31A-146 20 FORBES AVE BP-2017-0918
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A- 146 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2017-0918
Project ft JS-2017-001568
Est. Cost: $33366.00
Fee: 5216.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JASON HARRIS 75795
Lot Size(sq. 0.): 7666.56 Owner: SADOWSKI EDWARD W&MARY JOSEPHINE KRASON
Zoning: URB(100)( Applicant: JASON HARRIS
AT: 20 FORBES AVE
Applicant Address: Phone: Insurance:
120 NEW STATE RD (413) 862-4718 0 WC
MONTGOM ERYMA01085 ISSUED ON:2/10/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:GUT AND REFINISH BATHROOM,
INSTALLATION OF ROLL IN SHOWER, NEW EXTERIOR STAIRS
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: 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 2/10/2017 0:00:00 $216.00
212 Main Street. Phone(413)587-1240.Fax: (413)587-1272
Louis Hasbrouck- Building Commissioner
File#BP-2017-0918
APPLICANT/CONTACT PERSON JASON HARRIS p
ADDRESS/PHONE 120 NEW STATE RD MONTGOMERY (413)862-4718 O (�.
PROPERTY LOCATION 20 FORBES AVE �l �C`
MAP 3IA PARCEL 146 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY: 1 L�C,S*ce
PERMIT APPLICATION CHECKLIST 'P�
ENCLOSED REQUIRED DATE �
ZONING FORM FILLED OUT
Fee Paid 1 h
BuildingPermit Filled out y
Fee Paid
Typeof Construction: GUT AND REPT ATHROOM, INSTALLATION OF ROLL IN SHOWER, NEW se,
EXTERIOR STAIRS J
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 75795
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN, FQRMATION PRESENTED:
V 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
Inion Dela
ignature of:uild -g 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.
It" ed)fr T6 Si-cd,G Fcy4 -3-<12 e.,
Department use only
City of Northampton Status of Permit
Building Department Curb CutfDriveway Permit
212 Main Street SewentSemicAseAstiaay
Room IOC Water/Well Availability
Northampton, MA 01060 Two Sets of sbpctural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1•SITE INFORMATION
This section to be computed by office
1.1 Property Atltlress:a 2 io r {D es Ave
��J / Map Lot Untl
r,f r t a nIQ /0 i /VA Zone Overlay District
Elm St District CB District
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
fa5eh
Name Current Mailing Address:
7Yt.1C,(-41 — "Th. /Lc .. e Telephone
Sanature 1
2.2 Authorised Anent:
—IRS° Nam l _a/ tS- �. L/. e A VOrS
Name(P' ) Current Mall g Address:
443 PGS Vi7/• �
Signatu / Telephone
SECTI r •ESTIMAT ! CONSTRU TION COST'
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building "0101 /6 6 (a)Building Permit Fee
2. Electrical J 1 CO (b)Estimated Total Cosi of
_ /r t Construction from(6)
3. Plumbing Alla 00° Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection 33 J �/
6. Total=
(1 +2+3+4+5) )3rp<j! Check Number it,/ { O`�Jf l{
This Section For Official Use Only
Date
Building Permit Number: igvled;
Signature:
Beading Commissioner/Inspector or Buildings Date
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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0. DONT KNOW O YES 0
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 0/
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 CJ
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,ex ation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 171 Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolitionli ❑ New Signs [D] Decks [C Siding[C] Other]O]
BrWork: c/ {ici„idP re0+Ot bead ren It rn5✓m/kti el-T or roll in Slicwer nets ex-knot-5A, rs
Work::
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If New house and or addition to existing 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?
L 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, ,as Owner of the subject
Property
hereby authorize —3 a-50/-7 NGL
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
Tc`SOh / /c rri S ,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.
//ndtrrr
Print Name
ti. . Iwo 3-/ 9
Signatur. . OwnerlAge - Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction ``]Supervisor: Not Applicable
❑C
Name of License Holger: � et.5On Q. rr-7 C7 -(39(79r
License Number
/do //eu/ 574Aie Rd %n4o,7,n-vk o/orr
//- - j9
A:16:, /,.2, Expiration Date
//q61.44"43 5 2S- 970X
Sture Telephone
I
9..,RegisteeredHome Improvement Contractor: Not ApplicablevvC
J tyy 5{r^'�e ,4t rat ,a re. £Artnsor,e'S 7 is /c02r/
ConWany Name � r Registration Numbeer
/070 1 Qat, 5.4:11-e-5.4:11-e- //o
2- Rd n4nrrerrl 1 ,VA 0/Oryx /- 3 -/7
Address J JJ Expiration Date
Telephoned/3-c7c y7Of
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 0
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780. Sixth Edition Section 108.3.5.1.
Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there
is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that he/she shall be
responsible for all such work performed under the 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 l52(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
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: ;20 For he 4ve
The debris will be transported by:
Ru/k
The debris will be received by: no/poke /rra.y�S/C� 7�,4ion
Building permit number: J
Name of Permit Applicant _j, c , //CCM
a -3-/ 7p µ a
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
t -_ Department of Industrial Accidents
== 1
t_
=ii lI Congress Street,Suite 100
S_,;r1_ Boston,MA 02114-2017
, www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Dusiness/Organirationondividnap:Baystate Hardware 8 Accessories, Inc.
Address:120 New State Rd.
City/State/Zip:Montgomery, MA 01085 Phone#:(413)862-4718
Are you an employer?Check the appropriate box: Type of project(required):
I I am a employer with 4 employees(full and/or parttime)•
7. New construction
2.1:1I am a sole proprietor or partnership and have no employees working for me in 8. O Remodeling
arty capacity.[No workers comp.insurance required]
30 I am a homeowner doing all work myself Mo workers'comp insurance required.]* 9. ❑Demolition
14.01 am a homeowner and wiu be hiringcontractors to conduct all work on my0❑ Building addition
properN_ (will
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
s.❑l am a general contractor and l have hired the subcontractors listed on the attached sheet 13.❑Roof repairs
These sub-contractors have employees and have workers comp.insurance.
6.0We are a corporation and its officers have exercised their right of exemption per MGL c I4.0Odmr
152,§1(4),and we have no employees.[No workers comp insurance require.]
•Any applicant that checks box#I 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 name of the sub-contractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comppolicy number.
7 am art employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Travelers Insurance Company
Policy#or Self-ins.Lia#:IExpiration Date:2/20/17
Job Site Address: 20 Forbes Avenue City/State/Zip:Northampton,MA01060
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cerci under th pains and penalties of perjury that the information provided above is true and correct
Si ature: {] Date:
Phone#:(41 575-9708
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):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
TRAVELERS J WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (IEUB-1434N42-8-16)
RENEWAL OF (IEUB-1434N42-8-15)
INSURER: THE TRAVELERS INDEMNITY COMPANY OF CONNECTICUT
1 NCCI CO CODE: 12637
INSURED: PRODUCER:
BAYSTATE HARDWARE & ACCESSORIE P A PRYOR INS AGENCY
120 NEW STATE ROAD 847 SPRINGFIELD ST
MONTGOMERY MA 01085 FEEDING HILLS MA 01030
Insured is A CORPORATION
Other work places and identification numbers are shown in the schedule(s) attached.
2. The policy period is from 02-20-16 to 02-20-17 12:01 AM, at the insured's mailing address.
3. A. WORKERS COMPENSATION INSURANCE; Part One of the policy applies to the Workers
Compensation Law of the state(s) listed here:
MA
. z
B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work In each state listed in
o s item 3A. The limits of our liability under Part Two are:
Bodily injury by Accident: $ 500000 Each Accident
Bodily Injury by Disease: $ 500000 Policy Limit
Bodily Injury by Disease: $ 500000 Each Employee
C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here:
AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MD ME MI NE
MO MS MT NC NE NH NJ NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI
c=za WV
D. This policy includes these endorsements and schedules:
SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE
- 4. The premium for this policy will be determined try our Manuals of Rules, Classifications, Rates and Rating
Plans. All required information is subject to verification and change by audit to be made ANNUALLY.
DATE OF ISSUE: 01-08-16 AK
OFFICE: SPRINGFIELD MA 354 DIRECT BILL
PRODUCER: P A PRYOR INS AGENCY CLP51
COM 4
TRAVELERS J~ WORKERS COMPENSATION
ONE TOWER SQUARE AND
HARTFORD, CT 96383 EMPLOYERS LIABILITY POLICY
TYPE V INFORMATION PAGE WC 00 00 01 ( A)
POLICY NUMBER: (IE U13-1434N42-a-16)
CLASSIFICATION SCHEDULE:
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM
SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S
SIC-CODE: 1751 NAI CS: 238350
TOTAL ESTIMATED ANNUAL STANDARD PREMIUM STANDARD
4723
PREMIUM CINSTANT NONE
0900-20 EXPENSE CONSTANT 338
TERRORISM 43
TOTAL ESTIMATED PREMIUM 5104
TAXES AND SURCHARGES 269
DEPOSIT AMOUNT DUE 5373
Minimum Premium: $470 EMPLOYERS LIABILITY MINIMUM: $90
DATE OF ISSUE: 01-08-16 AK
OFFICE: SPRINGFIELD MA 354
PRODUCER: P A PRYOR INS AGENCY CLP51 COUNTERSIGNED-AGENT
A LA CERTIFICATE OF LIABILITY INSURANCE °`1t SOVW"
1/6/17
TNS CERTIFICATE M ISSUED AS A MAT ICN OF OFORMAMON OhLY AND CONFERS NO MONIS UPON THE DERTRCATE HOLDER TNB
CERTFICATE GOES NOT AFFIMIAnVELY OR NEOATTVELY AMEND. EXTEND OR ALTER TIC COVERAGE AFFORDED BY THE POUCIES
BELOW. TNS CERUF/CA1E OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TRE ISSUING RMURERIS).AUTIOR¢ED
REPRESENTS/WEOR PRODUCER,MR)TM Ct3TTTCATE ROWER.
W PORTANT: I the ceSieNe hater Ian ADDITIONAL IMMRUREO,4M poike1s)nest be ardesod. It SUBROGATION IS WMVED.SOLI to
the km and coalESbns of the poky,calk pothe may kph"an snor anent A stafemenc on W a uNBate dime nimta,M MN%to SIO
caN&e°boder In non Mouth endaseiwnkt.
PRWJCa n'•4L. Mark Lambert -
T.amhort S Pryor Insurance Agan _tarPEENa:an. 1413) 706-1720'--_'_gy 17VC Nn. 44131 786-4962
847 Springfield Street Maar NarkePryOrinegrange.goo
Feeding Hills, MA 01030 INWRFDDAEFORDIa WVId.6E Nut.
POURER A;Travelers Indemnity Ina.
BRUaD IMUReRa:Arbella Indemnity
Hays tate Hardware t Acceasoris ISD;
120 New State Road INSURER D. ^,,,,,.
Montgomery, ADL 01085 INma
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RNRER FL
COVERAGES CERTIFICATE PIONEER: REVISION NUMBER:
INSIS TO CERTIFY TWIT TLE PRICES OF EIWE T,IE RUSTED Bear NEVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDRATED. NOTWTHSSANOND ANY REQUIREMENT,TERN OR COMMON OF ANY CONTRACT OR OBER DOCUMENT WRY/RESPECT TO VOUCH THIS
CERTIFICATE WY BE IsSU111 OR MAY PERTAN,THE INSURANCE AFFORDED BY TEE POL8IES CES0118E0 HELEN ri SUBJECT TO ALL INE TERMS.
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AND CONDTCNS OF SUCH POLICES LEATS SHOWN WY HAVE SEEN REDUCED BY PAID CLAIM
liT11 TYPE OF MISURO CE y� PAM e4pc sus vary;
MRMW i.4YYY�TO Lasmo
A (imam WOW, 68070790491 4/29/16 4/29/17 EACRCecRaaEwe 1.000.000
A. CaMPA41
CCElEMLtNBMTY DAVAGETa
WOO 100,000
cutaelDE XIOCCUR MED wy.Men Rvup 5,000
PEASONM6Affi INAIaV 1.000.000
LaIeaL ACVREF.A17 2 000 000
GOD_ADDRCOATEIND APPLES PER PRODucl .mWaRP ARD 2.000.000
X1 PaICY fl Pith ftoe
H Anaaneu.aury 1020006479 10/5/16 10/5/17 Dae nI4.JNO[ttmn 1.009.000
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H oasLw .IA_....... ACS,EOATE s 1,000,000
D M REFROWN$ 5 000 ( d
A VNMCme oceeriaA7ae TDd1434N428 2/20/161 2/20/17 7WC Tlum6 X can
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OFF�mESIPER MILDEW N NIA EL.E+ExacaDEtB 1 500.090
MyyayyaaaE emit RsoiSCASE-EA EMPLOYEE : 10 009
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SHOOLDANY CP THE ASOVEb8SCRLLtD ROUGES BE CMICELLED BEFORE
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ACCORDANCE VIII RIR POLCY PROVMpNe.
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