31B-135 (3) 33 TRUMBULL RD BP-2019-1456
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.Block:3 1 B- 135 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: Deck BUILDING ILDING PERMIT
Permit 9 BP-2019-1456
Project# JS-2019-002364
Est Cost$4500.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROY OMASTA 006763
Lot Size(sa.R.): 4530.24 Owner: PAPANTONES MARK
Zonine:URC(100 Applicant. ROY OMASTA
AT. 33 TRUMBULL RD
ApplicantAddress: Phone., Insurance:
21 North St (413)247-5666 Workers Compensation
HATFIELDMA01038 ISSUED ON.6/2112019 0.00.00
TO PERFORM THE FOLLOWING WORK:REPAIR DECK
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: O_1: 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 6/212019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File k BP-2019-1456
APPLICANT/CONTACT PERSON ROY OMASTA
ADDRESS/PHONE 21 North St HATFIELD (413)247-5666
PROPERTY LOCATION 33 TRUMBULL RD
MAP 3 IB PARCEL 135 001 ZONE URCHGOV
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid * 10271
TypeofConstruction: REPAIR DECK
New Construction
Non Structural interior renovations
Addition to Existine
Accessory Structure
Building Plans Included:
Owner/Statement or License 006763
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION PRESENTED:
je�Approvecl 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
A/ Demolition Delay
GI, Z0101 f
SijAufum 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.
Department use only
-s City of Nort amp ECE'v ljWr'A'tV
rmit
Building De rim nveway Pemdt
212 Main tree c AvailabgiryRoom 1 0 JUN 2 0 20AvailabiliNorthampton, AO D60 Structural Plans
phone 413-587-1240 ax 4 - ns
DEPT OF 6URDING INSPFNDRTHAMTION.IAAON
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION
1.1 This section to be completed by office
'P�ae i deal - IC-( Map 36 Q' Lot I36 nit
MOO
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDRGENT
2.1 Owner of Record:
Mn",C PPLr�s iR - �� �,•
Name(Print) Current MailiAtldop:
telephone
SgneNre
2.2 Aut�hopprized Aaent: /
Neme(P�nra) _i / Current Mailing Atltlr
GF7—S—,66 c
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCMN COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bpermit applicant
1. Building �/S-Oo (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from e
3. Plumbing Building Permtt Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) `-G70, Check Number 5
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Canmissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
t
Section 4. ZONING NI Information aMat Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Thu column to h Nd iu by
Building Du nninl
Lot Size
Frontage
Setbacks Front
Side L:— U R:
Rear __ ---
Building Height -- -
E
quare Footage '--
pace Footagemioua bldg&pavM
ft of Parkin Spaces v
Fill:
wiwic&Iasdoul
A. Hasa Sp al Permit/Variance/Finding ever been issued for/on the site?
NO '� DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
V
NO DONT KNOW O YES O
IF YES: enter Book Page and/or Document if
B. Does the site contain a brook, body of water or wetlands? NO U 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 5.1,
IF YES, describe size, type and location:
E. Will 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,Men a Northampton Storm Water Management Permit from the DPW is required.
SECTION DESCRIPTION F PROPOSED WORK check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterofion]s) ❑ Roofing EJ
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [i[]-' Siding[0] Other(m
Brief De,gi�ccnpton of Proposed / er— -�
Work: 1(c,..td✓c AUX/d d1Gc �T Vo;,y ��74 .A,I-i��/Y ��is 7- 4,4 �Cyo-j*vrh
Alteration of existing bedroom_Yes "No Adding new bedroom Yes --�No
Attached Narrative Renovating unfinished basement Yes a
Plans Attached Roll -Sheet
Sa. If 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?
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? Yes No. Is construction within 100 yr. floodplain_Yes No
f Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank_ City Sewer Private well_ City water Supply
SECTION Ta-OWNER AUTHORIZATION.TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
<—
' ,as Owner of the subject
property
hereby authorize
to act on my behalf,in all m ers relative to work authorized by this building permit application.
Signature of Owner Data
I, / �/ �� r/® as Owner/Authorized
Agent hereb declare that the statements and information an the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed u r the pains and penalties of perjury.
�ihs�tfJ
Print Name q
Signahre ai Owner/Agent Date
e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction
SSupervisor: Not Applicable 13Name of License Hdder: I Fo ' 6 74 3
/ Licence Number
r� ,-,T 5 � i
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
/` 7.v Fa
Company Name Registration Number
,Z/ W,1W L 4C/ 'F
Address Expiration Date
G j7 <
Telephone
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(8((
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—._ ❑
City of Northampton
Massachusetts
G
�,t L
t IR+12 MinNr OF BUILDING0munii al Building
YSY Main Bticet • Municipal Builtling
Northampton, te. 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"reconstruction, alteration,renovation,repair, modernization, conversion,
improvement,removal, demdition, or construction of an addition to any preexisting 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 rmistered contractors.
Note:Ifthe homeowner has contracted with a corporation or LLC,that entity must be rerstere=
Type of Work: &1 k y ,< Est.Cost: q,5-,9
Address of Work: 3 3 'r/!✓— l-
Date of Permit Application:
I hereby certify that:
Regis on is not required for the following reason(s):
_-iPoWork 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 permit as the agent of the owner:
G�ao/2�IY 1`�7 Gd-�91yy mal f33
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
u± Y
I DSPANTdffiiT OF BUILDING INSPECTIONS
212 lain Stmt • Municipal Building '
Northampton, M 01060 0 0C
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 110.115.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.85, 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.
i
City of Northampton
fi —
Massachusetts
c
s
DB➢ARTNeNa OF BDILDING ZNSPBCTIONS ,L{
212 Min Strut an, Mipal lullEing
NortNuptu, !Ot OIOfiO
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:
33 -t�z'hS /C. P'�
(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)
Sign ture 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.
The Commonwealth ofMassaehusetts
Department of IndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Wxx.rken'Compenasnation Insurance Affidavit:Builders/Contracton/Electricians/Plumben.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information p,..�q Please Print Le 'bl
Name(Business/Orgmizatio'Nllndividmi): /991`0 r 'may `R f
Address: a. l ' /-/,(/fir.,,A / S +
City/State/Zip: 17Jfffl to AA Phone*
Are you an emp o W Chink Ne appropriate box: Type of project(required):
1.❑I am a employerwit employees(full aoNor et-timet. 7. ❑New construction
2.❑I am anile popmsr or pnmcsomp and have w eonbyees amusing fm me in 8. ❑Remodeling
my capacity.[No workers'comp,imureate required.l
3,M 1 am a hmrmowmr mag all wod myself Mo workers''comp.asmenee required j 9. ❑Demolition
4.1:1 1 am a ho rnownef and will be hiring eannecwrs to conduct all work on my property. 1 will 10❑Building addition
ismure that all conmmom enter hove workers'continuation amounts,manewit 11.❑Electrical repairs or additions
pmpdnois with no employees. 12.E]Plumbing repairs or additions
5.❑Ism t mund....anit 1Mvc hired doe smb<ommcmrs listed an to douched alsn. 13.❑Roof repairs
These wlh eowhamors have employees and Wye werrkey,tamp.uamamc.:
6.❑We ate a on wortimn and in omicrrs have itemised di:v right ofeaemption per MGL a 14.[�her JO e_
152,§1(4).aM we have mm employeer.INo workers'com,hamame onm d]
aPon,awlicmt Out checks but#I most also fill mot the section below showing theirwmlom i,ma,mat.policy Infomation,
t Homeowners who submit this affidavit indicating they are doing all work and ten hoe outside wntructors must submit a new affidavit indicating such.
lCoornmors that check tis box must attached an authorial sheet showing the mine ofthe rub- brournm and smm wheter or not those emn.a Moe
employees. If the sub<omvetma have employees,they most provide their workerscom,policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is the paltry andjob site
information.
Insurance Company Name: Z✓2f�A
Policy#or Self-ins.Lic.#: (OZ7-V,37F79-3W3/6 Expirstion Dater //7/11' 19
Job Site Address: 3/' Tza,^sit '<if City/StatdZip: /✓ r"^ "-94
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage u required ander MGL c. 152,§25A is a criminal violation punishable by a fine up to 51,500.00
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.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 rttt hee�pains andpendties of perjury that Me information provided above is nue and earrect.
Signature: /'"�" /�y_e' Date:
Phone#: ,97 , -5—C
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/Liceme#
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#:
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 of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not mora 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 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
Pleasc fill out the workers compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificam(s)of
insurance. Limited Liability Compania(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,arc not required to tarty workers compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may he 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 permitiliccnsc 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 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, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-21-15 www.mass.gov/dia
From: �STI 16 1`J//��-cJ i✓L
To:
Louis Hasbrouck
Building Commissioner
City of Northampton
212 Main Street
Northampton, MA 01060
The Massachusetts Building Code,section 107.1 allows for an exclusion from requirements for
construction control in certain situations. In accordance with code section 104.10, 1 request that you
grant a modification to waivethe requirement control of the project at
/
because the work is of a minor nature,will not affect structural elements,health,accessibility,life or fire
safety,and will be done in accordance with the prescriptive requirements of the code.
Thank you for your consideration.
Respectfully,