12-036 (5) BP-2023-1202
164 NORTH FARMS RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
12-036-001 CITY OF NORTHAMPTON
Permit: New Build
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-1202 PERMISSION IS HEREBY GRANTED TO:
Project# GARAGE/SHOP 2023 Contractor: License:
Est. Cost: 70000
Const.Class: Exp.Date:
Use Group: Owner: BEHRENS MICHAEL J
Lot Size (sq.ft.)
Zoning: WSP Applicant: BEHRENS MICHAEL J
Applicant Address Phone: Insurance:
164 NORTH FARMS RD
FLORENCE, MA 01062
ISSUED ON: 09/12/2023
TO PERFORM THE FOLLOWING WORK:
NEW GARAGE
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
L, ! I NV
I` ' Sr.
Fees Paid: $346.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
-z -014
File #BP-2023-1202
APPLICANT/CONTACT PERSON:BEHRENS MICHAEL J
164 NORTH FARMS RD FLORENCE, MA 01062
PROPERTY LOCATION 164 NORTH FARMS RD
MAP:LOT 12-036-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $346.00
Type of Construction: NEW GARAGE
New Construction
Non Structural Renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans/Plot Plan
Driveway Grade%
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED: 400
)( Approved Additional permits required(see below)
drfr
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
a3
Sign re 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.
4'
S ., The Commonwealth of Massach efts
rh
'10/ Board of Building Regulations and an d
Massachusetts State Building Code, 8Building Pert Application To Construct,Rair, • a evis d Mar 2011
One- or Two-Family Dwelling A'41'roN Mq PECri• oN3
This Section For Official Use Only r�O
Building Permit Number: QjO-�.j .J.1 o p, Date Applied:
& j� ` �� ► ir V*22
Building Official(Print Name) Signature / • Date
SECTION 1:SITE INFORMATION
1.1 Property 1.2 Assessors Map& Parcel Numbers
��f dA�t 2 y - 2 3�
1.1 a Is this an accepted street?yes ‘/• no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: i
G-eiC/q tdr- v G ,/c s'- --7,r—
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
Z oa ' 3 0 ' a ' 74 ' .."e,
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public IW Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system lSPV.---
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner;of Record:
Name(Print) City,State,ZIP
Ili J✓ - 1X t-- .,,. ,_ <74..y- s J- 9 -i',,4 —
No. and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Constructionxisting Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. Number of Units Other 0 Specify:
Brief Description of Proposed Work':
C/44° Kit, if1(s- Zr—d. " vC '/'
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ C J� a!s 6 I. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ S--o O CI Standard City/Town Application Fee
❑Total Project Costa (Item 6)x multiplier x
3. Plumbing $ — 2. Other Fees: $
4.Mechanical (HVAC) $ — List: _
5.Mechanical (Fire
Suppression) S Total All Fees: $
�) Check No. Check Amount: Cash Amount:
6. Total Project Cost: } '::)e' 0 Paid in Full 0 Outstanding Balance Due:
4
City of Northampton
f 1 ij
Massachusetts *_�__
✓ k DEPARTMENT OF BUILDING INSPECTIONS
1
i 212 Main Street • Municipal Building
--� Northampton, MA 01060
PROCEDURE FOR OBTAINING A BUILDING PERMIT FOR NEW
1 & 2 FAMILY DWELLING, ADDITIONS, POOLS, DECKS, ACCESSORY STRUCTURES,
FENCES, GROUND MOUNTED SOLAR, ETC.
I. Building Permit Application signed by legal owner and filled out by owner or authorized agent.
2. One set of plans and specifications of proposed work. (Digital and hard copy)
3. Site plan with location of proposed structure(s) and set backs.
4. Construction Debris Affidavit filled out and signed by applicant.
5. Worker's Compensation Insurance Affidavit filled out and signed by applicant.
6. Contractors must supply a copy of CS License, HIC Registration and proof of Liability Insurance.
7. Energy Conservation Compliance Certificate (new/ replacement windows).
8. Home Owner's License Exemption Form filled out and signed by Homeowner (if applicable).
9. Note any Conservation and/or special permit requirements (if applicable). 10.
Driveway Permit (if applicable).
11. Proof of Water and Sewer entry fees paid (if applicable).
12. Trench Permit - public land by DPW / private land by Building Dept.
13. Stretch Energy Code - all new construction will require a HERS Rater Affidavit to be submitted with permit
application before issuance of permit.
14. Please provide the appropriate fee in the form of a check made payable to: The City of Northampton.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
• License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Z#
Unrestricted(Buildings up to 35,000 cu. ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/ HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6: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 oi'fhe building permit.
Signed Affidavit Attached? Yes 0 No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to wort thorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
j13
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) "'yr (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
1
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE: p
REAR LOT DIMENSION:
REAR YARD `r /
XI 117.0 <110
•
.per J ,�-� �J
SIDE YARD
�" SIDE YARD
FRONT SETBACK a
FRONTAGE
� 7f f
City of Northampton
Massachusetts �„' ce,
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building 9�
Northampton, MA 010601ti
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: (i•ee z f y ,fe-C>/cc"�
The debris will be transported by:
Name of Hauler: ' ' me-,
Signature of Applicant: Date:
i.,
11
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston.MA 02114-2017
www.mass.govidin
Wasters'Conipensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
to BE FILED WITH THE PERMITTE44G AUTHORITY.
Annlicant Information Please Print Legibly
Name I BusincssOrgantzationindividuarl:
—- • —
Address:
City/State/Zip:_ Phone#:
- ,
r—
.4.re you an eniiikKser?("boil.the appropriate bot:
Tv yr Of project (required I:
1.0 I..;.1:rnployes*Lill _ cmpluyees 01141 text or part-time LI' 7. J New construction
20 1....,-ale propn.ior or purtnerattp and have TIO efrIplaVyNK7s 4..often! for me in g. 3 Remodeling
-ity.[No winters't:urnp.tnsurance required.]
•
3 TI a homeowner doing all work myself.[No w mp_orkers'co insumaioe required.]'
4.....
‘14.0 I ant a homeowner and will be hiring oontractors to conduct all work on my property_ I will 9. El Demolition
1 0 0 Building addition
ellISUCC that all contractuni either have swelters'corripen,ation mauranea or are sole 11.0 Electrical repairs or Ailditioris
proprietors with no employees.
12_0 Plumbing repairs or additions
3.0 I am a germeral contractor and I have hired the sub-contractors listed on the anacbed ski.-et.
These sub-contractors have employees and bare worker 8'comp.msoraire.: I.3.0 Roof repairs
6.0 We one a corporation and ira officers have exacised their right of exemption per h4CiL c. 14,-0 Other
I52,§I f 41.and we have no employers.[No worker' s'comp.Insurance.reoutretil
'An',applicant that checks bun n1 mini IILlij till OW the section below showing their workers compensation pokey information.
t'I Ili;ineowniers who submit this affishivit nisiscatinu they are doing all work and then hue outside itractors must submit a new affidavit intinaim5
:Contrackirs that cheil this box mu g arta:bed an,A=tritunal.beet showing the name of the sob-saantractors and state whether or not tho-4e entities ha.:
employee*. If the titth-runtrtmori hate onplutoo..Oct.rural prt:0.1.1e them workers"comp policy number I am an employer that is providing worAers'compensation insurance for my employer'.. Below is the polio and job..ite
informatiM tt.
Insurance Company Name: —
Policy#or Self-ins,Lic.#: Expiration Data:
Job Site Address: City/State:Zip:
Attach a cop", of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under NIGL c. 152, §25A is a criminal violation punishable by a fine up to$1.500.00
andlor one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to 5,50.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
cover-due +.entication.
i do hereby certify under the paha and penalti of perjury.that the( in fortnatios provided above A2rire fl f currect.
kPhone :
Official use only. Do not write in Mi., lifeli.to be completed by city or town official
i
('its or Town: Permit/License#
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone*:
a
City of Northampton
�OaYH A A.Tp,,O
Massachusetts
n "4 DEPARTMENT OF BUILDING INSPECTIONS
w» ' 212 Main Street • Municipal Building
sf• B d `��- Northampton, MA 01060 sprjti. +` 1
HOMEOWNERS'EXEMPTION ELIGIBILITY AFFIDAVIT j�,��
1,/ �'c �J (insert full legal name), born (insert month,
day, year),hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners' exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or work on a
parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'exemption,
does not involve the field erection of manufactured buildings constructed in accordance with 780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns 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 home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I qualify for
and will abide by the Massachusetts State Building Code's requirements for the supervision of the project or work
on my parcel, I am not engaged in construction supervision in connection with any project or work involving
construction, reconstruction, alteration, repair, removal or demolition involving any activity regulated by any
provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on my
parcel,I acknowledge that I am required to and will act as the supervisor for said project or work.
i4f
Signed under the pains and penalties of perjury on thin- day of V• , 20_2Z
(Signature
J' A/ A1F ( r CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE: • ,#1I./
REAR LOT DIMENSION: 7cp
REAR YARD
i
SIDE YARD SIDE YARD �'�
ti
FRONT SETBACK
FRONTAGE
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
' U Unrestricted(Buildings up to 35,000 cu.ft.)
City/Town,State,ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6: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 . 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLET D WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize \\ _
to act on my behalf,in all matters relative to work author' d by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
A/ 6.0 „6-1/2rmt.v3.2
Print Owner's or Authorized Agent's Name(Elhironic Signature)
NOTTS:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces _ Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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