06-057 (6) File p BP-2018-0660
APPLICANT/CONTACT PERSON BIERWERT KIM G&LOU ANN
ADDRESS/PHONE 297 HAYDENVILLE RD LEEDS (413)584-72560
PROPERTY LOCATION 297 HAYDENVILLE RD
MAP 06 PARCEL 057 001 ZONE SR(1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
LOSED REQUIRED DATE
ZONINGO FILLEDOUT
Fee Paid
Buildine Permit Filled out
Fee Paid
Typeof Comanuctionc FOUNDATION ONL F R 5WD FOR RENEWABLE ENERGY DEVICE
New Construction
Non Structural interim 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
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
_Demolition Delay
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.
—RECEIVED
tain
Department use only
am On Status of Permit
.> artment Curb Cut/Driveway Permit
t. `w- ^*ora¢��s>- _ Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413.587-1240 Fax 413-587-1272 PIot/Sile Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH
EMOLISH A ONE OR�TTWO FAMILY DWELLING
SECTION 1-SITE INFORMATION -91 Q /U LCA P(a Vi-5
1.1 ProceMAddren: This section to be completed by office
Zy � Hca-l—'>e0u,,\''LLT —)f> Map Lot Una
0 1 0 5 Zone Overlay District
Elm SL Diable CB Diablo
SECTION 2.PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: Q\013
�\lAt 1ZvVlt V T Zoll \V4J--%WN U1LLf
Name(Prim) Curtent Mallin Addreae
4�Z �'_,v }�1�7ZSL
Telephone
Signature
2.2 Authorized Aaent:
inent
191P ) J mailing
lil(�� / d �/Z (1 0 Z D,f"/ T
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by Permit applicant
1. Building 11 / IB,blit
n/` (a)Building Pemlit Fee ii
2. Electrical N l (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
B. Total=(1 +2+3+q+5) Check Number
This Section For Official Use Only
Building Permit Number Date
Issued:
Signature:
Building Commissioner/lmpector of Buildings Date
AtM4r 11 t @ !l/ t4/ C
EMAIL ADDRESS (REQUIRED; EITHER HO EOWNER OR CONTRACTOR)
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doom C3
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[0] Other[Oj
Work oiPro
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
as.H New house and or addition to existing housing, 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?
I. 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?_Yes No. Is construction within 100 yr. floodplain_Yes_No
j. Depth of basement or cellar floor below finished grace
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 K
I, IM -,;% c,_ as Owner of the subject
property
hereby autho '
to act on m 1( in al matters relative to work authorized by this building permit application.
12 —1 • i
Sgnelure o r Date 0115—
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 of perjury.
Pnnt Name
Signature of Owner/Agem Dale
City of Northampton
•�� �' Massachusetts
� a ]
DCPANTISNT OF BUILDING INSPECTIONS t)
212 Nain atreet • M icipal euiltl W rr jC�
Nortbe ton, Ma 01060
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"reconstrucb'on, alteration,renovation,repair,modernization,conversion,
improvement,removal, demolition,or construction of an addition to anypre-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"he
done by registered contractors.
Note.If the 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 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 RESPONSIBHATES 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 permit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as t,.f thea ve property:
Date Owner Name and Signature
City of Northampton
Massachusetts
L
F DEPARTMENT OF BUILDING INSPECTIONS
212 Nain Stveat •Nun icipal Building O�
Notth.Wton, Ha 01060 erY 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:
(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 a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit 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.
-
�� :j
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 a joint enterprise,and including the legal representatives of a deceased employer,or the
receiveror trustee of an individual,partnership,association or other legal entity,employing employees. Howeverthe
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 in 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 sub-conuactor s)name(s),address(es)and phone number(s)along with their cenlficate(s)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 fm confi ation of insmance 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 permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."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 forme permits or licenses. A new affidavit must be filled out each
Mr.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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 5-26-05
www.mass.gov/dia
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BELOW iX18 CERTIFICATE OFINSURANCEOOES NOTCONSWTUTEA CONTRACTeETWEEN THE ISSUING INSURER(S).AUTHORI2Eo
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPOR NT: III aa I tela older is an ADDITIONAL INSURED,the pdIcylies)must ham AOOTIONAL I UR Dorm, onsor ON
If SUBROGATION IS WANED,Subject to the IBM,and Conditions of the Polley,conaln Policies may require an endorsement. A slalemenl w
this certificate does not confer rights to the Certificate holder in lieu of such mdonoor on a).
PRODUCER
Michael R.Series
Sense and Fictionu se I- 413327-2700 MYSdT-Mtl
Insurance Agency o Ess: mOQWnaalnsuramo.com
69 Main Street
Easthampton,MA 01027 MsuRe sAnoROMe IxINEAIIOC xYVCa
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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SHOULDANY OF THEABWE DESCRIBED POLWIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF.NOTIMWU SB Oft1VLIK0N
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Kim 0.M.m d _
297 Haydanvllle Road
Leads,MA 01063 AYTNOM2Ea pi%tMENialMB /,., ,, 7L
O 1989-2015 ACORD CORRPPORARA�TIGIN. All lights Monts.
ACORD 25(2 016107) The ACORD name and logo are«Biarered marks of ACORD
Dec. 19. 201710:05AM No. 2102 P. 2
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pf Louis Hasbrouck<Hasbrouck@northamptonma.gov>
Re: leads plans
1 message
Louis Hasbrouck<Iasbrouck@northamptonma.gov> Tue, Dec 19,2017 at 6:16 PM
To: Mark Maynard <mmayn5@yahoo.00m>
Cc: David Roberts<droberts@northamptonma.gov>
Mark,
I checked back on the original permit for the turbine. It doesn't look like we did final building or electrical inspections on
the project. Is it finished?We'll need to do those inspections before we consider any more permits.
Also,we aren't going to issue this permit without engineering. I'm not sure why you sent a picture of a lighthouse, but
siding on the tower will significantly change the wind loads and push the structure into a whole other category.
Louis Hasbrouck
Building Commissioner
City of Northampton
Town of Williamsburg
(413)587-1240 office
(413)587-1272 fax
On Tue, Dec 19,2017 at 1:14 PM,Mark Maynard <mmayn5@yahoo.com>wrote:
last of the prints
Mark Maynard
This message contains PRIVILEGED AND CONFIDENTIAL INFORMATION intended
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any and all attachments. Thank you.
JV
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