32A-221 (4)83 POMEROY TER BP -2018-0923
Crl COMMONWEALTH OF MASSACHUSETTS
Block: 32A .221 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category Bath rono BUILDING PERMIT
Permit a SP -2018-0923
Proiect 4 JS -2018-001684
EAt Cost' 59500.00
Fee: 565.00 PERMISSION IS HEREBY GRANTED TO:
const Class: Contractor: License:
use Groin MARK SARAFIN 053434
Lot Sizelsp. ft. l: 13198.68 Owner. HENSON DEB
Zorn. CRC{1(10V Applicant: MARK SARAFIN
AT. 83 POMEROY TER
Applicant Address: Phone: Insurance:
42 Potnerov Meadow Road
Compensation
SOUTHAMPTONMA01073 ISSUED ON:3/1612018 0:00:00
TO PERFORM THE FOLLOWING WORK INSTALL SHOWER IN EXISTING 1/2
BATH/RELOCATE WATER CLOSET
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing
Inspector of Wiring
D.P.W.
Building Inspector
Underground:
Service:
Meter:
Final:
Footings:
Rough:
Rough:
House It
Foundation:
Driveway Final:
Final:
Final:
Rough Frame:
Gas:
Fire Department
Fireplace/Chimney:
Rough:
Oil:
insulation:
FinaleSmoke:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe: Date Paid: Amount:
Building 3A6120180:00:00 565.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Louis Hasbrouck- Building Commissioner
File 4 BP -2018-0923
APPLICAN'TlCON'TACT PERSON MARK SARAFIN
ADDRESS/PHONE 42 Pomeroy Meadow Road SOUTHAMPTON (413).527-7812
PROPERTY LOCATION 83 POMEROY TER
MAP -32A PARCEL 221 001 TONE URC!'1001!
TH15 SEC "I.f ON FOR OFFICIAL USE ONLY:
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 TINDER: § __
Finding Special Permit Variance'
Received & Recorded at Registry of Deeds Proof Enclosed
__Other Permits Required:
Curb Cutfrom DPW __Water Availability _Sewer Availability
Septic Approval Board of Health well Water Potability Board of Health
Permit from Conservation Commission Peranit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
L.3
Signature oPB di gOf cal 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.
SECTION 1 - SITE INFORMATION
oepamnera use only
y Northampton
JE�ljldi
Status of PenNt
g Department
Crab CuUDrWeway Pe mit
212)vlain Street
Sewer/SepdemAvailabirdy
f _. --Room 100
WaterMregAveikbigly
Northampton, MA 01060
Two Seta of. Structural Plains
phone 413-587-1240 Fax 413-587-1272
PkwSlte Plana
Dow Specify
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 Procertv Address:
(n� D
Dn� `CN1i r-Lp(,Jt` rV`151eP Lot do.I Ung
1 10K 1 vTAtA'�� AVWA A
Zone Overlay District
q V
Eim at Dishier Ca pgrlcl
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1
ka�a� v r1
Oh Irylu4
N�aAdm
Nam (Print)
y
Curzent Mailing Atltlress:
6ni4-ate ��f Al OLPO
TT�phone
S nature
2.2 Authorized Anent:
PMd
OS IIV,II� SOJ�tAW.7 ��
yq
_
[.lysY
Name�dn
Current Mailing Address:
O1o��
X13-sus-4aSc�
Signature
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION
COSTS
Item
Estimated Cost (Dollars) to be
Official Use Only
completed by pemnit applicant
1. Budding
i
(a) Building Permit Fee
2. Electrical
.y _
T00
(b) Estimated Total Cost of
t •
Construction from 8
3. Plumbing
j �1
ey . 006 .
Building Parmlt Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1+2+3+4+5)
df�.'f00•
Check Number
This Section For Official Use Only
Building Permit Number:
Date
Issued:
Signature: /
Building Commissionerfinspector of Buildings
Date
tti 8, 0 1.e. n -t-P,.r .A'T
EITHER HOMEOWNER OR CONTRACTOR)
14
Section 4. ZONING
AU 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 fkpartment
Lot Size
Frontage
Setbacks From,
Si e
Rear
L:_ 1L_
L:_...._ R:—
Building Height
Bldg. Square Footage
%
Open Space Fc tage
(Lot urea mhos bldg & paved
rktn )
%
# of Parking Spaces
FBI:
(vwume k Lnauon
A. Has a Special Permit/Variance/Finding ever been issued for{on the site?
NO Q DONT KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained O , Date issued:
C. Do any signs exist on the property? YES 0 NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO O
IF YES, describe size, type and location:
E. Will the twnstruction activity disturb (clearing, grading, excavation, or filling) over t acre or is it pan of a common plan
that will disturb over i acre? YES O NO O
IF YES, then a Northampton Stone Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑
Addition
pP nth ndowa Alaretlon{s) Rooflng
�
Accessory Bldg. ❑
Demolition 0
New Signs Decka E3 Siding t7) Other ID
Brief UescripUo{t of, ro _eyed )
Brief
is tap.#tom Ve }oen It Was Ctas2 �
I '�YS�n e� h e;ta,it.,t
Alteration of existing bedroom _Yes O�, No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement —Yes No
Plans Attached Roll - Sheet
Be. If New house and or addition to exlBUna housing, complete the f Ilp owing.
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 constructiar 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.
1. Septic Tank_ City Sewer Private wail_ City water Supply_
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS OR CONTRACTOR APPLIES FOR BUILDING PERMIT
^AGGENT
I, Deb Fi�evf SO.i� , as Owner of the subject
property
hereby authorize 1r Y iV44Z 4r t
to act on m ehaif, in all matters relative to worts authorized by this building rmit pficat'
I r
J'Sea
i of 4wne�- D to
I, M��vq.(t,� i�,rA�/C�avSiK as OwnertAuttrodzed
Agent hereby deGafe that the siatemenis and information an the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
M,4'2\( 'AYZw
Print Ne
) ` t
Signature of Owner/Agent Date
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed
Conalruction�S/upervisor:
Not Applicable ❑
Nameof Umse
Holger:_
`
_�Y \V�YL
7 wF��+
,SCS - 0S3y 3y
License Number
S
co-ss A
, (I,*aw
� to
4 uab) j
Aggress
ol0-)'�
E"pi—'ation,Date
jyj
Signature Telephone
9. Registered
Nome Improvemem(�Cordrallor:
Not Applicable ❑
5AaAi:
k
I-�-R$9111
Company
Name
Registration Number
g Il�l,s
Expiration Dat
Addres
Telephone
SECTION 10 - WORKERS' COMPENSATION INSURANCE AFFIDAVR (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
Yes....... ® No...... ❑
_ City of Northampton
Massachusetts
a
t"st.
DEPdR34gLiT OF HGILDING 3NSPSCTIONS
�
�JL,._
212 Nair Street a Ncaicipal Suilaing
C
Northampton, Ma 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, demolition, or construction of an addition to any pre-existing owner -occupied building containing
at least one but not more than four dwelling units .orto structures which am adjacent to such residence orbuilding" be
done by registered contractors.
Note: If the homeowner has contracted with a corporation or LLC, that entity most be registered
(� �i/F'}
Type of Work: �p-Jy)�y�' � Est.
y Cost: "1t5()C)•
Address
Date of F
I hereby certify that:
Registration is not required for the following reason(s):
_ Work 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:
Name
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
c
1 DIPART!ffiiT OF BDIDDZNG ZNBPECPZONs ;
212 Main 9ttaet •evnicipal auildiey
i�
Northampton, MA 01060
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:
g3 P,�,
nu
(Please print house er and street name)
Is to be disposed of at:
(Pleat
Plea print name 4ind local V
of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
xla-w
Signature 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 of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
ADDlicant Information n Please Print Legibly
Business/Organization Name:dO)' 1[%4!E\n �ut�r9Y'tC
Address: OS Q.�SSa��ut�l'E YoaW
A
Are ou an employer? Check the appropriate box:
I. FI am a employer with employees (full and/
or pan -time). -
2.0 I am a sole proprietor or partnership and have no
employees working for me in any capacity.
[No workers' comp. insurance required]
3. ❑ We are a corporation and its officers have exercised
their right of exemption per c. 152, § 1(4), and we have
no employees. [No workers' comp. insurance required]'
4. ❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' come. insurance rea.l
Phone #: 413 —S(v3 q a Sv
Business Type (required):
5. ❑Retail
6. E]Restarmulli r/Eating Establishment
7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
8. ❑Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
11.11 Health Care
12.❑ Other
'Any applicant that cheeks box 41 must also fill out the section below showing their worken' wmpensa ion policy information.
"If the eorpomte officers have exempted themselves, but the corporation has she, employees, goy keo' wniponosi. polity is required and such an
orpiumfion should chink box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company Name:^^,AN v
Insurer's Address: Q,O 6O, k'{] S i
City/State/Zip: Uo01DutY+ M,r 019%
Policy #orSelf-ins. Lic.# ab1-414 Expiration Date: LOIS-1%
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 $1,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
-13-19
Oficial use only. Do not write in this area, to be completed by city or town ofciat
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Once
6. Other
Phone
w mess.gov/dia
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