0 1
Accessory Bldg. ❑ Demolition ❑ New Signs E31 Decks ED Siding E3] Other C[3]
Brief De"iption of Prop �e_
'0_cCX_ I V00b
Work: \<4_
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement —Yes No
Plans Attached Roll -Sheet
ea.If Now house and or addition to 9ALAIng housing,comiplete.the following:
a. Use of building:One Family Two Family er_
r Bath
b. Number of rooms in each mily unit: Number
rooms
c. Is there a garage attached?
co
d. Proposed Square footage of Dimensions
e. Number of stories? of ne construction.
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.of wetlands s No. Is construction within 100 yr. floodplain Yes No
j. )r
Depth of basement or cellar floor be w finished grade
finished
g
k. Will building conform to the Bui g 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
1, —Xo2 C C', as Owner of the subject
property
hereby a#orize VA",t\L-
to act o y behal i)all matters relative to work authorized by this building permit application.
Signat of Owner Date
as OwnerlAuthorized
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 perjury.
VAV�I-Ov—
Print Na e
1 Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Nora Applicable Applicable 0
Name of License Holder:
License Number
PQ-MAVeLC-t M'40C4 SO_A_�, tV\6,. 07B
Addres
V
jJ I Expiration Date
Signature Telephone
9.RegfsU"yd.Hone Impmy.4MMA CofdMdW: Not Applicable 13
>
I Company Name Registration Number
!!,�4,Ayv,� —,I- 1-4- -0�
Addr6s's 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.......IX No...... 0
City of Northampton
•'�" '�' Massachusetts
DEPARThENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building yeti, Ca'
Northampton, MA 01060 ssb... .j�1~
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units .or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: 2-t'mac;"2 Est.Cost: i�-� '�� _
Address of Work: �3 ��v ��.� 1notL-F�,r�,�� c,^ \,/'V\\,4 0\0l00
Date of Permit Application: 9— 1 1
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building pe it the gen the ne
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts W����s
DEPARTNWT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building 2Jti. C
Northampton, MA 01060 sfb ��a
Debris 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.
The debris from construction work being performed at:
J52--�' C'Osa2 \ 6J---e-
(Please print house number and street name)
Is to be disposed of at:
U ee(- A1�--
(Pleas print namend locatiVrof facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
—a—dzp
Signature of Permit Applicant or Ow er Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (� Please Print Leeibly
Name(Business/Organization/Individual): �A.rtrw re\J\
Address:
City/State/Zip:�)G.,k1,t,,,,V" �IMva. 6(0`T--+,hone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.�&I am a employer with 3— 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ 7- ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers' comp, c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box#1 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 their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Vim-1 VV\
Policy#or Self-ins.Lic.#: y WCd_ WC> 00 Q 1�o'?j�_ DO}_+ Expiration Date:
��
Job Site Address: r��(' w� 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$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 the DIA for insurance coverage v rification.
Ido hereby certify nde he pa st
nalrjury that the information provided above is true and correct
Signature: Date: l
Phone#: !413 -5-LQ 3 S-o
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: Phone#: