31A-138 (5) 62 FORBES AVE BP-2018-1246
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block:31A- 138 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category,window replaced BUILDING PERMIT
Permit# BP-2018-1246
Proiect# JS-2018-002219
Est Cost:$6500.0
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: RICHARD AHLSTROM 073454
Lot Size(so ft.): 7230.96 Owner: TOMAYO ANDRES
Zoning, URB(100)/ Applicant- RICHARD AHLSTROM
AT: 62 FORBES AVE
Applicant Address: Phone: Insurance:
215 MADISON AVE (413) 533-9900 O Workers
Compensation
HOLYOKEMA01040 ISSUED ON:512412018 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE 2 EXISTING WINDOWS WITH 2
LARGER WINDOWS
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 5/24/20180:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File 0 BP-2018-1246
APPLICANT/CONTACT PERSON RICHARD AHLSTROM
ADDRESS/PHONE 215 MADISON AVE HOLYOKE (413)533-9900 0
PROPERTY LOCATION 62 FORBES AVE
MAP 31A PARCEL 138 001 ZONEJ 1001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildim Permit Filled out
Fee Paid
1�ypeofConstr ction: REPLACE 2 EXISTINNWIhIPMS WITH 2 LARGER WINDOWS
New Construction
Non Structural i [ ror renovations
Addition to Existing
A cessory Structure
Building Plans Included'
Owner/Statement or License 073454
3 seta of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFgAMATION PRESENTED:
Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance'
Received&Recorded at Registry of Deeds Proof Enclosed
_Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
_Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Ehn Street Commission Permit DPW Stone Water Management
molition Delay
ftrtl[we of Buildi rfficial Da
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 we granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more info rnation.
RECEIVED
` City ofN a pion
MAY 2 3 13�OIlAng epepa ment
212 M in S1 eat r '�
1
T OF Fulton AINSPF
NonTNAMP1�Optl.1®ns ton M 01060
phone 413-587-1240 Fax 413-587-1272
ii�vs w
t
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION
1.1 Property Address: This section to be completed by office
6F2 Fae&s 44royal Map Lot / 3P nit
N< w/Pfi✓ �? Zone Overlay District
Elm SL District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
,4,q 42! Ina, T ..,_t ,, Gz zli Ar. N�.7�lr+.arit—
Nam¢(Print) / 7 Current Mailing Address:
/d11L_ L/r Telephone /w'3 7G?-/Go7
Signature 4a�
2.2 Authorized Aaent::
clt.t /1_r'4_ lsxti +Y y/S Mw.tr•s..• 4.tr.
Name(Print) Current Mailing Address'.
rfTr
WS -7.'97-4e,624
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b ermit a licant
1. Building 5 0 O GO (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
q0
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number / 7
This Section For Official Use Only
Date
Building Permit Number: Issued:
T
Signature' -
Building Co su.nerlli s,ectorof Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All 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 LR:L_J L:= R:=
Rear
Building Height
Bldg.Square Footage L__j - %
Open Space Footage %
park area minus bldg ffi pavW
parking)
#of Parkin Spaces
Fill:
(volume&location)
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
s
IF YES: enter Book C� Page[= and/or Document
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES
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
IF YES, describe size, type and location:
E. Will the construction activity disturb(deamg,grading, exravabon, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO Q
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 I Aheration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [lam Siding[p] Other[CQ
Brief Description of Proposed
Work:
/2�0/< �
Alteration of existing bedroom_Yes No Adding new bedroom Yes No Q n �
Attached Narrative Renovating unfinished basement _Yes No )-
Plans Attached Roll -Sheet
ea.If New house and or'addkion M"Istina housing, c07 letei tiY JO111owina:
a. Use of building :One Fani 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?
I. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. 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
/- e S ^ �✓t hs as Owner of the subject
p
properly
hereby authorize Q2 /d" �.f 7
to act on my behalf, in all matters relative to work authorized by this bwldmg permit application.
,J�-
SlgnatdreofCramer Data
as Owner/ thonze
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of m77nowledge
and belief.
Signeddduunder the pains and penalties of perjury.
e / -A A r fY I�L es
Print Name
Signatum ofer/Agent Date
'\ 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 Please Print Legibly
Business/Organization Name: 1121149Xe �rmOs<e �•��
Address: /t� e, Aq//AAX /O11ZL
City/State/Zip: Phone#: ll' / OG 0
Are you an employer?Check the appropriate box: Business Type(required):
L❑ I am a employer with employees(full and/ 5. ❑Retail
orpart-time).` 6. ❑RestaumnUBar/Eating Fsmblishment
2..V I am a sale proprietor or partnership and have no 7. ❑Office and/or Sales(incl. real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp. insurance required] S. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§I(4),and we have 10.❑Manufacturing
no employees. [No workers'comp. insurance required]*' I I ❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp, insurance req.] 12.❑Other
'Any applieam that checks box 41 most also fill out the section below showiig their workers'compen%alion policy information.
r r l tax eorponteorim have exemptedthemselves,butthecorporation has one,employees,aworkers'oompeosation policyisoo,orol orad such to
organization should check box WI.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lie. # Expiration Date:
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 STOP WORK ORDER and a line
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, under the pains and penalties ofperjury that the information provided above is true and correct
Simaum� /_— Date S 4z_/i g
Phone#: / 3 ^ e e 2
Official use only. Do not write in this area,to be completed by city or rows official.
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
Contact Person: Phone#:
wwwataae-govldia
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervise r: NotApplicable ❑
Name of License Holder:
License Number
-24S Nati�i Scn fjr/f / �io/d� /Y/i9 y�/O LZO Lo
Address Expiration Date
�S,nwuljls Telephone
9.Registered Home Imm"wel Mti ontinic .3'FF Not Applicable ❑
Company Name Registration Number
r� 0. �OX /OZG 51`6Ii8
Ad�drreesss� // Gz9 Expiration Date
✓U���/Avr/,�L r%� ��OG/ Telephone /
/
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....... !2/' No...... ❑
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street a Municipal Building a� `C
xortaaepton, MP 01060 '8>�
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: 1
�Z f�OrhtS /h/cyicc� /l�vr�.r�,ot�-r�
(Please print house number and street name)
Is to be//disposed of at:
vt, lteq 12
(Please/print name/and to ion of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
s/7-z�s
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.
U
s L�ry n t"