32A-221 (5)83 POMEROY TER BP -2018-0970
GIs n: COMMONWEALTH OF MASSACHUSETTS
MamBlock: 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)
Categorv: renovation BUILDING PERMIT
Permit it BP -2018-0970
Proiect# JS -2018-001772
Est. Cost: $6000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK SARAFIN 053434
Lot Size(so. ft.): 13198.88 Owner. HENSON DEB
Zonine: URC(100) / Applicant: MARK SARAFIN
AT. 83 POMEROY TER
Applicant Address: Phone: Insurance:
85 RUSSELLVILLE (413) 563-9256 0 Workers Compensation
SOUTHAMPTONMA01073 ISSUED ON. -3/18/10/8 0:00.00
TO PERFORM THE FOLLOWING WORK. -REMOVE CLOSETS IN UTILITY ROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing
Inspector of Wiring
D.P.W.
Building Inspector
Underground:
Service:
Meter:
Smoke:
Final:
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 3/28/2018 0:00:00 $65.00
212 Main Street, Phone (413) 587-1240, Pax: (413) 587-1272
Louis Hasbrouck — Building Commissioner
File # BP -2018-0970
APPLICANT/CONTACT PERSON MARK SARAFIN
ADDRESS/PHONE 85 RUSSELLVILLE SOUTHAMPTON (413)563-9256Q
PROPERTY LOCATION 83 POMEROY TER
MAP 32A PARCEL 221 001 ZONE URCf100Y
THIS SECTION FOR OFFICIAL USE ONLY:
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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:
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 Debts,
✓7
1 f%
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.
fir..
Oepanrneit use only
1.1 Property Address:
;\');ity,of Northampton
Status or Permit,
Z
Map "aAA LW Aqi Unit
Building Department
Curb CutiOnsiswey.Permit
f, q,
2,t2 Main Street
Sewer/Septic AvailabiAty
Room 100
WaterNVeil Availability
�_-
N ham ton, MA 01060
ns P
TmSeq of Structural Plana
�
' ph
e 43-587-1240 Fax 413-587-1272
Plousae Plans
////
Telephone
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section
section to be completed by offlce
1-
80 PoN,��~—KQLNC�
Z
Map "aAA LW Aqi Unit
Zone Overlay District
Elm at District CB Dlsrrkt
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�_-
C3 I
1n
RM'tV.2U.A -eel
Name (Print)ss:
Print)
Current Mailing Addre
////
Telephone
Signature
2.2 Authorized Agent:
SS P�zz�tlr,tll�� S M�
ato
Name (Print) ./n
�i
Current Mailing Address:
�'%n/�•//�/ f(/
Signature
y i �—Sc�3-9 a fro
Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item
Estimated Cost (Dollars) to be
Official Use Only
completed by p2witapplicant
1. Building
(a) Building Permit Fee
2. Electrical
(b) Estimated Total Cost of
Construction from 8
3. Plumbing
_—
Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6, Total=(1+2+3+4+5)
1 U, 006. --
Check Number 1(
7/
This Section For Official Use Only
Building Permit Number:
DateIssued:
Signature:
Building Commissioner/Inspector of Buildings
Date
V
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
'i'
Section 4. ZONING
Ali Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing
Proposed
Required by Zoning
Tlds column to be fi11N in by
Building Department
Eat Size
Frontage
Setbacks Front
Side
Rear
L:_R:
L—R:_
Building Height
Bldg. Square Footage
%
Open Space Footage
(Int area minus bldg & paved
ranking)
`k
N of Parking Spaces
Fill:
(volume&t bmri
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O YES O
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 O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O 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 O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, (gxlcavation, or filling) over f acre or is it pad of a common plan
that will disturb over i acre? YEE O NO V
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S- DESCRIPTION OF PROPOSED WORK (check all aoolicable)
New House ❑
Addition ❑
Replecement Windows Alteration(s) I� Roofing
Or Doors ❑ S4
Accessory Bldg. ❑
Demolition1t ❑
New Signs � Decks (0 Siding M Other [®
Brief Descriptipn of Proposed
CLOSQ..iS ivx V �, K
Work t.wuat . a0 �
Alteration of existing bedroom _Yes No Adding new bedroom_Yes No
Attached Narrative Renovating unfinished baseent es _�zNo
Plans Attached Roll - Sheet
se. H New house and or addition to exisUna housing, complete the following:
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
L 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, `O FkKv17 as Owner of the subject
property
� `
hereby authorize �r,\,ArLJL :5y4vZW'F7�
to a on my eh�alf�iinn7all matters relative to work authorized by this building pennit application.
�—
Sure
or Date
I, Y ' \ WK 1L �V1rLverF t `�1 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.
OA \4q ItnaaF1 n
Print Na //
Signature of Owner/Agent Date
SECTION 8 - CONSTRUCTION SERVICES
S.1 n d Conattuctlon Supervisor '
Nameof Lloenae •v&r '. 'NoWer. 7 Wft\H
Not Applicable 0 I
C'S —015310
n ,� 4r1
o< Q..,55eU� m -e 124?iln. oda v\A 4 4516
License Number
- ^ �—
A;7 &j
Evirabon DaW
Signature Telephone
9. R�9alil"ill" Nome Imorp99r99m Conr�tractor.
Not Applicable ❑
parr. Name
Address . f\� }
Telephone
Registration Number
Expiration Date
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be c mpleted and submitted with this application. Failure to provide this affidavit will result
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 .or to structures which are adjacent to such residence orbuilding" be
done by registered contractors.
Note: If the homeowner has contracted with a corporation or LLC, that entity must be registered
a t
Type of Work: 04000l a'-" Est. Cost: is ,poo .
Address
Date of
1 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 owneroccupied
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:
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
M1+
y <<
Q�'�
LL
s
DEPAR� OF BVZLDING INSPECTIONS
®
212 Mein Street • rnu,
QF
m
C
[Tampng
010
Nocton, HA 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 .or to structures which are adjacent to such residence orbuilding" be
done by registered contractors.
Note: If the homeowner has contracted with a corporation or LLC, that entity must be registered
a t
Type of Work: 04000l a'-" Est. Cost: is ,poo .
Address
Date of
1 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 owneroccupied
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:
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
�.s. ✓,�
Massachusetts
DEPARTDffiiT OF aOI MG Z Spscrxms
\ 212 Hain Btzeet •BLniciPal Building i c<
Northampton, NA 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:
(Please print house num and street name)
Is to be disposed of at:
(Pleas rint name and location facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
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 IndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
ul www.mcss.gov/Iia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information ^-� Please Print Legibly
Business/Organization Name:
Address: SS 2s-,SS4.t�.av it e �tQ
Are ou an employer? Check the appropriate box:
I.I am a employer with -�3 employees (full and/
or part-time).'
2. ❑ 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, §l(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' comp. insurance req.]
Business Type (required):
5. ❑Retail
6. E]Restaurant/Bar/Eating Establishment
7. ❑ Office and/or Sales (me]. real estate, auto, etc.)
8. ❑Non-profit
9. ❑ Entertainment
10.❑ Manufacturing
I I.❑ Health Care
12.❑ Other
-Any applicant that checks box M i most also 611 out the section below showing their workers compensation Nliry information.
• Ifthe corporate officers have exempted themselves, but the wrporation has other employees, a workerscompensation policy is required and such an
organbation should check box N I.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Contour, Name: A v6,
Insurer's Adc r
City/StatwZip:
Policy # or Self -ins. Ltb.(��7 Expiration Date: &1)5:118
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.
I do
the
Oficial use only. Do not write in this area, to be completed by city or town oJliciaL
true
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6. Other
Phone
,J 4\0.-"
�U,
r100 rC
�"gc)QC