48 Chestnut Ave Ext new SFHFile# BP-2019-0476
APPLICANT/CONTACT PERSON ED JAZAB
ADDRESS/PHONE 9 SHEPHERDS HOLLOW LEEDS (413) 222-49 l O ()
PROPERTY LOCATION 48 CHESDillT AV EXT LOT 1
MAP 06 PARCEL 064 000 ZONE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
T eof Construction: NEW SINGLE FAMILY H
CONDOMINIUM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 050099
3 sets of Plans / Plot Plan
LISI
REQUIRED DATE
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
__ Approved __ Additional permits reqrlired (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§----------'. i .
Intermediate Project: ___ Site Plan AND/OR ____ Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
•I ( Ui
ZONING BOARD PERMIT REQ(!;~D'_UNDER!. 'f-._,___ ______ _
Finding _____ _ Special Pe~it _______ 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 Delay
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 ofMGL 40A. Contact Office of
Planning & Development for more information.
RECEIVED
OCT 1 fit1rnBNo ham
Bu[ding D part ent
21 · Str et
Department use only
Status of Permit:
Curb Cut/Driveway Permit--------
Sewer/Septic Availability ________ _
Water/Well Availability _________ _
Two Sets of Structural Plans _______ _
Plot/Site Plans ____ _
Other Specify ___ _
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION I I lli r1S
1.1 Property Address: I This section to be completed by office
o& Lot (j (£ '1 Unit Map
48 Chestnut Ave Extension (Lot 1) Leeds Zone Overlay District
Elm SL District CB District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT I
2.1 Owner of Record:
Patrick J.Jvtelnik,Jru*e 110 King St. Northampton Ma. 0 I 060
Name (Prir lK-Current Mailing Address: 584-6750 A Telephone
Signatu/e/
2.2 Au'fuorized Agent:
eJv,)A~J J' -4~ "'"
, (tJflf l...e,....J .J ).J p llo vJ Lea.,/ r ~A
Name (Print) ~\(\. ~ Current Mailing Address : ()\()t'.J
",,-'111-J_'}a -~, /o
Signature \v ' Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollars) to be Official Use Only
completed bv permit applicant
1. Building 140000. (a) Building Permit Fee
2. Electrical 15000. (b) Estimated Total Cost of
Construction from (6)
3. Plumbing 15000. Building Permit Fee //q ~57(/IJ 4. Mechanical (HVAC)
5. Fire Protection 25000.
6. Total= (1 + 2 + 3 + 4 + 5) 195000. Check Number ~/ '/{jl
This Section For Official Use Onlv
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of 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 11 acre 11 1 acre 11 I
Frontage 1200 11200 11 I
Setbacks Front ~ CJ CJ
Side L:ITI:J R:CJ L:CJ R:CJ CJ CJ --------
Rear [1W] CJ CJ
Building Height [L] [I[:] CJ
Bldg. Square Footage 140001 !I[:]% 149061 115%1 CJ
Open Space Footage
L9A I @rJ %
L8A I 185%1 CJ (Lot area minus bldg & paved
parking)
# of Parking Spaces [CJ [I[:] CJ
Fill: I () II 0 i [ I (volume & Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O YES {!)
IF YES, date issued:! 4/9/2008
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IFYES: enter Book I 9482 Pagel 3 and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO @ DONTKNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued: ~' -----~
C. Do any signs exist on the property? YES
IF YES, describe size, type and location:
0 NO {!)
~
0
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{!)
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 {!)
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK (check all applicable)
Replacement Windows Alteration(s) D
Or Doors D Roofing D New House [Z] Addition
Accessory Bldg. D Demolition
D
D New Signs [DJ Decks [D Siding [D] Other [D]
Brief Description of Proposed New single family home as additional unit to existing 4 unit condominium Work: _____________________________________ _
Alteration of existing bedroom ___ Yes ___ No Adding new bedroom Yes ___ No
Attached Narrative Renovating unfinished basement ___ Yes ___ No
Plans Attached Roll -Sheet
Sa. If New house and or addition to existing housing, complete the following:
a. Use of building: One Family x Two Family ____ Other ___ _
b. Number of rooms in each family unit:_6 ______ Number of Bathrooms_2 ____ _
c. Is there a garage attached? _y_e_s __ _
d. 1426 sf . . 40'x38' Proposed Square footage of new construction. _________ D1mens1ons ---------------
e. Number of stories? 2 --------------
f. Method of heating? --'g=-a_s ____________ Fireplaces or Woodstoves _O ____ Number of each
g. Energy Conservation Compliance. _y_es ________ Masscheck Energy Compliance form attached? _y_e_s ____ _
h. Type of construction wood frame
i. Is construction within 100 ft. of wetlands? Yes _x __ No. Is construction within 100 yr. floodplain ___ Yes ~No
'l
j. Depth of basement or cellar floor below finished grade __ __. _______ _
k. Will building conform to the Building and Zoning regulations? X., Yes ___ No.
I. Septic Tank__ City Sewer ~ Private well City water Supply .)( v" -----'---
SECTION 7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ----~(/._T_/4._,_l_k __ 'f_._,-. __ l,_/~~-'-"-------------------· as Owner of the subject
property
Edward Jazab
permit application.
1J
I, ~"" (_ "( T. ,.,,r J..,. JI( . 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.
~AC '1 -:r , ~ {;vJ>f
Print Name
SECTION 8 -CONSTRUCTION SERVICES I
8.1 Licensed Construction Su[!ervisor: Not Applicable D
Name of License Holder : Edward Jazab
License Number
9 Shepards Hollow Leeds Ma. 01053 CSFA o r-oo "l'I
Add'UD~ Expiration Date
4/2/20*9 20
Signature -t--Telephone
413-222-4910
9. Registered Home lm[!rovement Contractor: I Not Applicable D
Com[!anlt'. Name Registration Number
Address Expiration Date
Telephone
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 building permit.
Signed Affidavit Attached Yes ....... ,Jf No ...... D
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
The debris from construction work being performed at:
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Edward Jazab ------------------------------
Address: 9 Shepherd's Hollow
City/State/Zip· Leeds Ma 01053 Phone #: 413-222-491 O
Are you an employer? Check the appropriate box:
I .O I am a employer with ____ employees (full and/or part-time).•
2.[Z] I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.] 3.o I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.o I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers' comp. insurance.I
6. 0 We are a corporation and its officers have exercised their right of exemption per MGL c.
152, §1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. D New construction
8. D Remodeling
9. D Demolition
10 D Building addition
11.0 Electrical repairs or additions
12. D Plumbing repairs or additions
13.0Roofrepairs
14.00ther _______ _
• 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.
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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ____________________________________ _
Policy # or Self-ins. Lie.#: ___________________ Expiration Date: ________ _
Job Site Address: City/State/Zip: ________ _
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 ofa STOP WORK ORDER and a fine ofup to $250.00 a
day against the violator. A copy of this statement may be forwarded to the Office oflnvestigations of the DIA for insurance
coverage verification.
I do hereby certify under the p sand penalties of perjury that the information provided above is rue and correct.
Si nature: Date: 9 J1 ')I
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#: _______________ _
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as " ... every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in ___ ( city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i .e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
Revised 02-23-15
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as " ... every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However, the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply your insurance company's name, address and phone number along with a certificate of insurance.
Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members
or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy
is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office oflnvestigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that
must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (ifnecessary). A copy of the affidavit that has been officially stamped or marked by the city or town
may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business
or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this
affidavit.
The Department's address, telephone and fax number:
Fonn Revised 02-23-15
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel.# 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
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MUNICIPAL WATER AVAILABILITY APPLICATION
Northampton Water Department
23 7 Prospect St.
Northampton, MA 01060
587-1097
A Department of Public Works Trench Permit shall be required prior to any construction or
connection activity associated with this application.
Location: Unit #1 #48 Chestnut Ave, Ext.@ 28 Evergreen Road, Beaver Brook Estates, Leeds
Inquiry Made By: Pat Melnik 584-6750
Date of Inquiry: 11/3/11
Number of Type of Single Family x Type of Private X
Units: 1 Unit(s): Accessory Apart. Ownership: Condo
Multi-family Rental
<Applicant to PU 0v1 the ahoye}
Municipal Water Main in
Front of Location? Yes: X No:
Existing service to
site? Yes: X No
Size of Water Main: 8" Material:
Approximate Static Street
Pressure:
Size of Service Connection
Suggested Meter Size:
40
1"
%"
Cast Iron Age: 1956
Flow Test Conducted: Yes: No: X
If done attach results
Comments: The Water Department cannot guarantee adequate water pressure during peak demand
times at elevations above 320 feet.
• A corresponding water entrance fee shall be paid prior to making any connection to the municipal water
system .
•
David W. Sparks, Superintendent o Water Entry$ NIA Meter $150.00 Radio $100.00
cc: Ned Huntley, Director
cc: Louis Hasbrouck, Building Commissioner Note: If this availability is for a new construction,
it must be hand delivered to the Building Inspector.
:i..:
MUNICIPAL SEWER AVAILABILITY APPLICATION
Northampton Streets Department
125 Locust Street
Northampton, MA 01060
413-587-1570
A Department of Public Works Trench Permit and Sewer Entry Permit shall be required prior to any
construction or connection activity associated with this application.
Location: 48 Chestnut Ave Ext. Lot 1
Date of Inquiry: Patrick Melnik ----------------------------
1 n quire r with contact info: 584-6750 ----------------------------
Re as on for Request: New construction ---------------------------
Municipal Sewer Main in Front of Location: Yes No
Size of Sewer Main: Material: Age: -----
,Qepth of Sewer Main: __________________________ _
Length of Sewer Main: ----------------------------
Size of Service Connection:
Type of Service Connection:
Domestic Tie In: __ ($1,250)
Tie-in to Private Sanitary: /. $ -NJ A
Comments:
Subdivision Tie In : __ ($2,500)
Tie-in to Existing Sanitary Service: $ -N/ A ----
City Requires 6" cleanout installed at City Property Line
Note: If this availability is for new construction, this form must be hand delivered to Building Inspector.
A corresponding "sewer entrance fee" shall be paid prior to making any connection to the
municipal sewer system. Arrangements of such installation shall be made with the Northampton
Streets Department with a minimum of 5 working days notificaiton. All work shall conform to
Northampton Streets Department specifications.
Date:
Sewer Dept. Foreman
Sewer Entry $ ___ µ__,_/fr __
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City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street• Municipal Building
Northampton, MA 01060
Fee Calculator for Residential Properties
Location: L~ (~;,)
Square Footage Amount
Basement @ .20 ,~1 I~,.,~
1 sr Floor @ .50 "181 L-11).st>
2nd Floor @ .50 44] d-d \ . S'i)
Y, Floors, Finish Attic,~ @ .20 o'-f 0 '-{lj.(JO
Deck I Porches @ .20 / y 0 J.8 .cfl)
Total: 'i B.r. ~ o