43-065 BP- 2010 -0894
GIs #: COMMONWEALTH OF MASSACHUSETTS
:Block: 43 - 065 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categor BUILDING PERMIT
Permit # BP- 2010 -0894
Project # JS- 2010- 001324
Est. Cost: $1100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 15507.36 Owner: OLMSTED ROBERT E
Zoning SR(100 /� II Applicant: OLMSTED ROBERT E
AT. 56 DUNPHY DR
Applicant Address: Phone: Insurance:
56 DUNPHY DR (413) 687 -1812 O
FLORENCEMA01062 ISSUED ON :411612010 0:00:00
TO PERFORM THE FOLLOWING WORK.- 10 X 10 SHED
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 4/16/2010 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
File # BP- 2010 -0894
APPLICANT /CONTACT PERSON OLMSTED ROBERT E
ADDRESS /PHONE 56 DUNPHY DR FLORENCE (413) 687 -1812 Q
PROPERTY LOCATION 56 DUNPHY DR
MAP 43 PARCEL 065 001 ZONE SR(100)/ /WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: ERECT 10 X 10 SHED
New Construction
Non Structural interior renovations
Addition to Existin
Accesso1y Structure
Buildiniz 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:
V 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
41 I by 10
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.
yr- .
City of Northampton try
Building Departments
212 Main Streetx
,1 Room 100 rR�
Northampton, MA 01060
phone 413 - 587:1240 Fax 413 - 587 -1272 $' g
a �
f
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Proper Address
map Lot Unit
F M i M 6 010 Zgne Qverlay District
�� t `81i St CB District
SECTION i':2 - PROPERTY" OWNERSHiP[AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) Curren�t Mailing Address.
L
LE 3 �-
Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONST RUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit appli cant
1. Building l ec
) (a) Building Permit Fee
� l
2. Electrical (bj Estimated Total Cost.of
Constructionfrom 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) «00 Check Number lop
This.Sectian For Offrcial Use Onf
Rate
Building Permit Number Issued`
Signature:
Building Commissioner/lnspectorof Buildings Date
I
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 Department
Lot Size _..
Frontage
Setbacks Front
Side L: R :.---
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg & paved
p arkin g )
.. _........... _........
# of Parking Spaces
Fill:
(volume & Location
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON KN OW YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO _0 DONT KNOW 0 YES 0
IF YES: enter Book Page? and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO
(P DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained
0 , Date Issued:}
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
fliere any propased' cfianges to or a (tons of ignsinteQd the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb telearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 1
Accessory Bldg. Demolition ❑ New Signs [0] Decks [C] Siding [o] Other [EI]
Brief Description of Proposed (
Work: t — 5 - p . A L 6"31
Vin(( °�, C'Ua ^d+�n S�� T' C�tt0.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa
in
.ift.fiiotseldMor �tcitf" xfiadstrrg3siicl .copretrfifis}rig:
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
j. 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 7a - OWNER AUTHORIZATION - T0:1 CO
MPLI =TED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
as Owner of the subject
property
hereby authorize
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 of perjury.
Print
igna ur Owner /Agen ate
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.,:Rectisterei3. Home ;:linpr�rr+�iiettfGar%tcaetor' Not Applicable ❑
D .,..x �, >,,. >a..� .�,, >, >.az �,xva .�,,. ,
Company Name Registration Number
Address Expiration Date
Telephone
S ECTION 10- 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...... ❑
_. The_current_ exemption for "homeowners_" was ex tended to include Owner-occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780 Sixth Edition Section 108.3.5.1.
Definition of 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 consid a homeowner.
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.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
m .
o7 owner Signature
The Commonwealth of Massachusetts
Department of Industrial Accidents ,
Office of Investig, ations
a 600 Washington Street
Boston, MA 02111
www.massgov /dia
-Workers' Compensation Insurance Af ldavit: Builders / Contractors /Electricians/PIumbers
Applicant Information Please Print LegIbIv
Name (Business/organization/individual):
Address:
City /State/Zip: Phone. #:
Are you an employer? Check the appropriate box: Type of project (required)..
1. El am a employer with 4. E] I am a general contractor and I
employees (full and/or part-time)-*
have hired the sub- contractors 6. ❑New construction
2. Ell am a sole proprietor or partner- listed on the attached sheet: 7. Remodeling
ship and have no e=ployees These sub - contractors have. .8. Demolition
working for me in any-capacity. employ a nd have workers' 9. ion
-- - --
[No workers' comp. insurance p insimance.� . __ -
_.. -.... .
required] 5. e a corporation and its 10.❑ Electrical repairs or additions
I I a-m- a -homeowa doino all werIt — - r��a dJ�iL _ �1 � ]?lambing repairs or additions
myself fNo workers' comp. right of exemption per MGL 12.Q
Roof repairs
insuran required] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below.showing their workers' compensation poficy information.
t Homeowners who submit this affidavit indicatiag they are doing alt work and then hire outside contractors must submit anew affidavit indicating such.
ZContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp..policy numbs.
I am an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site
Lf
Insurance Company Name:
Policy # or Self-ins. Lic. #: Expiration Date:
Job Site Address: City /State/Zip:
Attach a copy of the workers'" compensation policy declaration page (showing the policy number and capitation date).
Failure to secure coverage as required under Section 25A ofMGL c. 1 can lead to the imposition of criminal penalties of a
fine up to $1, 500.00 and/or one - impriso 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. lie advised that a copy of this statement may be forwarded to the Ofti'`ce of
Investigations of the LIA for insurance coverage verification
I do_hgreby certify under the pains penalties ofperjury that the information prov ded -above &-true andcorrect
tore: ate .. .
- Official use only. Do not write vi this area, to be comp ed by city or town ociaL
City or Town: Per-mitUcense #
Issuing Authority (circle one):
I: Board of Health 2. Building Department 3. Ci Town Clerk 4. Electrical I nspector 5. Plumbing Inspector . -
- - - - --
6. Other
Contact Person: Phone #-
J
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he /she resides or intends 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."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own_ construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations Th_ election process_reauir that the building department be calle to
inspect work at various stages, which include foundation /footings (before backfdl),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing _& gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
------ ,- - - -pe, t s-in -con} unction,- to Ahe- buildingp- ermitissued,_and that they get their required
inspections. Failure of the individual trades to secure. the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
understand the above.
.(Home owner /resident's signatur requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
v
Address of work
location
—NOTE —
THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT
TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED.
BUILDING LOCATION ACCURACY IS NOT GUARANTEED
97.61'±
to 10
to
BOOK 4172, PAGE 68
PLAN BK. 88, PGS. 60 -61
LOT #16
±I ±I
NOTE:
SUBJECT TO EASEMENTS AND Ln
RIGHTS OF WAYS OF RECORD. I
[77777777
- -;
r
#56
2' WIDE UTILITY
EASEMENT
100. 994
DUNPHY DRIVE
TO: BANK OF CANTON &
FIRST AMERICAN TITLE INSURANCE COMPANY
TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF
I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING
MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON
THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES,
EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN
A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR
COMMUNITY #250167
—NOTE —
SURVEYO R(J�ir.Sl_��Q Z . 2 9� THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY
-- AND DOES NOT CONSTITUTE A PROPERTY SURVEY
- OF µ4s — MORTGAGE LOAN INSPECTION PLAT —
s q� NORTHAMPTON, MASSACHUSETTS
o RAKE. �-4 PREPARED FOR
v IZER y ROBERT E. OLMSTEAD
#35032 SCALE: 1 " =40' AUGUST 27, 2009
R O � HAROLD L. EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET — HADLEY — MASSACHUSETTS