43-006 155 WESTHAMPTON RD BP-2019-0154
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:43-006 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:REPAIR BUILDING PERMIT
Permit ft BP-2019-0154
Proiect# JS-2019-000263
Est Cost $25000.00
Fee: $163.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Yankee Millwork & Building 14572
Lot Size(sa.fl.): 36590.40 Owner: OMASTA JOHN&JOHN P OMASTA
Zoning: Applicant. Yankee Millwork & Building
AT. 155 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
229 Wisdom Way (413) 247-9269 WC
GREEN FIELDMA01301 ISSUED ON."12018 0.00:00
TO PERFORM THE FOLLOWING WORK.•REBUILD GABLE END OF BARN AND POUR 3
PIERS
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 8/9/2018 0:00:00 $163.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0154
APPLICANT/CONTACT PERSON Yankee Millwork&Building
ADDRESS/PHONE 229 Wisdom Way GREENFIELD (413)247-9269
PROPERTY LOCATION 155 WESTHAMPTON RD
MAP 43 PARCEL 006 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLIC ECKLIST
ENCLOS REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvaeof Construction: REBUILD GABLE ENDO A POUR 3 PIERS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 14572
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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
Permllition Delay
S1 B mg •ral
Note: Issuance of a 2 int permit does not relieve a applicant's burden to comply with all caning
requirements and o fain 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.
Venicnl.Z_CAuuu*Fow"uiJdin Permit Mayl5,2000
A
RECEIVED City of Northampton Statuacit
b3uil,ling Department curb euvo
2 2 Main Street A
AUG - 7 2018 Room 100 6 'Njjqj
P,orth;i mpton, MA 01060
DEPT 0FBU1LDJNGhR58 '-1240 Fax 413-587-1272 MrS11:' 'dNV1 al'
�ORTHA'APTGNAAAOIoso
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
0zt6L_.1=by office
This semoon,
1.1 Property Address
o Map Let 00(a Unit
oe-"fg"� Zone Overlay District
Floe. w CP_ /K
--------- ---- ----------- Ebn St.District CB ofesict
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Pnnt) Current Mailing Address:
- "-//-S _F 'L o3 /.......
Signature Telephone
2.2 Authorized Anent:
A.1i sDoyx 1v—y
Name(Print) Current Mailing Address
/ //, 3
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Offical Use Only
completed by permit awlicant
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
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
S+ re::
S' re:
narm. r . t.,
Build §i5ineMs!Pctor of Buildings Date
U
C H / L_ 0 S 9
Versoml.7 Commercial Building Permit May 15,2000
SECTION 4 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 15,000
CUBIC FEET OF ENCLOSED SPACE .�A{,,.,S
Interior Alterations ❑ Existing Wall Signs [j Demolition lRepairs Additions ❑ Accessory Building El
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other ❑
Brief Description .Enter a brief description here (�
Of Proposed Work: Rt /n ,(o(e ?fk�Q B.' (3af h)
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly13A-1 ElA-21:1A-3 131A ❑
A4 ❑ A-5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educalmnal ❑ 2B ❑
F Fact. ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3g
M Mercantile ❑ 4 ❑
R Residential I R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Gmup'. ...... _...__ _._ 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(sq
1.
_..
2^°
q'^ _.... _.. 4th ... _.
Total Area(so - Total Proposed New Construct on.(sf)
Total Height(ft)
Total Height It _.. _. . .....
7.Water Supply(M.G.L.e.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public Pnyaale ❑ Zone Outside Flood Zone❑ Municipal 0 On site disposal system❑
r Version1.7 Commercial Building Permit May 15,2000
8. N0RT1ffA11lMON7.9&G
Existing Proposed Required by Zoning
This column m be filled m by
Building Depamnmt
Lot Size
Frontage ---- --- ------
Setbacks Front -
Side L R:—-.. L:__. R:''
Rear _...
Building Height ---'
Bldg.Square Footage --- %
Open Space Footage , r .._. % --
(Lot ares minus bldg&paved
#of Parking Spaces ---- --
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
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 WII the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Sic"Water Management Permit from the DPW is required.
t
Version L7 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 118(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Regetant):
Registration Number
Address
E puabon Date
Signature 9 Telephone
9.2 Registered Professional Engineer(s):
Name.._ _...,. ,,... _. Area of Responsolity
Address Registration Number
Signature Telephone Expiration Date
Name Area of Respons b lily
Atldress ---
Registration Number
Signature Telephone 6pwation Date
Name Area of Responsibility
Address Registration Number
Signature Telephones Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
c' /tj (d� t N
Not Applicable ❑
Company Name
CL7t
Responsible In Charge of Constmcbon
Address
Signature Telephone
Version 1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
---- --
hereby authorize W kr ....9— ` t f CIL 1� to
act on my behalf, in all matters relative to work authorized by this building permit application
Signature of Owner Date
I, _- __.............. 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 ofperlury
Pont Name
Signature of OwnerlAgent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ✓�l L L c CA S
License Number
day wtsrDo,,.`. wr_� p130 � ...__
Address Expiration Date
Signature Telephone olgIll
SECTION 13-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 No Q
t
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:
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date A1,7
f Permit Applicant
The Commonwealth ofMassaehusetts
��•••077���'''������ Department of IndustrialAccidents
I Congress Street,Suite 100
Boston,MA 01114-10177
unitminass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
ADDlicant Ieformation Please Print Legibl
mY c y
Business/Organization Nae: - � (Uc ��,r fFC
,6-6- iJo a U_ (� (�
Address: 1 S ,� nCe�¢S'F��-r v'� S
City/State/Zip: Phone#: ��
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
2.) orpan-time).• 6. ❑Restamantipar/Eating Establishment
I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp,insurance required] 8. ❑Non-profit
3.❑ We are 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'camp. insurance required]- I1 ❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp.insurance req.] 12.❑Other
"Any applicant that checks box#1 most also fill out the section below showing thew wodess'con xicealun policy automation.
''ifdic cotpurete officers have exempted themselves,but the coryomtion hat oNm employees,a werluss'compensation policy is required and such an
otgaweztion should chcckbox#1.
/am an employer that is providing workers'compensation insurance for my employees Below is the polity 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 S 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 verification.
/do hereby cc under Palo a penalties of perjury that the information provided a/b%'e 1s ue anQ t.
c ec
Sienature' v " ' ' '" _ Cq�— Date' �/ 7�f
Phone#: L
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/Liceoae#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/fown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www. ssgovrdia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written"
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ofan individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers'compensation insurance, if an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers'compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple pernit/icense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Fmm Revised 02-23-15