07-060 (4) 373 NORTH FARMS RD BP-2018-1394
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Mali.-Block:07-060 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
Cateeorv:renovation BUILDING PERMIT
Period 4 BP-2018-1394
Pro ject# JS-2018-002475
Est.Cost: $150000.00
Fee:$975.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: HANS DALHANS 101628
Lot Size(so.ft): 32582.88 Owner: LEVINE BRIAN&AMY
zoninz RR(100)/WSP(IOG)/ Applicant: HANS DALHANS
AT: 373 NORTH FARMS RD
Applicant Address: Phone: Insurance:
11 CHERRY ST (413) 977-6094
EASTHAMPTONMA01027 ISSUED ON:7/9/2078 0:00:00
TO PERFORM THE FOLLOWING WORK.RENOVATE EXISTING WING OF HOME WITH
KITCHEN, LAUNDRY & MUDROOM. REPLACE ALL WINDOWS & SIDING
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 Occuoancv Shmarure:
FeeTvpe: Date Paid: Amount:
Building 7/9/2018 0:00:00 $975.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2018-1394 -� s D/✓/rG�%
APPLICANT/CONTACT PERSON HANS DALHANS
ADDRESS/PHONE 11 CHERRY ST EASTHAMPTON (413)977-6094
PROPERTY LOCATION 373 NORTH FARMS RD
MAP 07 PARCEL 060001 ZONE RR(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TvueofConstruction RE ING WING OF HOME WITH KITCHEN LAUNDRY&
MUDROOM. REPLACE ALL WINDOWS&SIDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101628
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
em lition Delay
ve of Builds g Q 1 ial ]-)are /J
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.
Department use only
-'s
MR
Status of Permit:
Curb CutfDriveway Permit
Sewer/Septic Availability WaterNYVellAvailability
60 Two Sets of Structural Plans
poD -5 -1272 Plot/Site Plans
NORTHAMPTON.MA01060 Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH
/"AA.ONE OR TWO FAMILY DWELLING
LI
SECTION 1 -SITE INFORMATION / tel/ l bd—
1.1 Properly Addrear This section to be completed ce
teed by offi
Map Lot OIL CJ Unit
37 3 N rarms Rd-
Florence, M iq v i o &"I Zone Overlay District
Elm SL District CB Dlatdct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
n Lev 31 a N FL, ms 20
Name(Print) Current Mailing Address:
413 - ,1 f.,,- 4145
Telep me
Sign re
2.2 Atdhorlletl Agent: �j 11 \ n(� j�
J S�' ( tiS 1 V�51vh�F1TV.�tl"'h1 .
Name( nit
Current Mailing Add
413 U3 6r�iJ
ature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by Peit applicant
1. Building / l O�Q (a) Building Permit Fee
2. Electrical I C� (b)Estimated Total Cost of
1 �D9 Construction from 6
3. Plumbing 1 UVB Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
& Total=(1 +2+3+4+5) OOo 1 Check Number
This Section For Official Use Only
Building Permit Number: IDssued:
Signa re:
Building Ca // i wnerMspector of Buildings Date
/ a'q sea rpl)Lr L @ ,C/�4/. Coy✓\
�\ The Commmnwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 0211 4-2 01 7
www.em ss.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Avyllicant Information Please Print Le ibl
Business/Organization Name:
Address: 0 14 -
City/State/Zip: A 0101�1 Phone #: r1 t
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ 1 am a employer with employees(full and/ 5. ❑Retail
or part-time).' 6. E]Restaurant/Bar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no 9, ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] g. ❑Non-profit
3.10 Weare a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152,§I(4),and we have 10.❑Manufacturing
no employees. [No workers'wrap.insurance required]• I 1 ❑ Health Care
4.❑ Weare a non-profit organirffiion,staffed by volunteers,
with no employees. [No workers'wrap. insurance req.] 12.0 Other
*Any applicant that checks bon 41 must also fill ran the section below showing ihe'uworkers compensation policy information.
**nas,mrpmme oRcershive exempted @emcelves,but the coryornion has otheremployecs,a workers'compensation policy is required and such an
organ'vation should check box pl.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lia# Expiration Date:
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-y 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 violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA fo uranw age verification.
1 do hereby ceand pe aLties of perjury that the information provided above is nue and correct
Si a Dat
Phone#:
Official use only. Do not write in this area,to be completed by city or town ofjrciaL
City or Town: Permit(License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Citytfown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
SECTION E-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition Replacement,}\'Intlows Atte atlon(s) Roofing
{ Or Doors �,
Accessory Bldg. ❑ Demolition Y/N New Signs [O] Decks [0 Siding y] Other[OJ
Brief c=SI Proposed [ l� I — 1�I t �� f, p�U I�nm ,r1e�1 ,11 S
Work. nJ 'r-.r _ A-�,11'Wn hgl U 6hyp W/ (L�Tr. eye , molly .raJ fA R II WI
Alteration of existing bedroom es No Adding new bedroom YesNo
Attached Narrative V' Renovating unfinished basement Y Nc 1
Plans Attached Roll -Sheet ty9j 1
ea. If New house and or addition to existing housina, 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?
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 R.of wetlands? Yes _No. Is construction within 100 yr. floodplain_Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. SepticTank CitySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize
to act on my behalf, n all matters relativd10 wo&authoriz d by this building permit application.
Q✓?_ � ' .e 3/3a I i8
Signature Date
I, G G ,as Owner/Authorized
Agent hereby declare that Ihe statements and inforrnation on the foregoing ap ication re true anq qgodurate,to the best of my knowledge
and belief.
iPdht
under the ins and aloes of perjury.
l �v
a
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisc, 1 Not Applicable 0'1
Name of License Holder: 1 r ! �`� CSS ra
License Number
ur M� 1 oilll �Il �antR
tu-te
77
Telephone
!IR Istere0 Home Im rovement Contractor: Not Applicable ❑
GvS � a� opFan ��`1'4
Com Nam T I�9istration Number
Address q �I Brp ti Date
O/ n Telephone 13 ti I km
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submined with this application.Failure to provide this affidavit will result
in the dgnial of the issuance of the building permit.
Signed Affidavit Attached Yes....... Ci- No...... ❑
Section 4. ZONING ALL 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 Dnpanmcnt
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Int an,a minus bldg&paved
padurno
#of Parkin,Spaces
Fill:
o.I..a tnsatioo
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Massachusetts
D212 M,n S ee BUILDING al a`i TIONS
212 Main 9CceaG HuMici010 0uilrling
NoxH,empWn, Hx 01060 V i-h x�Po
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, orconstruction of an addition to any prs-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which am adjacent to such residence or building"be
done by registered contractors.
Note:/jthe homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est.Cost:
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following resson(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 uAury:
I hereb pe d as th agent of the own
<{J
D 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
Q,
z'
( � Massachusetts
�L`' A w x
DEPARTMENT OF BUILDING INSPECTIONS
212 Hain Street • d icipal
QSuilainq 1.Fs
doct},emptoo, N 01060 t• O
W soy^
Massachusetts Residential Building Code
Section 110.R5.1.2
Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside,
on which there is, or is intended 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 homeowner.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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 building permit.
As acting Construction Supervisor your 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 reference to Chapter 152 (Workers' Compensation) and Chapter 153
(Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts
General Laws Annotated, you may be liable for person(s) you hire to perform work for you
under this permit.
City of Northampton
Massachusetts
DEPARTDfENT OF BUILDING INSPECTIONS "fit
212 Win Stra t •W cipal H ild ng j.
Northampton, b 01060
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:
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in aIdulmpster onsiterentedor leased from: p p
(Company Name and Address)
ck) )
gnature of Pe d Applicant or-Owner 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.