22B-020 13 MEADOW AVE BP-2019-1251
GIs#: COMMONWEALTH OF MASSACHUSETTS
MaRBlock:22B-020 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-2019-1251
Proiect# JS-2019-002016
Est Cost:$210000.00
Fee: $1365.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DOUGLAS THAYER 107699
Lot Size(sa.ft.): 17816.04 Owner., HILBINK TOM
Zoning: URB(100)/ Applicant. DOUGLAS THAYER
AT: 13 MEADOW AVE
Applicant Address: Phone: Insurance:
P 0 BOX 60322 (413) 530-4785 0
FLORENCEMA01062 ISSUED ON:5/9/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:RENO OF ENTIRE STRUCTURE
**SEE NOTES***
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: M 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 5/9/20190:00:00 $1365.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck- Building Commissioner
File 4 BP-20194251
APPLICANT/CONTACT PERSON DOUGLAS THAYER
ADDRESS/PHONE P O BOX 60322 FLORENCE (413)530-4785 O
PROPERTY LOCATION 13 MEADOW AVE
MAP 22B PARCEL 020 001 ZONE URB(IQO)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATO ECK
I'SINCLOSED EQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildine Permit Filled out
Fee Paid
TypeofConstruction: RENO OF ENTIRE STRUCTUA
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Buildin¢Plans Included:
Owner/Statement or License 107699
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project Site Plan AND/OR Special Permit With Site Plan
Major Projece 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
Demolition Delay
-- 5- WIq
Signafilre of Budding 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.
Department use only
-- City of Northampton Stahre of Permit:
..> Building Department Curb CuVDdveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/WellAvailability
Northampton, MA 01060 Two Sets of Stnx:turai Plans
phone 413-587-1240 Fax 413-587-1272 Pwsite Plans
Dow spec y
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Ave Map Ia - Lot �n Unit
Fla•,mcf tJAA 01062 Zone Overlay District
l�/04 �.y rYlR le Yvt�r CO WI Elm SL District CO District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Torp we 1"� l`itdot., Aze FloveitC
Name(Print) �\-c\ Current Mailing Address: q( 7 7 7 e G777
Telephone
Signature
2.2 Authorized� AceAgent:{
I oURIAS 7ha t, P0 fiq SO L2,2 Fly-eftce
�Name(P' Current Mailing Address:
G� v«- 930 - VIL5
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Building ) 90 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
30 Construction Iran B
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) ')�
5. Fire Protection IO
8. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Dale
Building Pa" Num r: Issued: ry p
Signature: �' -I zo I
Building Commissionedinsltector 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 he fi11M in by
Building Dapamnent
Lot Size 141
Frontage F1P Loi
Setbacks Front
Side L:-R:- L: R:
Rear
Building Height
Bldg.Square Footage 1`� % 1-107
Open Space Footage °k
d,m area minus bldg&paved
parking)
#of Fiarki ng Spaces
Fill:
volume&location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page ��ffffand/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 9 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
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(clearing,grading,�excavation,or filling)over 7 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO t
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION&DESCRIPTION OF PROPOSED WORK(check all apolicabiel
New House ❑ Addition FReplacemen,
Wlndowa Alteration(s) ❑ Roofing ❑
oorsOAccessory Bldg. ❑ Demolition ❑ Signs [0] Decks IQ Siding[a] Other[In
Work ascription of Proposed R�raa 1TON OT Cn���/� S�yRC Ra.�C
Alteration of existing bedroom_Yes—L No Adding new bedroom A—Yes No
Attached Narrative Renovating unfinished basement _Yes --)L—No
Plans Attached Roll -Sheet
so.If New house and or addition to exlstlna housing,complete the fo[lowina:
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? �J In_
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? r O(S
I. Method of heating? —dVtf Ire f %. OL !t J Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction V001 YBot
L Is construction within 100 ft.of wetlands?_Yes k No. Is construction within 100 yr. floodplain_Yes_XNo
1
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? --%,_Yes N\o..
I. Septic Tank City Sewer_ Private well City water Supply JL
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN TT
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 70 N; I htk k ,as Owner of the subject
property
hereby authorize R
to act on my be g,in all dgitters r tivp to wo authonz by this building permit so lication.
1II(1 5
signature of Omer Date T
I, 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 ur er the p ins and pen as of perjury.
a
Ptlnt Nama U Sill
Signature of OAVRIA6ent le
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: TI I. Not Applicable ❑
Name of Lloenae Holder: k10U4�Q S 1 "u�t'Y CS — 10769or
Q— License Number
e r0lo7/2 0
Add Eviration Date
n11�1/l y13 Sad- 97S r
Sign�� Telephone
9.Registered Home Inumvement Cordrodar: Not Applicable ElC64)ler -1hy J-7`30 ;3
Company Name Registration Number
Pat.()
Address 6cP.r./,. Date
Telephone
SECTION iP 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...... ❑
S\5 S'C
[ ldassachusetts
® c
V� s
I n&PHR141ENT OB BUILDING INSPECTZOPa i
\ 212 Mein attest . Municipal Building
Noithevpton, !A 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pm-existing owner- upend building containing
at least one but not more than four dwelling units .orto structures which are adjacent to such residence or building"be
done by registered contractors.
Note.Ijthe homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: Est.Cost:
Address of Work:
Date of Permit Application:
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 owneroccupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBD.ITES 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
i
-•" Maseachuaetta
x
DBPATiTMENT OF BOILOING INSPECTIONS Z n
212 Nein Sheat • Municipal ecildin c
\,;, NoxV,amp[on, M 01060
Massachusetts Residential Building Code
Section 110.R5.1.2
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.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Oficial, 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.
Massachusetts
I nspaa2aaM1' or eaianixc ixseecrroirs
212 Main Street •Municipal Building i CA
Northampton, MA 01060 rah `o
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�e number and street ria me)
Is to,be disposed of at:
I gopc,jlk COC
(PI ase print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
,4MI0(fS �- �VkCICtrLY
(Company Name and Address)
��.
Signature mit 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
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
W],edrigers'Compeureation Insurance Affidavit:Builders/Contmctors/Electricians/Plumbem
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leuibly
Narne(Business/Organiz iooWIndividual): / t1` �{ 4C
2S Iha
Address: PL) l7l� ( Q
City/State/Zip: F E'V Phone#:
Are you an employer?Check the a r raprlate box: Type of project(required):
I.[]I see a employer with employees(full and/or prt-time).• 7. ❑New construction
I am a sole proprietor or part.rsup and have an employees working be=in g,CIRemodeling
purity.INo workers'romp.imwmce required.] V�U'�DB
3.M I an a homeowner doing at work myself[No workers'comp.insurance required]t 1 Building
10 Building addition
4.M I an homwwner and will be hiring wohacbrs m rorMuet all workce or property. ]will
ensure that all contractors either have workers'wmperusatiance
insuroron are sole 1 I.Q Electrical repairs or additions
proprietors wim m employ.,. 12.❑Plumbing repairs or additions
5.[]1 ane ge unal wntracmr and I have hired the subcontractors listed on the anuched sheet. 13.❑Roof repairs
These sub-coMrectors have employ.,and have wmkers'comp.ins....
6.[:1 We arc a weromfion and las officers heveexercised their right of exemption per MGL c 14.❑Other
152,§I(4),and we have or employees.[No workers'comp.insurance required]
'Any applicant and cheeks box 41 most also fill out the section below,slowing their workers'competes&ion policy orientation.
I Homro.who submit this affidavit indicating on,are doing ell work arM then hire outside contractors must submit a new affidavit indicating such.
tCo,mmtors that check Nis box mum anointed an additional,hent showing the name of the sub-contractors and state whether or not those enfities have
employees. If the sub-contractors have employees,they must provide then workers'comp.policy number.
I am m employer that is providing workers'compensation insurmee far 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 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.
/do hereby cerJciy�� [)Ike pains andpertohiea•ofperjury that the Information provided ba is true and entree.
Sianffiure; sz; 1 /� Date �5/
Phone#
official use only. Do not write in this area,to be completed by city or town OBIctaL
City or Town: PermittLicense#
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#:
GITY OF NORTHAMPTON
BUILDING DEPARTMENT
These plans have been reviewed
And approved. w r-rK tivTEs
Date 5- q- ZDia
174 / /J
172.85 1/50.26 2 Signature l�
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