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31A-142 (4) 36FORBESAVE BP-2019-1286 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A- 142 CITY OF NORTHAMPTON Lot:-001 PERSONS CON7RACIING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permitil BP-2019-1286 Project il JS-2019-002078 Est.Cost: $141855.00 Fee: S922.00 PERMISSION IS HEREBY GRANTED TO. Const.Class: Contractor. License: Use Grow JAMES PHANEUF 011632 Lot Size(sa.ft.): 6926.04 Owner: CZAPLINSKI MATT Zoning: URB(100)/ Applicant: JAMES PHANEUF AT. 36 FORBES AVE Applicant Address: Phone: Insurance: 74 Old Stage Rd (413)247-9993 W HATFIELDMA01088 ISSUED ON.5124/2019 0:00.00 TO PERFORM THE FOLLOWING WORK:ADD MUDROOM TO REAR, RENO KITCHEN 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 il Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Depertme[ Firephtce/Chimuey: Rough: On: 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: 17"Type: Date Paid: Amount: Building 5/2420190:00:00 $922.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Pile Al BP$019+1286 APPLICANT/CONTACT PERSON JAMES PHANEUF ADDRESS/PHONE 74 Old Stage Rd W HATFIELD (413)2474993 'G PROPERTY LOCATION 36 FORBES AVE M"!LA 2AULL JAZA01 ZONE URBf M THIS SECTION FOR OFFICIAL.USE ONLY: PERMIT APPLICATION CHECKLISZONING FORM FILLED OUT T ENCLOSED QUIRED DATE Fee Paid An N Building Permit Filledt Fee P ' Tvneof Construction, AD R M TO REAR. RENO KITCTIEN Now Construction _ —Non Structural interior renovations Addition to Existina __Accessory Structure Building Plans Included: Owner/Statement or License 011632 3 sees of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: ✓Approved_Additional permits required(see below) PLANNBVG BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OA Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Spacial Permit Variance- Received&Recorded at Registry of Deeds Pmof 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 Penril DPW Storm Water Management Demolition Delay 5-Z3 Za9 Signafmc 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 of MGL 40A,Contact Office of Planning&Development for more information. n � City of Northam ton stews uPerm '4+I ' I Building Depart ent MAY ) q 212 Main SIT at ckeos� tau �a�lagrty _ _ Room 10 Northampton, 01dgjj�O9TnUILDMCIN �'e+or6 tlg of actural plays phone 413-587-1240 Fax - - rON ` _. 4 - APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION _ 1.1 Property Address This sect on.to be completedd by oH¢e l ,36 T Qir-os AVE' M.P int %e7 r unt -- L��{H ' I Zone Overlay D,stri,t Elms ostrd cecsmr _ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: CSL trlsL) 36 Farcr,�s AX Nam P J Cunard Mallrg Address: 4TelaDhena S nature 2.2 Authorized Aaent TAnt�-S 7 � a�D sips, �D w, urs Name(PMD 4� Current Maiflng Address: p Signature P� Telephone SECTION 3-ESTIMATED CONSTRUCTION COTS Item Estimated Cost(Dollars)to be _ Official Use Only ' completed bpermit applicant 1. Building ' ( p �j (a)Building Permit Fee - - 2. EleUflcal 1 (b)Estimated Totalcost of r Construction from 6 ' - r 1 S 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) �� 5.Fire Pretection 6. Total=(1 +2+3+4+5) 14-1 $,S Check Number This Section For Official Use Only Date Building Permit Number, Issued, - Q Signature: Building Commissioner/Inspector of Buildings. gate �Ma1l ��anvu�dim �� rvucAQ, CA-M 7 Sectlon4. ZONING All lnformatbn AW#Be Completed. Pamir Can Be Denied We To Incomplete Information Existing Proposed Required by Zoning This colwm to be SBM in by EmMiny Deparmnmr Lot Size 0 0 Frontage Setbacks Front FM ��-�--}}�� r--��{{ O Side L:LI y 1 R:Ql L:�O/I Rr Rear ® Building Height Bldg.Square Footage ® Open Sp Coram comace bI4,&a O X ,a_—�. O O ( m Ndg&pavd Ion #of Par S aces Fill: -- v 1.&Iasaion A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO © DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the pennit recorded at the Registry of Deeds? NO © DONT KNOW YES IF YES: enter Book I Pagel and/or Document#� B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained © , Date Issued: C. Do any signs exist on the property? YES © NO E) IF YES, describe size,Type and location: T� D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or Is it pad of a common plan that will disturb over 1 acre? YES © NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. • t SECTION 5.DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Replacement Windows Alteragon(s) ❑ Roofing Or Doom O AccessoryBldg. ❑ Demolition ❑ Now Signs [O1 Decks [M Siding 101 Otner101 Brief Description of Proposed Work: AVD Ik.LA24*4 TV "AP—I TZ6 K O It I TZ I4r,nI Alteration of existing bedroom_Yes / No Adding new bedroom Yes k' No Attached Narrative Renovating unfinished basement Yes Nc Plans Attached Roll -Sheet ✓ Ga. if New house and-or-ddition fo existing housing. complete the following a. Use of building:One Family V Two Family Other b. Number of rooms in each family unit: Number of Bathrooms •.S c. Is there a garage attached? Ah) p- f d. Proposed Square footage of new construction. C) s YQ/ Dimensions C e. Number of stories? I I. Method of heating? PH ft Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? It. Type ofoonstruction Wbly FRA(4 r I .O i. Is construction within IODR ofN wetlands? U Yes _No. Is construction within 100 yr. floodplain � Yes_No - j. Depth of basement or cellar floor below finished grade AIA_ Pl5a k. Will building conform to the Building and Zoning regulations? Yes—No. I. Septic Tank_ City Sewer V 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 here b u on to a behalf,1all mat re lab"to work authorized by this building pe it a lirabon. 9 Sig re c Owner Da 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 unpains and penalties of perjury. der the Print Name •L.Jt d Signatureol Owner/Ag nl Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor l/�l, r� Not Applicable Name of License Holder: UA�Q�' 'V"�1��"'�7. License Number ?� 0LI> STAc>� V4> w, HATfIr.(,D dl ( 63� Address Expiration Date Signature Telephone ' 13 tl2-O (� X4-7 , T29 --2, 1 dim mveidCCoh")1a r"ra..h* n ` " .^C+' Not Applicable £ rb6ltFs `�bdA-r)'riLt�' Company Name r Registration Number 1a�- z.oq Address STelephone Expiration �1 iratio/n Da/(e a � SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT Ill c.162,§28C(6)) 111 666 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...... £ 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 hive 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 srmcmres.A person who constructs more than one he.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 buildipe permit. As acting Construction Supervisor yew 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 Gable for person(s) you hue 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, The Commonwealth of MassachuseBs Department of IndustrialAceidents I Congress Street,Suite 100 Boston,MA 02114-1017 wtvw.massgovildia WWorkers'Compensation Insurance Affidavit:Builders/Contmetors/Electricians/Plumbers. 1'0 BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information �'f� Please Print Le ibl Name(Bminess/Ofl;aairatimAndividuai: r7lY Address: -7 Y V"� S 7 City/State/Zip: Phone#: P'Y7 9 q !qy An you to emplo erT Cheek roe appropriate Eos: 7. [ ofproject(required): I �lem aemploym wiM employees(full and/orpm-timek' 7, N construction 2 lamawleprapdemrmpatmetshipmd Wwwcmplo mking formeM 8. Remodeling / 'sur,capacity.[Nomrken'camp insurance minuet 3.l am a hommwnerdoing all mh myself[No workers'comp.iinwancereq out]t 9. ❑Demolition 4.❑Ires.homeowmr wit will be hiring cantmewrs to coMuct all work on no property. Iwill 10 Building addition emure wan WI conoxiots either love wmkms•mmpeimaon imuranm mare sole 11.❑Electrical repairs or additions proprietors with no employee. 12.❑Plumbing repairs or additions 5.[3 I sm u gerami convector am i have hired thesubconuacton listedon the amched sheer 13.[:]Roofmpairs Thew submme ctom have employees aM have workers'romp.imomnce s 6[]W. 14.❑Other Iszre(41 and we have an employes.[No woken comp imwmes,minima.l 'Any applicant that checks box#1 must now fill out the section below showing Meir workeri mmpensation policy information. t Homeowners who submit this affnavit indicating they are doing all work and Mm hire outside consumers moat submit a new affidavit indicating such. :Connecmrs list check this box must menchel m additional Am showing the name of the sul contmnors and sow whither or not Mose entities have employees. If ds subcanuamors have empoyeca,Mry must Provide Then woMrs'amn0.policy number. I am an employer that is providing workers'compensalion insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Polity#or Self-ins.Lic.#: Expiration Date: Job She 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. I do hereby reedfyyn rthepdns dpen n a ofperjury the the hit rmationprovided stove`!is ue andcorrect. Signature, l/ / n�"r`'J/, q Date: ? W!? - Phone#' /s"e 7— !�Z Official use only. Do not write in this area,to he completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/fawn Clerk 4.Electrical Inspector 5. Plumbing Inspector b.Other Contact Person: Phone#: 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 AA- The MGL c 111, S 150A. Address of the work: 3 C �()1�debris will be transported by: U rQ. W ( { & The debris will be received by: Odd.... IC...u.Yc. Building permit number: Name of Permit Applicant Y1�f S `�►�iy►� S 1tP f Date gnature of Permi pplicant - „ti ,C6 if�O1710 1j L - - - l�mt� b0 - - 00 - I i e � . 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