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83 Pomeroy Building Permits83 POMEROY TER hfap: 32A LDl: 221 Permit Electrlcal EP-2018-0738 COMMONWEAL TH OF l\iASSACH.USETTS CITY OF .NORTHAMPTON ELECTRICAL PERMIT Ca1egory: ADD RECESS LIGHT TN BATHROOM 2ND FLR Permit# Electrtca! PE"'l11SSJON JS HEREBY GRANTED TO: Pmim,I JS-2018-001684 Est. Co~t: Contractor: License: Fee: $65.00 BEN'S ELECTRICAL SERVICE Master 12981A PO BOX 578 Owner: HENSON DEB Applicant: BEN'S ELECTRICAL SERVICE AT: 83 POMEROYTER (413) 527-3760 C-(413) 531-0617 BECKET MA01223 ISSUED ON:3/22/20180:00:00 TO PERFORclf THE FOLLOWING WORK: ADD RECESS LIGHT IN BATHROOM 2ND FLR Call In Date: Date Requested Inspedion Datt>!SignOff: Trenchl1JG; S edal Instrnctions ' S r-ciai Instructions: d, /CJ· ·ff oo"" Final: 'Y ~" \ SRE Called In: Sinnature: fee Tv e:: Amount: DatePa!d Electrical $65.00 3122/2018 0:00:00 6075 Liability, MPT54344 Reiruipect?: 2'12 Main Street Phone (4IJ) 587-1244, Fax (413) 587-1272 -fospcctor of Wires ~ Roger Malo EJ\JCATiONi\L VERAGE; l hava a current !labl!iiy insura!"V"& poHcy or its substantial equlvalertt which ~ the requfrements of MGL Ch. 144. YES qc !F YOU CHECKED YES. ?LEASE if,,IDJCAJE THE TYPE OF COVERAGE SY CttECKJNG iHE APPMP!::iATE BOX BELOW ' OWNER'S tNSURANCE WAlVER.: ! am aware that the )ie-ensA:a f.loes nqJ_have the insurance coverage by Chapter i4.2 of the &fa:ssachusetts Genera:! la;vs, and that my signature. on this pi,rmft app!lcatkm thls requiramrmt CHECKONEONLY: OWNER Bnd thau,1: plumtring woA a0d 1nstaiimions M8S&!d1W$Bt\S State Plumbing Code @r:d under !he 1)€!trr1it isnuB<l for '1{2 of !hs G1.,rs:-.c1i Laws !'l')i 1rr 7::::1 _£ 5!'/ ~ '~t.#fr/ ;#24& 4'~# ~ 'rtu7c' 9//Qf I c I \rb!,UOIIEt} MOL Vi,bUOl\ii:O MOl:IU,11 v;1,10,,1 1,r11rim>1e , 11.1:111,!'0J<"I!' ""''""" ' ' - 83 POMEROY TER GIS #: Map:Block: 32A -221 BP-2018-0970 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS ._Pes,_nne,iect: ___ Bs,_u,,,i,,,ld,,_in.,,g DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Pennit # BP-2018-0970 Prniect# JS-2018-001772 Est. Cost: $6000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK SARAFIN, ___ ___,Oe,5,,,3:,:,43e.:,4 LotSize(sg. ft.): 13198.68 Zoning: URC(lOO)/ Owner: HENSON DEB Applicant: MARK SARAFIN AT: 83 POMEROY TER Applicant Address: Phone: 85 RUSSELLVILLE (413) 563-9256 () SOUTHAMPTONMA01073 ISSUED ON:3/2811018 0:00:00 Insurance: Workers Compensation 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: Footings: Rough: Rough: House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: 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, Fax: (413) 587-1272 Louis Hasbrouck -Building Commissioner File# BP-2018-0970 APPLICANT/CONT ACT PERSON MARK SARAFIN ADDRESS/PHONE 85 RUSSELLVILLE SOUTHAMPTON (413) 563-9256 () PROPERTY LOCATION 83 POMEROY TER MAP 32A PARCEL 221 001 ZONE URC(IOO)/ THIS SECTION FOR OFFICIAL USE ONLY· PERMIT APPLICATION CHEC"' !ST ZONING FORM FJLLED OUT EN~SED .. / Fee Paid "' ··-Buildinn Permit Filled out ,; Fee Paid ':;> Tyr1eof Construction: REMOVE CLOSETS IN UTILITY R 0""~ New Construction Non Structural interior renovations Addition to Existin Accesso Structure Buildin Plans Included: Owner/ Statement or License 053434 3 sets of Plans/ Plot Plan ")EQUIRED 7 ---, DATE THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: _V_A 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 ___ Demolition Delay ~;UJ Signature of Building Official ____ Permit DPW Storm Water Management _:$7_,_/~' ''~· --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 ofMGL 40A. Contact Office of Planning & Development for more information. ·"'-·" .·," ·· •'.' ·: bty_of Northampton Building Department 1 2,f2 Main Street ,. / Room 100 Department use only StatusofPamlt Curb Cut/Driveway Penni! ______ _ Sewer/Septic Availabillly -------Water/Well Availability ________ _ Two Sets of Structural Plansc.....------Plot/Slte Plans, ____ _ Others~ •0,-;}'-,,, N9'thampton, MA 01060 ph. e "Y3-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION I 1.1 PrQ~!!:IX Addrey: This section to be completed by office 8~ POW\-<~ k<,<. .. c .f Map ~A-Lot ~, Unit Zone Overlay District Elm St. District CB District SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner 2f Record: N~ g~ ~ .. '!,Q~ 1-eefU,CG::: Current Mailing Address: - ----. Telephone Signature 2.2 Authgtl~ Agent: ~~~~ ~S" e.., ... ,:t 111.11 11 ... ftJ ~·Li II ,4. a lo Current Mailing Address: N,;,,e(PooQ ~---- '-l ,~--s-ea:s-9' a S't.. Signature Telephone §l;CTION ~ -ESTIMATED CQN§TRJ,!CTION C~T§ I Item Estimated Cost (Dollars) to be Official Use Only comnleted bv ""'rmit a""licant 1. Building '-/.ooo. (a) Building Permit Fee - 2. Electrical ;},ooo. (b) Estimated Total Cost of -Construction from (6) 3. Plumbing -Building Permit Fee /j 1/3 4. Mechanical (HVAC) -5. Fire Protection 6. Total=(1 +2+3+4+5) (.,, 000, -Check Number /~''-T7/ This Section For Offlclal Use Onlv Building Pennit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings 0'1e @ EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR} 'f Section 4. ZONING Alt 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 Frontaoe Setbacks Front Side L: __ R: __ L:_R: __ Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved ---kjna) # of Parking Snaces Fill: (volume & Location' A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES 0 If YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q 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 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q IF YES, describe size, type and location: NO 0 E. Will the construction activity disturb (dearing, grading,Acavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YEf Q NO U IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK (Check all appllcgblel New House D Addition Replacement Windows Alteratlon(s) 1"71 Roofing D Accessory Bldg. D D D Or Doors D J,4r,,J ~ ______ ......._ ______ ___, Demolition New Signs [DJ Decks ID Siding 1DJ Other [D Brief DescriP(tn of Proposed Work·. ~"""'0->< \V\ Alteration of existing bedroom ___ Yes~ No Attached Narrative Plans Attached Roll -Sheet I,) ~ \, .\..... -a.,"' ""' f Adding new bedroom Yes ,/ No Renovating unfinished basement ~ ..:( oa. H New hoUH and or addition to existing housing. complets lhe lollowlng: 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? ___ _ No 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, __ '"\)f,._.~-':o---~\+='f~Vlc.,..,)~°"=------------------------·· as Owner of the subject property hereby authorize \fl\ IA-oil \l__ S: 'A-ot'l ~ \ V\ to a on my ehalf, in all matters relative to work authorized by this building permit applicatfon. Date I, V'v\\A¥'t.\c... 5\A."2,~\"'\ ,asOwnerlAuthorized 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. ;f;:t/~r%? Print Na ~ Signature of Owner/Agent Date SECTION 8 ~ CONSTRUCTION SERVICES I 8.1 ~ Conatruct!on Suoervtsor: Not Appicable D Ham§I gt bl~OB: H2~!!:r : 'f:!·.,.,IJ,(]. \t._ ~.....n,as;:,"' C.:".:> -!2">~<4'3'1 License Number ~< {L.,,,;.,e.\\,,-\\]! e,0. ~:Rv.. ... ¢o,i' v\J\-11 0.19 "3: ~-.;J 8-1g: A'i?lJU_(!~ Expiration Date !ti ?.-S:11 ,-'i'.>~l, Signature Te/ephcne i!-B!:Distered Home lmgroventent ~ntractoc: Not Applicable D s~..._1--,"' ~ u' ~ dl Y:::t:S !+-~Se'f Comoanv Name Registration Number 5 tAVV"\ ~·· Cj-13-18 Address Expiration Date Telephone - SECTION 10. WORKERS' COMPENSATION INSURANCE AFflDAVIT (M.G.L c. 152, § 2SC(6)) I Workers Compensation lrn;urance affidavit must be completed and submitted with this application. Failure to provide this affidavit will resutt in the denial of the issuance of the building permit. Signed Affidavit Attached Yes ... " N No ..... o City of Northampton Massachusetts DEPAR7'MENX OE BUILDING INSPECTIONS 212 Main Street • Municipal Building Northst11pton, 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 "mconstructian, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner--0ccupied building containing at feast one but not more than four dwelling units .or to structures which are adjacent to such residence or building" be done by registered contractors. Note: q the homeowner has contracted with a corporation or LLC, that entity must be registered. TypeofWork: ~-fl/lOvC\-fl~"', Est.Cost: ~,000. Address of Work: 'a 3 QC>=:<: ,z "'" ~<[ tZ "4-l r.. & Date of Permit Application:. ___ 3,.,_-_,ole.1".1_-_J\c,S.,_ ________________ _ I hereby certify that Registration is not required for the foUowing 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: Date Contractor Name HIC Registration No. 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 DEPAR!ZMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal. Building No:i:thm11pton, M1I. 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: rint name an facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) SignatureotPermit 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. ~ I \ . . . ... The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, M4 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Business/Organization Name: ~,f\'"'\. :?u, \:9.«."1:& Address: 'B<,; (Z'?!>s:e.\\..,, \\,e t?,,Q City /State/Zip: 4. " -l ,M Ill O(O~'<;Phone #: 41 ~~si,3-q;;,5"b A'ji[u an employer? Check_tb"e appropriate box: Business Type (required): 1. I am a employer with '"==3 employees (full and.I 5. 0Retail 20 or part-time).* 6. 0Restaurant/Bar/Eating Establishment I am a sole proprietor or partnership and have no 7. 00ffice and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. 8. 0 Non-profit [No workers' comp. insurance required] 30 We are a corporation and its officers have exercised 9. D Entertainment their right of exemption per c. 152, §1(4), and we have 1 o.O Manufacturing 4.0 no employees. [No workers' comp. insurance required)*' 11.0 Health Care We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.00ther *Any applicant that checks box#! must also fill out the section below showmg theu workers compensatmn pohcy mformatmn. nu the corporate officers have exempted themselves, but the corporation has other employees, a workers· compensation policy is required and such an organization should check box# I. I am an employer that is providing workers' compensation insurance for 119-' employees. Below is the policy informaJion. Insurance Company Name: ,;}\ ""'- Policy# or Self-ins. Lt Expiration Date: &, {IS°, ,a 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 ofMGL 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 fonn ofa STOP WORK ORDER and a fine ofup 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. perjury that the information provided above is true and correct Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: ________________ Permit/License# ______________ _ Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/fown Clerk 4. Licensing Board 5. Selectmen's Office 6. Other ____________ _ Contact Person: Phone#: www.mass.gov/dia -' '3 ~ 7 (.>AA_,.,_~ \ 2 <l. =~ " \)e \o \~"'">""' II., I --------~~--, -... ··--.. " I lo ~ -"' -~ ~ C.VI,,...,,,.,, -l 7'. 2 11/16" 12'-2 1/21'2'-1 1/2 ·~ 4'-5 3/16"b ' I ' \.)\,\,l~ QOO""'-"·\ i lo ' i ~ I -lo £ X\":,~~ ~ I ~ ~ ~ -ex, "' BATH ' b ~10'-11"x7'-11" . ~ /-i ex, ' I I, I r, I ,, ! ~ '" I --, .. -! ' LIVING AREA 339 sq ft 83 POMEROY TER GIS#, Map:Block: 32A. 221 BP-2018-0923 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -00 l PERSONS CONTRACTING WITH UN REGISTERED CONTRACTORS LPscerm"";""'--·"'B"'u""ild"'in..,,.g DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: Bath reno BUILDING PERMIT Perm;,# BP-2018-0923 Pmject # JS-2018,001684 fut, Cost: $9500.,.00 Fee: $6.S.OO Const. C!ass: UseGrOl\L Lot Si:ze(sg. ft.): 13198.68 Zoning: URC(190)1 Applicant Address: 42 Pom.\";!roy Meadow Road Compensation PERMISSION IS /IEREBY GRANTED TO: Contractor: License: MARK SARAFIN, ____ ..s0,,5,,:34"'34"' Owner: HENSON DEB ApPlicant: MARK SARAFIN AT: 83 POMEROY TER Phone: Insurance: (413) 527-7812 SOUTHAMPTONMA01073 ISSUED ON:3116/2018 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL SHOWER IN EXISTING 112 BATH/RELOCATE WATER CLOSET POST THIS CARD SO IT IS VISlBLE FROM THE STREET Inspector of Plumbing Inspector or Wiring D.P.W. Building lnspe(tor Underground: Service: Meter: Footing:s: Rough: Rough: House# Foundation: Driveway Final: Final; Final: Rough Frame: Gas: Fire Dgpartment Fireplace/Chimney: Rough: lns11lation: Final: Smoke: f'inal: Workers 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 3/16/2018 0:00:00 $65.00 212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272 Louis Hasbrouck ..... Building Commissioner File# BP·20I8-0923 APPLICANT/CONT ACT PERSON MARK SARAFIN ADDRESS/PHONE 42 Pomeroy Meadow Road SOUTHAMPTON (413) 527-7812 PROPERTY LOCATION 83 POMEROY TER MAP32AflARCEL221 001 ZONE URC('lOO)/ THIS SECTION f.OR OFFICIAL USE ONLY: PERMIT APPLICATJON CHECK! 1ST - ,,,.--~OSED ' REQUIRED DATE ZONING FORM flLLEOOUT Fee Paid \\_ \ 'J I Build in<> Pennit Filled o,,t " ' / Fee Paid ._, Typeof Co11~truction: INST ALL SHOWER J:.N E'-'ISTJNr. "/2 BATH/RELOCATE WATER CLOSET New Construction '-~ .... Nor1 Structµral mtenor nmovattons __ 2A~d~dition tg ExistiJs• '--------------------------- Accessorv .. S•.e"-""'"'""'"'~-------------------------Building P!~ns Included; Owner/ Statement qr Lic-ense 053434 3 sets of Plans/ Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLlCA TJON BASED ON INFORMATION PRESENTED: VApproved ___ Additional pennits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER,§ ... lntennediate Project:_ ... ___ Site Plan AND/OR Special Pennit Wirh Site Plan Major Project: Site Plan AND/OR _____ Special Pennit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: §------~ Finding __ _ Special Permit, ________ Variance* ___ _ ___ Received & Recorded at Registry of Deeds Proof Enclosed, ___ _ ___ Other Penn its Required: ___ Curb Cut from DPW --~ Water Availability ___ Sewer A vailabi!ity ___ Septic Approval Board of Health ____ Well Water Potability Board of Health ____ Pennit from Conservation Commissi()n ____ Permit from CB Architecture Comminee ___ Permit from Elm Street Commission ___ Demolition Delay ____ PelTI'lit DPW Storm Water Management 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 arc granted only to those applicants who meet the strict standards ofMGL 40A. Contact Office of Planning & Development for more infonnation. I ' \ A ·ty Northampton B ildi g Department l _-c--c~--~"212 f,1ain Street : :~_:__:_.-,:-'-Room 100 Northampton, MA 01060 Oepar1ment use only Status of PtWmtt Curb Cut/Driveway Permit ______ _ Sewer/SepticA_lilY. ______ _ WatsrNVellAvailability _______ _ Two Sets of structural Plans, ______ _ phone 413-587-1240 Fax 413-587-1272 Plot/SIie Plans~--- Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION l 1.1 PropertyAddress: ~ ~ This section to be completed by office l)qe .. ~-1 sdr,, s :s ll\M-t::-"d ti fC\/'4,.p 221A: Lot Af} Unit ~Dl!t{...,_1-"\pl{),\, \I\,\ y'\ Zone Overlay Dlstrtct Cl,NAO Elm St D18b1ct CB lllstrtet SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Own@rofRecord: ~\o \.w.V\'>I'>~ B~ .POIMtJA, --i:e'!<'l<l.(-1 ~ 't,, .. ,IA A N~(P,;,h Cu~nt M~i:'9.... ~d~ss. • l "'' ''"0 • e,. "1/7~ -------= Telephone ·- S nature 2.2; Authorized Agent: ~ N,~~ ~< f ..rrl-e 11.., .11 e 5,..,.J.{,,.,.., fl k"" • , Current Mailing Address: 0 \Olf ~\~-~l,3-'1~ '{&J Signature Telephone §~!ION ~ -ESTIMATEQ ~~§TR~C!IQN gOST§ I Item Estimated Cost (Dollars) to be Official Use Only comnleted bv --rmit a--licant 1 . Building " l,,()oo. -(a) Building Permit Fee 2. Electrical ~ t I <ex,• -(b) Estimated Total Cost of Construction from '6) 3. Plumbing ~ _;i '()O(> , -Buildlng P1M'mlt Fee f:f {ji 4. Mechanical (HVAC) 5. Fire Protection 6. Total-(1+2+3+4+5) ... "'' '!(CO . -Check Number Thia Section For Official Use Onlv Building Permit Number: Date Issued: Signature: ~" J /f(., /,. /,/ 2,/1 t., /t 'J'. V Building Commissioner/Inspector of Buildings Date -5 °' '(l_ "' V. "' 8 \ @ (:J,,,c, A \-e -~-.\-- ( _;•• AIL ADDRESS REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) Section 4. ZONING A!t Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required hy Zoning This column to be filled in by Building Department Lot Size Fronta~•e Setbacks front fil4s L __ Rc __ L: ____ R:_ Bsl!! Building Height Bldg. Square Footage % Open Space Footage % (Ult area minus bldg & paved nark.in<>) # of Parking Soaces Fill: /volume & Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON, KNOW O YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON, KNOW O YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONi KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Heeds to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: O. Are there any proposed changes to or additions of signs intended for the property? YES Q IF YES, describe size, type and location: NO 0 E. Will the construction activity disturb (clearing, grading, excavation, or filling} over 1 acre or is it part of a common plan that wm disturb over 1 acre? YEf Q NO Q IF YES, then a Northampton Storm Water Management Permit from the OPW iS required. SECTION 5:: QESQRIPTIQN OF PRQPQSEQ WORK {check all applicable) New House D AddHlon Replacement Windows Atteratlon(s) ~ Otlloots D Roofing D Accesso,y Bldg. D Demolition D D New Signs 1CJJ Decks D Siding DI Other IQ "' ei""'.l""'~ 1/a \:let,+11\ / fli lore. f-! Alteration of existing bedroom __ Yes o<..., No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement __ -_~Ye-,-___ No Plans Attached Roll -Sheet ea 11 New house and or addition 19 exlaung housing. complete the loHowlng a. Use of building : One Family----Two Family ____ Other ___ _ b. Nvmbef 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. SepUcTank_ CltySewer __ _ Private well ___ City water Supply __ _ SECTION 7a ~ OWNER AUTHORIZATION~ TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, --.,--'.De=~X).,.__~\.l~,t"''"=»<'=-'------------------------·· as Owner of the subject property hereby authOrize Vv'\ ~ \ ehalf, in all matters relative to work authorized by this building I, 1V\~\/... :S"""2"""''"' ,as()wne,/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, (1/\,4~\c -:J:tt_v\ P,iot?Ji/.2 Sigoatu,e of Ow,e,/Ageot Date 3:-13-rs SECTION 8 -CONSTRUCTION SERVICES B.1 Licensed Construction Supervisor: Name or License Hq1ger : M\AJ,,/{, \,_ ~ \4\,'f=, v, 9. Realaterad Home •morovement Contractor: :S!A41A f\ V\ ::;?u, \.9, ... c;, Company Name Addces"'.5 iA-W\ /£ ____________________ Telephone, ______ _ Not Applicable D MCS-o~~~~'i License Number ':I 1r~t 1'l Expiration a Not Applicable D 11-'i'seq Registration Number Expfrlti!~ ~tl I g SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L c. 152, § 25C{6)) l 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 ...... J No... D City of Northampton Massachusetts DEPARiMENT OF BUILDING INSJ>ECXIONS 212 Main Street • Municipal Buil.(ling 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, modemizatfon, 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 or building'' be done by registered contractors. Note: If the homeowner has contracted with a corporation or LLC, that enJity must be registered Type of Work: e-e-moc9t I 'R.A-~11'. Est. Cost: "I q,..;vo. - Address of Work.: _ _,~_,_2,..,__,f.ue>,._-Nl=_:,:'t.,,'(c,b"'1q _ _J/,_,f._.,Z,.._,1!_.,C,"e,_-f'..:... ___________ _ (i Date of Penn it Application: _ _,'3,,__-_cl~..,_-=.JILa80-_________________ ~ 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 pennit as the agent of the owner: 3-l~-,e, Date Contractor Name HIC Registration No. 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 DEPAR7MEN!' OF BUILDING INSE'1&Ci'IONS 212 Main Street • Municipal. Building Nol'thampton, M1I. 01060 Debris Disposal Affidavit ln 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 Permrt 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: Is to be disposed of at: of 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 Industrial Accidents 1 Congress Street, Suite 100 Boston, M4 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY, Applicant Information Please Print Leeibly Business/Organization Name:. _ __,S.,,.\A~"'-=""=£-'~"'~-3~="'~'~\J)=~~"'-~C:~----------- Address: 8~ f-:,..,~-o l\ u, \ \-e 'I oe..cJ City/State/Zip: '\M-4 0 Ill~ Phone#: Ai;:iou an employer? Check the appropriate box: Business Type (required): 5. 0Retail I.!p--1 am a employer with 3 employees (full and/ or part-time).* 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. 6. 0Restaurant/Bar/Eating Establishment 7. Ooffice and/or Sales (incl. real estate, auto, etc.) [No workers' comp. insurance required] 3. 0 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. D We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance req.] 8. 0 Non-profit 9. D Entertainment I o.D Manufacturing 11.0 Health Care 12.00thec *Any applicant that checks box #l must also fill out the section below showing !heir workers' compensation policy infonnation. niflhe corporate officers have exempted lhemselves. but the corporation has olher emp!oyees, a workers' compensation policy is required and such an organization should check box# I. I am an employer that is providing workers' compensation insurance for ng., employees. Below is the policy information. Insurance Company Name.,_ -~A~~'-""'--~---------------------------- lns,rre,'s Addcess, P,b &" 'ii?, I City/State/Zip, \.)'.)o'ou,zv-.. M va. 018'bS Policy#orSelf-ins.Lic.# Uti>e..-!()0-~0iJU3i? -80\~ ExpirationDate: l.,s,-1"5""-18 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 ofMGL c. 152 can lead to the imposition of criminal penalties ofa fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the fonn of a STOP WORK ORDER and a fine ofup 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. jury that the information provided above is true and correct. Si Date: -13-18 Phone#: Official use only, Do not write in this area, to be completed by city or town official City or Town:---------------Permit/License# ______________ _ Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/fown Clerk 4. Licensing Board 5. Selectmen's Office 6. Other ____________ _ Contact Person: Phone#: www mass.gov/dia File # MP-2018-0026 APPLICANT/CONT ACT PERSON SALLOOM W ROGER & DONNA C ADDRESS/PHONE 83 POMEROY TERR PROPERTY LOCATION 83 POMEROY TER MAP 32A PARCEL 221 001 ZONE URC(lOO}/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: ZP A-MAINTAIN HOME AS CONTRACT PURCHASER'S RESIDENCE AND MAINTAIN 3RD FLOOR ACCESSORY DWELLING BUT ADD B&B ON 2ND FLOOR (2 BEDROOM SPACE) 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 I~~RMATION PRE~NTED: ~pproved _V_ AAcdd1t10nal permits reqmred (see below) <r6-TA5Cl o F use 3SO ... lD PLANNING BOARD PERMIT REQUIRED UNDER : § ....,-::> .1 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 Signa~l;d:/ Date I 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 ofMGL 40A. Contact the Office of Planning & Development for more information. File Please type or print all informa 10n an return this form to the Building Inspector's Office with the $30fi.lingfee (check or money order) payable to the City of Northampton c{-l .J 1 i'\ "I . II ' . I I -. ~ , - . ./f we q (JOO<A'1.M/,ia.s~. CAw\. Name of Applicant: )folQ6"«~ M, • ~ Address: '14 r1) vJ. V uS~4.r vJ~ ~ ~ Co Telephone: ~o </)J-> J-_ -mf Owner of Property: ~O~ ~/ ~~ 5M, {(J'TQ"M.- Address: ~3 ~~fV()..CfL-- /V~~OIO,o Status of Applicant: Owner Contract Purchaser t/' Lessee ___ Other (explain) ____ _ 1. 2. 7 Telephone: __ • ________ _ 3. 4. Job Location: ~ '.. 1> nv--tro1 f e<r. ?«-4-Parcel Id: Zoning Map# _____ _ Parcel# ')-;J,..{ Oistrict(s): ________ _ In Elm Street District In Central.Business District ___ _ (TO BE FILLED IN BY THE BUILDING DEPAR"PMENT) 5. ExistingUseofStructure/Property: ~~U.. bry <A!~ ~S.'is~'{~~ ~@.,( flk ¥i:)_J 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): 7. Attached Plans: Sketch Plan Site Plan 7 flti{-pf~ Engineered/Surveyed Plans __ _ 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ___ _ DON'TKNOW V YES ___ _ IF YES, date issued: ______ _ IF YES: Was the permit recorded at the Registry of Deeds? NO ___ _ DON'T KNOW _V--__ _ YES ___ _ IF YES: enter Book ___ _ Page ____ and/or Document# _____ _ 9.Does the site contain a brook, body of water or wetlands? NO V---DON'T KNOW __ _ YES __ _ IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ___ _ Obtained _____ , date issued: ______ _ (Form Continues On Other Side) W:\Documents\FORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004 10. ( \ ' .· " ' ,, [ f .. ,':' '.' 1 'th , ... Do any signs exist on ,the propert ? YES ----• j IF YES, describe size, type and l cat :..:..-._-~_~--"~--_-_-_-_._ .. _.,__-+------------------ NO ·<Are there any proposed changes to or additions of signs intended for the property? YES NO~ --- IF YES, describe size,. type and location=-------------------~------ 11 . Will the construction activity disturb (clearing, grading, excavation, or filling) 07acre or is it part of a common plan of development that will disturb over 1 acre? YES • NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION This column reserved for use by the Building D tm t epar en EXISTING PROPOSED REQUIRED BY ZONING Lot Size # ) o...e,,r '<-.. 1 ~ Frontage ~~cl ui I-I?~ Setbacks Front, I ' Side L: R: L: R: L: R: Rear \. ( (.~ l( I.. \ Building Height "?· sM .. <--5· .~ s~~· ' ' • Building Square Footage lf lrL( ( l{ 2,<{ ( % Open Space: (lot area ~ . f(t)f-I'~ minus building & paved ~ parking # of Parking Spaces • • ~ s- # of Loading Docks 0 0 Fill: 7 7 (volume ft location) • . 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. Date: tcjt '{µ ?= Applicant's Signature~·~---~---------_-:_-_---~--~ NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning requirements and obtain all required permits from the Board of Health, Conservation Commission, Historic and Architectural Boards, Department of Public Works and other applicable permit granting authorities. W:\Documents\FORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004 11/16/2017 City of Northampton Mail -83 Pomeroy Terrace Louis Hasbrouck <lhasbrouck@northamptonma.gov> 83 Pomeroy Terrace Louis Hasbrouck <lhasbrouck@northamptonma.gov> To: Carolyn Misch <cmisch@northamptonma.gov> Carolyn, Thu, Nov 16, 2017 at 6:44 PM I checked the permits for 83 Pomeroy Terrace. Aside from some bathroom renovations in 2014 and a backup generator in 2009, the only other permit was for converting from a 3 family to a single family. That permit was signed off in November 2006. The assessors list it as a 2 family. There's no recorded restriction for an accessory apartment. Based on the assessors card and the lack of a recorded restriction, I consider the house a 2 family dwelling, allowed by zoning. It may or may not meet the building code requirements for means of egress, fire separation, smoke detectors and electrical wiring. Configured as a 2 family, it can not be a Bed and Breakfast. Louis Hasbrouck Building Commissioner City of Northampton Town of Williamsburg (413) 587-1240 office (413) 587-1272 fax https://mai I .goog le.com/mail/ca/u/O/?ui=2&ik=ec5f19a57 e&jsver=M-xh RWnOlpO .en .&view=pt&msg= 15fc 738362becb6b&search=sent&siml=15fc 73836... 1 /1 Material cost=$ 9200.00 Labor cost=$ 12,500.00 Total cost=$ 21,700.00 Contractor Supervisors License number 082531 Home Improvement contractor Registration number 135204 I propose to supply materials and labor-in accordance with above specifications. ,, _ ,-'7 This proposal may be withdrawn i:·:;,(i·· -ii / _./ .. .----J By us ifnot accepted within 30 days Authorized Si~ure , ~ ~Q J:....<q~/ Acceptance of proposal Signature\ / ~'\,\f'vL...;;; ~ V Stephen Camp Construction 46 East St. Easthampton, Ma O 102 7 ( 413)527-7124 Submitted To: Roger Salloom Phone-210-7482 584-6324 Address: 83 Pomeroy Terrace Date -10-10-2014 Northampton, Ma 01060 We hereby submit this estimate for -Bathroom Renovations and other renevations as found in Mark Gelotte's drawings. 5-28-2014 To start the project I will supply a dumpster and build a shoot to go From the back roof into the dumpster. I will completely demo were needed and work with the plumber and electrician For there demo also. I will remove the old tub and open area's needed for plumber & electrician. Me and my workers will clean up on a daily bases. I will do all framing for the floors, walls and ceilings as necessary. The insulation will be done as requested and I will subcontract any spray foam needed. R-19 minimum exterior walls. The 5 new Marvin Integrity windows will be installed. I will do all sheetrock ready for paint. ( roger will hire his own painter as talked about. ) (All linoleum and tile work will be done by others.) The new doors will all be installed. ( pine 4 panel doors ) I will install vanity's and medicine cabinets picked out by the customer's. All trim work will be done as the blueprint shows. I will supply all building materials needed for my work. I will supply the building permit and trash removal for complete job. Jesse Camp will do all electric work INSPECTOR Louis Hasbrouck Building Commissioner City of Northampton Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street• Municipal Building Northampton, MA 01060 Chuck Miller Assistant Commissioner HOME OWNER EXE1\1PTI0N 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 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 ------------------------ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ____ )j~+-fAf'l-'~--·~'v?.~//( __ """L'--',l).__,__~ef/,__ _______________ _ Address: l/~ LA-Jr 5 f v'<A'/" City/State/Zip: /AJ fl.-/7Jv ri,t~ iJ/o2)Phone #: Are you an employer? Check the appropriate box: 1.Jjj I am a employer with 2-4. 0 I am a _general contractor and I employees (full and/or part-time).* have hrred the sub-contractors 2. 0 I am a sole proprietor or partner-listed on the attached sheet. ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.+ required.] 5. D We are a corporation and its 3. D I am a homeowner doing all work officers have exercised their myself [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. 0 New construction 7. J2{] Remodeling 8. ~ Demolition 9. D Building addition 10.0 Electrical repairs or additions 11. 0 Plumbing repairs or additions 12.0 Roofrepairs 13.0 OthertJ?t/4,tt~: lv•1'Pllv1 * Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractors 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 number. Below is the policy and job site I am an employer that is providing workers' compensation insurance for my employees. information. Insurance Company Name:_ ..... A--'--"'c'-'· c~-,!l.'-+-'-1_1/J_A_r.--=, ~c.;.·-"-~----"1-'-1.. ..... f._•_--={_;(.,c__')_,_, --------,-------:-- Policy# or Self-ins. Lie. #:_&.c...,_5_-(p_._Z_u_r:J __ -_J._~_q_·o____,_y_._7_2-__ Expiration Date: o/'11 ' Job Site Address: 1J r/Jo1 <Oj /tvv'tt C (' City/State/Zip: /1tJlf1,/IJ; fvt& cJ/dl D 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 hereby certify un~er the !'!'-ins anjpenalties of perjury that the information provide~ above is true and correct. Signature: ~.~ ~ Date: / 0 -/ 0 -I Y -2· ;;? Phone #: J 7 _, / / 2 Y ' Official use only. Do not write in this area, to be completed by city or town official City 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 I 8.1 Licensed Construction Supervisor: Name of License Holder : ____ -1kf:_-·....,.,,.,+~--¥~---L_/J~~¥1-~·-"/ _____ _ Not Applicable £ 08'2 'f ]/ (rt. £AJt: .{fv~r License Number /l-2J-~I< Expiration Date Signature /T Telephone .9. Reqistered.Home'iinproven:i~tit'C611tFadt6r:·;·,;k2;;/f.:i~,:;:,~··ieL2:1:;;;:;_;;;'ELL.,.::Z.;;E::l:' Not Applicable £ /J>2oY 1\~w C-4-rvf,(' LJ J/1 ft ,n_rc:_/, v--/ Company N me · Registration Number l·-)J --/ ~ C/b £A-sr ~'7"//'~-t-r Expfration Date Address ________________ Telephone ;)? 7-71 2,/ SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c.152, § 25C(6)) I 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 b!JH'{'ling permit. Signed Affidavit Attached Yes ... V. £ No ...... £ The current exemption for "homeowners" was extended to include Owner-occupied Dwellings ofone (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 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··----------------------·--- SECTION 5-DESCRIPTION OF PROPOSED WORK (check all applicable) New House D Accessory Bldg. D Addition Demolition Brief Description of Proposed ~ ./ Work: /l "1.fJllth D D Replacement Windows Alteration(s) Or Doors [ll tf) New Signs [DJ Decks [D QcJ Roofing D Siding [D] Other [D] Alteration of existing bedroom ___ Yes _L_ No Adding new bedroom Yes ___ No Attached Narrative Renovating unfinished basement ___ Yes ___ No Plans Attached Roll -Sheet 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 , as Owner of the subject I, S+ef /-.t~ . (A~ , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best ofmy knowledge and belief. Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning i TI11s column to be filled in by Building Department Lot Size ! i l r i Frontage I. jj IL_ i -·-.I Setbacks Front c=i CJ CJ Side d IR:l I L:I I R:i 1 CJ CJ Rear L_::J CJ CJ Building Height CJ [ =i CJ Bldg. Square Footage CJ c----, % l -1 ! ::J CJ Open Space Footage c __ J [__ ! % [ _j L::J r=J (Lot area minus bldg & paved parking) CJ \i ti l .. · 1 # of Parking Spaces -·-- Fill: r·"· w.w • ...,_ • ..,,,,, . --·,ir-,_,,.. ,,.,..,_,,..,,,., .... ...,_.,, , ... r ~ .. ---· ·-· -··i (volume & Location) ii ~ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO . 0 DONT KNOW O YES 0 r---------i IF YES, date issued:! ! , _ _.._ ___________ _, IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES 0 IF YES: enter Book[-----·-·-] Page[-· . ---] and/or Document #1··-----·---·1 B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 . Obtained 0 I Date Issued: c _____ __, C. Do any signs exist on the property? YES IF YES, describe size, type and location: 0 NO 0 --·-··=1 D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 0 IF YES, describe size, type and location: !_ ----------·-·---------_ _J E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan ,. that will disturb over 1 acre? YES Q NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. (C~ij~l~ D OCT I l 20\4 \i City of Northampton Building Department 212 Main Street Room 100 E ectric, Plumbing & Gas Inspections Northampton, MA 01060 Nor\!;2-mr\on, MA 01 13-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A Clli5..0R TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: ??J SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT i. 2.1 Owner of Record: re. fl t ,/ V,-·· ot' fl n '\ Name (Print) Signature 2.2 Authorized Agent: Signature • SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item 1. Building 2. Electrical 3. Plumbing 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 + 2 + 3 + 4 + 5) ?3 Current Mailing Address: Telephone Current Mailing Address: [Z.? -I I z i / Telephone Official Use Only (a) Buildin9. Permit Fee (b)Estimated Total C::ost of Construction from. 6 Building Permit Fee This Section For Official Use Ont Building Permit Number: ___________ _ Date! Issued: _________________ _ Signature: ---'-----------,--------,-. . . . . Building Commissioner/lns~~ctor of BuHdings. Date File# BP-2015-0443 APPLICANT/CONTACT PERSON STEPHEN CAMP ADDRESS/PHONE 46 EAST ST EASTHAMPTON (413) 527-7124 () PROPERTY LOCATION 83 POMEROY TER MAP 32A PARCEL 221 001 ZONE URC(IOO)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DA TE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ~cJo-< Fee Paid f/)J?)b Typeof Construction: REMODEL 2ND FLR 2 BATHROOMS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 082531 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: ~roved __ 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 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 ofMGL 40A. Contact Office of Planning & Development for more information. 83 POMEROY TER GIS#: Map:Block: 32A -22! BP-2015-0443 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS _Pe~rm~it~: --~B=ui"""ld=inc..,..g DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2015-0443 Project # JS-2015-000816 Est. Cost: $21700.00 Fee: $130.00 Const. Class: Use Group: Lot Size{sg. ft.): 13198.68 Zoning: URC{ 100)/ PERMISSION IS HEREBY GRANTED TO: Contractor: License: STEPHEN CAMP ____ 0.;...;:8=2..;:;;..;53~1 Owner: SALLOOM w ROGER & DONNA C Applicant: STEPHEN CAMP AT: 83 POMEROY TER Applicant Address: Phone: Insurance: 46 EAST ST (413) 527-7124 () WC EASTHAMPTONMA01027 ISSUED ON:1114/2014 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL 2ND FLR 2 BATHROOMS 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: 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 11/4/2014 0:00:00 $130.00 212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272 Louis Hasbrouck -Building Commissioner