17C-148 (4) Official Receipt for Recording in:
Hampshire County Registry of Deeds
33 King St.
Northampton, Massachusetts 01060
Issued To:
ELISSA FORMAN
33 KEYES ST
FLORENCE MA 01062
Recording Fees
--------------------------------------------
Document Recording
Description Number Book/Page Amount
__ _______e_e____s________________=_a__________
DECIS 00015648 9544 226 $75.00
DECISION
$75.00
Collected Amounts
_____________s__s____n__n_s____ - r
Payment
Type Amount
m----------------------------------------------�
Check 1087 $75.00
$75.00
Total Received $75.00
Less Total Recordings: $75.00
Change Due $.00
Thank You
MARIANNE DONOHUE - Register of Deeds
By: Linda N
Receipt# Date Time
0193374 0711712008 08:47a
Reprinted By: Linda N
Reprinted On: 07/17/2008 08:47a
i �. � i..
�� i � �
'��
�s 1- I � � i,��,)
li
� � ! �,,,
._.,
_ _ � i _
. � � ;,
M ,_ _ _ _
,���
f _.
��
/ �� ti . �`
_� r
�._. ,.
�...», l �
.. ,
. ." I� �,
�_. 5- .
__ � . .
�_ ..
-_ i � � �
4`,'
_�
r�� � � �
t..
�: n
�;
���
.,
�. � . .
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. 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
The Commonwealth of Vassachusetts
_ Department of Endustriai_4ccidents
Oft rce of fnvestig ations
%-� 600 11 ashington Street
Boston, Ma 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
N=e (Business/Oreanization/Indiv y� . r idual): T C _
Address: Q1 e_UOuC k d
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4• ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.&1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5- ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work
officers have exercised their 11.0 Plumbing repairs or additions
myself. [?v o workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.) t c. 1�2, §1(4), and ti�-e have no
employees. [No workers' li. Other
comp.insurance required.]
'Any applicant that checks box"1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the narne of the sub-contractors and state whether or not those entities have
employees. If the sub-contactors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
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 expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1, 00.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce i. u der the pains and penalties of perjury that the information provided above is true and correct.
Signature: 6M Date:
Phone#: &S-9
Of
f7eial use only. Do not write in this area, to be completed by city or town officiaL
Citv or Town: Permit/License#
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#:
SECTION 8 -CONSTRUCTION SERVICES `
8.1 Licensed Construction Supervisor: Not Applicable G❑
Name of License Holder: e v `
License Number
,A,ddre s 3� r Expiration Date
Signature Telephone
9.-Reciistered`Home Improvement Ctntractor _,- Not Applicable ❑
Y- - a C'0 lF Z-1 2.0
Company Name Registration Num er
f
Ad ess Expiration Date
Telephone Ila
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 rOwner Egemptoni
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-vear 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 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
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
J
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicabley
New House Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[Oj Other[0]
Brief
Work DescriptiQnAf Pryosec,.
Alteration of existing bedroom Yes No Adding new bedroom Gam/ Yes No C/
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If NeW house and'or addition to existing housing,complete the'followinq
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-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i—'tR lr'!A) as Owner of the subject
property
hereby authorize I e–
to act on my behalf,, ill matters relative to work authorized by this building permit application.
zoob
SSgnature of Owner Date
AA
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 Name
'A o t l_ 25 -C)O
Signature of Owner/Agent Date
^
~
1 Section 4. ZONING Alt information Must Be Completed. Permit Can Be Denied Due To incomplete information
Existin- Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
l3uilding Height
131d.-I Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
I parking)
Spaces
(volume&Location)
A. Has a Special Permit/Yariance/Finding ever been issued for/on thesite?
NO �_��� DONTKNO\Y YES v~��
�
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
�� YY
NO �� DONTKNO YES
�
IF YES: enter Book Page and/or Document#� )
B. Does the site contain a brook, body of water orwetlands? NO DONT KNOW 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission? '
Needs tobeobtaned �-� Obtained /~� Date �
' n�� Obta' �~/ ' '
C. Do any signs exist on the property? YES �.� NO
�
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES y—� NO
|FYE3. describe size, type and location: ! �
E. Will the construction activity disturb(clearing,gradingexcavation, or filling)over 1 acre orish part ofacommon plan
that will disturb over 1acre? YES C ) NO O�)
`~/ x_-
n Sfo—rm—VVffe—r Mg-n—agemen-t-Permit from the DPW is required.
IF YES,then a Northampto
Department use only
City of Northampton Status of Permit:
Building Department 1v\Lter&V Curb Cut/Driueway Permit
212 Main Street Sewer/Septic Availability
Room 100 e lk=SU ;,ill f-,
Northampton, MA 01060 v0 gf ra t la s
phone 413-587-1240 Fax 413-587-1272 rt�P as '
Other Specify` :is
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE ORhDEMaY&A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: _— section to be completed by office
3 f ey es Map Lot Unit
1�` �� Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
CL_ A,ri l�il=yES 5r
Name(Print) Current Mailing Add{ess
Telephone
Signature
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
om leted by ermit applicant
1. Building �., (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use.Onl
Building ermit Number: Isste-
9 Issued:
Signature:
Building,Commissioner/Inspectoro Buildings Date
File#BP-2009-0070
APPLICANT/CONTACT PERSON FORMAN ELISSA
ADDRESSIPHONE 33 KEYES ST FLORENCE (413)587-4261 Q
PROPERTY LOCATION 33 KEYES ST
MAP 17C PARCEL 148 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fe,e,Paid
L-duiWipg Permit Filled out
P Paid 0.00
Typeof Construction:_Deck Addition
New Construction
Non Structural interior 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
INFO,WqATION 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.
33 KEYES ST BP-2009-0070
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 17C- 148 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck Addition BUILDING PERMIT
Permit# BP-2009-0070
Project# JS-2008-001437
Est. Cost: $4700.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Homeowner as Contractor
Lot Size(sq. ft.): 10890.00 Owner: FORMAN ELISSA
Zonin :URB Applicant: FORMAN ELISSA
Applicant Address: Phone: Insurance:
33 KEYES ST (413) 587-42610
FLORENCEMA01062 ISSUED ON.711712008 0:00:00
TO PERFORM THE FOLLOWING WORK.-Deck Addition
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings: f/OLL$
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: O r 7- 9_ m g'14
THIS PERMIT MAY BE REVOKED BY THE TY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULA N
Certificate of Occu anc Si nature:
FeeType• Date Paid: Amount:
Building 7/17/2008 0:00:00 $50.00768
212 Main Street, Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo