34-036 (23) No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
Ci OF S -H fa�Y�AO
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components
3 cation --- �i �,�� � Qa,vner'sNa e
i ap/Parcel# Nan—�al �.° ( I / S
J`
Lot# ll
elephone;t
Installer's Name Qesigner's,IName
Address Address
Telephone# Telephone H
Type of Building: Lot SizeSA- At ! Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder 4PS
Other—Type of Building No. of persons Showers
( ), Cafeteria ( )
Other fixtures
Design Flow (min.r quired)- 1-A�-pd Calculated design flowg?I�) gpd Design flow provided(-M pd
Plan: Date_ Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 60 Z
DESCRIPTION OF REPAIRS OR ALTERATIONS 5 1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE�,cnd r a _not to place�the s ystem in operation until a Certificate of Compliance has been issued by the Board of Health.
Sio "
� Date
Inspections
PLAN,4PPROVE O
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 Director of Public Health
Tel. 413-587-1214
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ), Upgraded( ),Abandoned( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5196
- - --- --- - --- - - ----------- - --- - ---- - - - ---------- ---- -- - -- -- ---- - - ---- -----
'1o. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
l>91 ri OF ,� '}� �
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct S4 Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components
ocation _ -T�Qwner' am,CV
Map/Parcel# A dress
(P0- 6-7-7 - �i �X 1T
Lot# Telephone#
Installer's Name —Desi!r�'s--N„rme
Address Address
Telephone# Telephone#
Type of Building: Q=k- Lot Size St 4 re Sq.feet
Dwelling—No.of Bedrooms Q Garbage Grinder
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(mi .re wired)�_gpd Calculated design flow gpd Design flow provided(j��gpd
Plan: Date _ Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator g� Date of Evaluation 2
DESCRIPTION OF REPAIRS OR ALTERATIONS i `E:)(Q
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and furth to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
S' 4/� le�s Date M-2-ZZ6�
Inspections NORTHAMPTON BOARD OF HEALTH
PLAN APPREWED 01"T
FORM i - APPLICATION FOR DSCP DEP APPROVED FORM 5/96Ernest . Mathieu,R.S.,M.S.,C.H.O.
Director of Public Health
--------- -------- --- - -------- - -Te-1-ga.?..sg 4
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
NO. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
l ip
OF 13 ��-"A mp't(Zs
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct f Repair ( ) Upgrade ( ) Abandon ( ) -Complete System ❑Individual Components
ocation Owner's Name
5 1 ��c .
Map/Parcel# \j i Q r�ss -0003!t
Lot# e ephone#
Installer's Name Designer; Name _
Address Address
LlIZ-dai0q-77,15 n
Telephone It Telephone#
Type of Building: t tS Lot Size St Av-re— Sq.feet
Dwelling—No.of Bedrooms Garbage Grinder 14S
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures q
Design Flow(min. required) t�l� -pd Calculated design flow CM® gpd Design flow provided(L gl
Plan: Date_q IQ,I Z(Q Number of sheets Revision Date
Title
Description of Soil(s) 3 P.Op
Soil Evaluator Form No. Name of Soil Evaluators. !j j Date of Evaluation(01 ':>.
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of
TITLE 5 and further n�W to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Sign Date 9
Inspections N-O—RTF-40TONBO RD Or. LEBAL H
PLAN APPROVED O <
44 94!7�L
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/ est J. Mathieu,R.S.,M.S.,C.H.O.
Directorof Public Hult1L__
Tel. 413-597-_] i4
No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE - ' 2 ;
Description of Work: ❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ), Repaired( ),Upgraded( ) Abandoned( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. THE. COMM NWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH / � 6/y�5
DISPOSAL SYSTEIV CONSTRUCTION PERMIT
Permission is hereby ranted to Construct ( ) Repa' ) U grade ) Abandon ( ) an individual sewage
disposal system at �. described
in the application for Disposal System Construction Permit No. dated '0407/6(-
Provided: Construction shall be completed within three years of the date of this perr Il local c ditions must be met.
Date /7 �U4 Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96 ERNEST J. MAT7,?17U, R.S., M.S., C.H.O.
DIRECTOR OF HEALTH
FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON
No. C- -'� THE COMMONWEALTH OF MASSACHUSETTS FEE fy
BOARD OF HEALTH �( � dapo/z/17ff
DISPOSAL SYSTE�M�ONSTRUCTION PERMIT
Permission is her ran e C�astruc R pa' 3Upgrad ( ) Abandon ( ) an individual sewage
disposal system at a described
in the application for Disposal System Construct on Permit No. D�lj—�� dated U G
Provided: Construction shall be completed within three years of the date of this permit.All local co itions must be met.
Date r L 2 Board of Health —
FORM 2 - DSCP DEP APPROVED FORM 5/96 ERNEST J. MAT41E-U, R.S., M.S., CH.0.
DIRECTOR OF HEALTH
FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS - BOSTON
No. 2k THE COMMONWEALTH OF MASSACHUSETTS
FEE
BOARD OF HEALTH tea( L I6*odl�?�
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby rante to Cons�,tcuc4ri
ai ( U r de
disposal system at p ( ) a ) an individual sewage
as described
in the application for isposal System Construt No. �()��—d2 dated
a
Provided: Construction shall be completed within three years of the date of this permit.All local condit' s must et.
Date 7 21 Board of Health_
FORM 2 - DSCP ��
DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) TM ERNEST J. MATHIEU, R.S., M.S., C.H.O.
H&W HOBBS&WARREN PUBLISHERS- BOSTON DIRECTOR OF HEALTH
Nothampton DPW 413 587 1583 p. 3
3. Annual Reports that are stamped by a Registered Professional Frugineer documenting the
actions completed as required by the Operation, Maintenance and Inspection Agreement.
shall be submitted to the Northampton Department of Public Works by October 1„ of
each year.
4. If construction of the proposed stormwater system has not.�tartcd within five years of the
issue date of this permit, then the permit will expire and a new permit will be required.
Construction is defined as clearing, grading, excavation, filling, and installation of
drainage structures on the lots specified in this permit,
Specific Permit Conditions:
1. This project will be required to submit one or more Notice of Intent (NOI) to the U.S.
EPA for coverage under the NPDES Stormwater Construction General Permit. A copy of
the final NOI and Stormwater Pollution Prevention Plan (SWPPP) shall be submitted to
the Northampton DPW.
2. The infiltration basins proposed on Lot 3 shall not be used as temporary sediment traps
during construction and sediment and runoff shall be diverted away from the proposed
basins until the site is stabilized.
3. All Stormwater systems shall be installed as proposed and stabilized prior to receiving
drainage flows and within 4 months of the installation of pavement or start of building
construction.
4. All disturbed areas must be loamed, seeded, and vegetation established prior to issuance
of a certificate of occupancy.
5. The applicant shall be required to obtain an easement from the City of Northampton
install the proposed 12" RCP culvert across Turkey Hill Road. The casement shall
specify that all maintenance of the culvert, outlet, and plunge pool shall be the
responsibility of the owner of the property.
mkk&A(I 0—�. z 1 °7
ignaturc City Engineer Dat
cc, Planning Board c/o Office of Planning and Development
Building Department
Conscrval.ion Commission c/o Office of Pltinning and Developmew
MASIormwater Permii.s\Stormwater Perm its\Pcrmih Aclive\Turkey Hill ROMI\Turkey dill R(md Amendmem.doc.
Page 2 of 2
Nothampton DPW 413 587 1583 p. 2
f STOR.MWA'1 FR MANAGEMENT PERMIT
AMENDMENT OF PERMIT
City of Northampton
Department or Puhtic wurk4
Project /Site Name: Turkey Hill Conservation Project (Lot 3) —
Project Street or I.ovation/Assessor ID: Turkey !fill Road/ Mar 34 Parc1 1.04, Lot 3
Applicant Name: .ledoron Realty Inc.
Applicant Address/Phone: 1fi4 Brickyard Road, Farmington CT 06032 1202/860-677-781 fi
Date of Original Permit Decision: -IZ23/2006
THE FOLLOWING ACTION BY THE NORTHAMPTON DEPARTMENT OF PUBLIC:
WORKS HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION
PRESENTED:
X Amendment for Lot 3 only to the previously approved Stormwater
Management Permit Application subject to any conditions, modifications or
rectrictians required by the Department of Public Works (see below)
Standard Permit Conditivub:
1. All clearing, grading, drainage, construction, and development shall be conducted in
strict accordance with the following plans and information submitted with the application
and as amended by any conditions attached to this permit:
a. Lot 3 Driveway Grading Plan (Sheet S-1), Site Details (Sheets D-1 & D-2),
Turkey hill Road, Northampton, Mass achusettsStormwater Management Plan,
Turkey Hill Road, revised 2/9/20017, ~tamped by Kelly Killeen, P.L., Coler &
Colantonio, Inc.
b. Limited Drainage Analysis & Design for the proposed improvements to
Assessor's Map 34, Parcel 04, Lot 3, Turkey Hill Conservation Project, Turkey
Hill Road, Northampton, Massachusetts, Prepared for.ledoron Realty, Inc., dated
1/11/2007, stumped by Kelly Killeen, P.E., Coler & Colantonio, Inc.
2. The Northampton Department of Public Works (DPW)or its authorized representative
shall be provided access to the property to conduct inspections before, during, and after
constniction acliviiie.c ac necessary_ The applicant`hall arrange with the DPW to
schedule the following inspections: Initial Inspection, Erosion Control Inspection, Bury
Inspection, and Final Inspection. The DPW may also conduct random inspections to
ensure effective control of erosion and sedirncutatiuu durifIg all pfidNCS of coTTSU uCtiMi.
M:\Sinrmwater Permits\Stormwater Perm it`\Permits_ActiveCl'urkey Hill Road\Turkey Hill ROMI AmcndmeTit.doc
Pagc I or Z
JAN-12-2007 12:39 FROM:NORTHRMPTON BOARD OF 413 5871221 TO:918606511822 P.3
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BOARD OF HEALTH
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This license is granted in c nformity with the Statutes and/or Ordinances relating
thereto and expires on_p ,ALeM! .-rJ-3/ ,2005 unless sooner
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■ ' Director of Public Health
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Northampton Board of Health
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BOARD OF HEALTH
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DATE'_�• �_�2006
? Ernest.J.MaUkreu,RS.,M.S.,C.H.O.
Director of Public Health
Northampton Board of Health ;
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BOARD OF HEALTH _
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NAME
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Is Hereby Granted a Permit to Install an Individual
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LOCATION- '
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suspended or revoked. �
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Ernest.J.Mathieu, S.,M.S.,C.H.O.
j Director of Public Health
_. Northampton Board of Health
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636 Associates,
Construction Management Inc.
2 Gordon Street
Simsbury, CT 06070
860.651.1617 860.651-1822 fax
636associates@slbcglolbal.ffnet
City of Northampton
Tony Patillo
Department of the Building Inspector
212 Main Street
Northampton, MA 01060
RE: Building Permit Application for 320 Turkey Hill Road
Dear Tony;
Enclosed is the completed Section 8 of the permit application for 320 Turkey Hill Road.
Also enclosed is a copy of my License.
I think we have resolved all our issues with planning and we are now finalizing a few
drainage details for the Town Engineer.
Sincerely,
Dan Dumas
www.636associates.com
\ °yam rr�
Otu Cf IILfIJ&I11�JtDlt _
• � DEPARTMENT OF BUIL.DO�C INSPc(71-10'.S
I I::SP[C'TQ2 212 I4ain StrccL ' A'lunicipal Buildinu °
NOrthamptor, MAS-5. 010GO '-
quare Footage R.Inount
;1st Floor @ $-�o
2nd Floor @ $..30
1/? Floors, Attic, Garage
Deck Porches $_
• �Ts� _�y p_30
3 wu
--j �/fro ,�O
(SUBJECT TO ATTACHED CONDITION 1 & 2)
Permit No. D 17-07
Conditions: Driveway Permit
In lieu of plan approved by City Engineer
I agree to the following added conditions:
1. I will contact the Department of Public Works and have an inspector check
and approve the graded gravel base prior to paving to insure compliance
with slope and location;
2. I further agree that if in the inspections any of the permit conditions are not
met that I will at no expense to the City remove and replace the driveway as
directed by the City Engineer.
By:
P ti Toner
636 Associa es, 2 Gordon Street
Simsbury, CT 06070
860-651-1617
Note: The Public Works Department recommends that you provide a plan showing the
proposed driveway with grades and location in the future to avoid possible expense
which you will incur by not getting approval of actual plans in advance.
For commercial and industrial applicants, a plan showing the proposed driveway
with grades and location is required.
cc: Building Inspector
Permit No. D 17-06
CITY OF NORTHAMPTON,MA 3��
DRIVEWAY PERMIT
Date: 11/15/06
FEE: $25.00 CHECK#: 1753
THE BOARD OF PUBLIC WORKS
Driveway must be staked and house & lot number posted
The undersigned respectfully petitions your honorable body for:
Permission to install a driveway at Quarry Hill Project to install a new driveway to this
complex.
Fifteen (15) foot maximum width at the street line. Gutter drainage not to be disturbed All
drainage shall be directed off the driveway surface to adjacent land and not on the existing
roadway. Driveway surface to be paved as soon as possible if the grade of the proposed driveway
exceeds 3% or more. Homeowners will be held responsible for any cost to the City of
Northampton in the event of a washout of this driveway.
By:
(--! Associates
Telephone#: 860-651-1617
Proposed Location g _
Inspected By: / -2 / ``� G
Gravel Base Grade
Inspected By:
Final Approval
THE BOARD OF PUBLIC WORKS voted that petition be granted.
Edward Huntley
Director of Public Works
CITY OF NORTHAMPTON, MASSACHUSETTS
DEPARTMENT OF PUBLIC WORKS
125 Locust Street
3 Northampton, MA 01060
413-587-1570 jG.
Fax 413.587-1576
George Andrikidis, P.E. S� t
Director
ASSIGNMENT OF HOUSE NUMBE S
Street: Turkey Hill Road
Assessors Lot No. Area House No;
I.D.
34-036 3 3.1292 ACf 320
34-034 1 13.1807 AC'f 332
34-035 2 5.8221 AC t 364
Date: June 27, 2006
Remarks: See Plan of Land in Northampton, Massachusetts prepared for Jedoron Realty,
Inc. by Holmberg & Howe, Inc, dated June 11, 2006. See also Plan titled
Turkey Hill Limited Development prepared for City of Northampton dated 06
March 2006. Note: Builder's Lot 1 was numbered (#332) according to the
location of a common driveway access as shown on the referenced plans.
These house numbers were requested by the Applicant for permitting purposes.
Ned Huntley, P.E.
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City Engineer
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cc: Central Dispatch
Water Division Tax Collector
Sewer Division Massachusetts Electric
Streets Division Verizon Telephone
Inspectors Comcast
Assessors Bay State Gas
Police Department Post Office(Northampton)
James Thompson(GIS Coordinator) Post Office(Easthampton)
Applicant: Office of Planning and Development
City of Northampton
210 Main Street, Room 11
Northampton, MA 01060
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" DEPARTMENT OF BUILDITjG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNlR 108.3.4 to
act as his/her construction sups.: sor. 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 any 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. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfill),
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
permits in conjunction to the building permit issued, 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
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
Q�tv>rfT (1 \
QCrib of
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4 o DEPARTMENT OP BU1LDNC tNSPECTIOt.•S
212 Alain Street Afunicipal Building
Northampton, Afars. 010601
«''RICER'S C 0 ENSATION MSUIZANCF AFTIII)AVIT
(li ccvsxJperm�rice)
\%iLb a principal place of buisiness/residence at:
L-2 �r/Y6e U �, I yn.4 l//� , �T
t
(su=/c�ty/s'aUcf�p) 0669 -�
do hereby certify, under the pains and penalties of perjury, .hai
( ) I an an employer providing the following workers comoensctior. cove,c for illy
empiovccs wor.'Ding on Uns job:
N
(insur-� T 0nr-=- Y) u--zir_r) ;pirti r,Datz)
am a sole proprietor eneral contractor r homeowner (ccie one) and Lave hired
the coouactors bs-ted below wbo stave the worker's coLo°neon policies:
,�/� ov_err Z�(� ,'c AL �i,6s✓ �v�ii� #&1eZ -3/S -3 - o 3G z
l/ ' � - — -- U o�-
// (i+SID^, 0i r0�r:-'Ci0") (111R!r3Ilt,:. COInD177�'IPGUC"i ?�tl1rIIL<:) (T"_?:i)lidGOi'. 1�:ItC)
RKM�,�7 S, V-/L,,4 .21,s-la J7
(Name of otrzcaor) (I.rl_sunne; Comoa V/Po6c tlmLrr) (L»ircion Daic)
/(Name of (Insurance CompanyfPoticy t�it�:',mb s)/ ('Expin600 Daic)
5--of-06
t
(Nimc of Cootracior) (Lusuran� Compz- y/PoLcy Numb (Expiraooa Daac)
(ntxa�:d'!i;;ocal r'uct,if ncocs..n•to indudr iaform.�oo pc-ta'�to.1J ooc�-row) ( g
( ) I am a sole proprietor and have no one working for me.
( ) I am,2 home owDer performing all the work myself.
NOTE:pl=x be w17t ts— +'1 )c 6ocox>vvm�-bo
carp Icy p<=-Lon3 to d.r-.;.-,.-"...-. �;.:woo c r.•,au•orz oa c d..cCLC of
not Mott thc.o tJ;rw ua?j io%t-in 6 the bocnoow-ocr raider or oo tbc.p-vjzZr z7ptrtr2.r1 tbcctn c.t oot C)-rUy oc-=r.6.-cd to be
citployc�uo�ctbc..nicfsc Pc=:.,•mpct GL152s I S
� ( )�:-pplia600 by n 6omooavo fer c�e=_or unit c=y n4denoc the
1cg n-.,,,of e ¢ployw uodoc dao Wock'CeL comp' Jioo Aec_
1 u.d r Li d ths.x OpPY of thi.—1—m y t e for--,ded to tbo D of 1-6ut;d An 6— Offs—of lrrauinoe for the
oovcrv� t'trircazioo end t1L1 L•iltat to tenor tovcrnsc ttnScr soction 25A of MOL 152 cw Ind to the imposi ion ofcrim wl pcatltin
eoasiricS of a tint oCup to S 1500.00 eodrtx iszsprisom� of up to Ou Y.cod a'iJ p=.+t•.io io L`c form of-Slop Wort;Ordcr god a
fim oC 100.00&d_y cpja-g t>x
For do nm j u, oa7y
Z Permit Nuol-s
Lot r
S' ZtuyrofLtc=LSCC/P --
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder qS�p
( � License Numb/er
.� l
z0/_U
Address ---
Expiration Date
�✓� X22262, ��� �5 �' /lo/ �
Si iatur Telephc.-e
9. Registered Home Improvement Contractor Not Applicable ❑
Company Name Registration Number
iAddress Expiration Date
Telephone
SECTION 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....... 2 No...... ❑
11. - Home Owner :r+�xemption
The current exemption for"hon:r ers"was extended to include Owner-occupied Dwellings of one(l) c, two(2) families
and to allow such homeowner tc 2ngaee an individual for hire who does not possess a license,provided tha' the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s i who own a parcel of land on which he./she resides or intends to reside,on%rhich 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-vear period shall not be considered a homeowner.
Such "homeowner"shall submi, to the Building Official,on a form acceptable to the Building Official,that ne/she shall be
responsible for all such work performed under the building permit
As acting Construction Supervisor.our presence on thejob 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 ir: 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 Sta,c Building Code,City of
Northampton Ordinances, State and L Kcal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered-Home Improvement Contractor: „ _ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 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...... ❑
11. Home Owner exemption
The current exemption for"homeowners"was extended 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 considered 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 buildine 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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors E]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O] Other[O]
Brief Description of Proposed
Work: �-O -3 n liA►? w 14
Alteration of existing bedroom Yes ` No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes �No
Plans Attached Roll Sheet
6a,:lfNew house and or addition to existin'' hous n comN lets the followin
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms �i• 5
c. Is there a garage attached? 7 Jam/
d. Proposed Square footage of new construction. S T Dimensions
e. Number of stories?
f. Method of heating? /�✓4'�'y✓r G Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance.611!/ .'J Masscheck Energy Compliance form attached?
h_ Type of construction /G J" v
i. Is construction within 100 ft.of wetlands? Yes /'/�No. Is co ruction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade C eloll' X. '' S'
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank 4,""' City Sewer Private well J City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS 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 authorized by this building permit application.
Signature of Owner Date
AJ u 4 i 3G sjdt.ti let as Owner/AutkieritvI
Agent hereby de-=fe that the statements a nformation on the fgFegoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pai and penalties of perjury.
If r
Print Name �:l /
Signature o Ow, 'A@ao4- Date
'
` .
. . ~
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
Rear
Building Height -Te
Bldg. Square Footage 0
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Hasa Special Perm it/Vuhunoe/Find/ ever been issued for/on the site?
�
�� �
NO \^�' DON'T K0UVV \_1) YES \�v
IF YES, date issued:, 241' 06 !
IF YES: Was the permit recorded at the Registry ofDeeds?
N0 D0NTK wuvx YES y��
\~�
IF YES: enter Book � �r �� �� �- ' Page //�2- � and/or Dooument#
B. Does the site contain a brook, body of water orwetlands? NO DON'T KNOW YES
IF YES, has u permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained /~� Obtained /—\ Om*aissumd' �-----------�
\~�/ \~� ' �
Dn mn y u8n� �xu�m, ux, p'vpv'�y ,co _
�--��----- �-��----'��-� — �-
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES /—� NO
IF YES, describe size, type and location: ! /
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre nris it part ufa common plan
that will disturb over 1acre? YES NO ( �
IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ^~
Department use only;
City of Northampton Status of Permit
Building Department Curb Crat/ IUeuuayBertt
212 Main Street Sew&S- ti6,A, ila6zllty
Room 100 Water/V1lell Avai�labrf�ty
- hampton, MA 01060 Two 0ets ofStructural Pkans
phone41 7 1240 Fax 413-587-1272 Blot/Site l?ans
t�ther. pecify
APPLICATION 0 CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATIONI
1.1 Pro pert Address: �� / This section to be completed by office
3 L Q WIfAl f/' �( �QG� Map Lot Unit
(S Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.11 Owner of Record:
o p 3�o SC lP erm j-A v
/!C.
Name(Print) Current Mailing Address:
Telephone
Signs re
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
UU �� -Construction from 6
3. Plumbing Building Permit Fee
400 Glr,i'
4. Mechanical(HVAC) 11.0001 Llai
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-0677
APPLICANT/CONTACT PERSON 636 ASSOCIATES CONSTRUCTION MANAGEMENT INC
ADDRESS/PHONE 2 GORDON ST SIMSBURY (860)651-1617 Q
PROPERTY LOCATION 320 TURKEY HILL RD
MAP 34 PARCEL 036 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONL'.
PERMIT APPLICATION CHECKLIST
ENCLOSED R 017-
ZONING FORM FILLED OUT , �`/
Fee Paid
BuildiniZ Permit Filled out 0 4P
Fee Paid )Toro '&11jaAJ
Typeof Construction: CONSTRUCT 3 UNIT CONDOMINIUM BUILDING �.
New Construction
Non Structural interior renovations
Addition to Existing 0/Z Td
Accessory Structure
awl
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN
INFORMATTnN nr--
Ly/O� 3 required(see 1 O ad, pre — /3P
N�
'REQUIRED
S7
Plan AND/C
e Plan AND/C
)UIRED UN
'ermit
egistry of D
�a
Water Availability Sewer Availability
-.,Yuc Approval Board of Health Well Water Potability Board of Health
I
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission
r
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden torcomply 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.