25-055 (5) 17 CROSS PATH RD BP-2020-1207
GIS#: COMMONWEALTH.OF MASSACHUSETTS
Map:Block:25-055 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2020-1207
Project# JS-2020-002028
Est.Cost: $5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use croup: Homeowner as Contractor
Lot Size(sq.ft.): 12501.72 Owner. FOURNIER JARED
Zoning: Applicant: FOURNIER JARED
AT: 17 CROSS PATH RD
Applicant Address: Phone: Insurance:
21 CROSS PATH RD (413) 210-7304 ()
NORTHAMPTONMA01060 ISSUED ON:7/20/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-EXPANDING KITCHEN 80 SQ FT ALSO 64 SQ FT
TO EXISTING ENCLOSED PORCH
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 7/20/2020 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2020-1207
APPLICANT/CONTACT PERSON FOURNIER JARED
ADDRESS/PHONE 21 CROSS PATH RD NORTHAMPTON (413)210-7304 Q
PROPERTY LOCATION 17 CROSS PATH RD
MAP 25 PARCEL 055 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT le
Fee Paid
Building Permit Filled out Ly
Fee Paid
Typeof Construction: EXPANDING KITCHEN 80 SQ FT ALSO 64 SO FT TO EXISTING ENCLOSED PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
/Af
/Z --7--_[7
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 of MGL 40A.Contact Office of
Planning&Development for more information.
City of Northampton
^' Northam tor
Building Department
w' l
}ti ri:
rix r 212 Main Street $eiwleptEc Avallbliity ti" ......
' L..
Room 100 '�
V,� mdvl�eFp ws�"ry
�� i1 w4� W %T��Vrrrl�,Illy v 1v .� ?1�i�1,1;
Northampton, MA 01 ,, ! "" tiStrtt 19ttAM?1
Phone 413-587-1240 Fax 413= 112,72
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVAtr;0 DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thi ion to be completed b�
y office1.1 Pr a Addr s6: 011 0104-S pucCAdGO MeP Lot Unit
Zone Overlay District
Elm St District
COI)i4trict
SECTION 2•PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Ownof Record. �-
reJ -lroc��' I Gloss
�N,ame(Ar t) Current Malling Address,
O�7 V
Telephone
Sigr4113-e
2.2 Authorized Agent:
Name(Print) Current Mailing Address,
Signature Telephone
SECTION 3-ESTIMATED CON TRUCTION GOSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building dam (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing --7
Building permit Foo
4. Mechanical(HVAC)
S. l=ire Protection 7
6. Total=(1 +2+3+4+5) D Check Number
action For Official Use Only
Building Permit Number; Date
Issued:
Signature: !�f 7. /'7.-
Building
.7-Building Commissionedi nspector of Buildings 1 , Date
�X�00c-vl K@ �vv_%
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
1'000/T000z tO9 03 STddnS aolovaL 99LLLZ9CTf ZYd HY OT:9 OZOZ/9T/90
Section 4. ZONING Ali Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
niis column to be filled in by
Building Departincilt
LOt Si7e
Frontage
..................
SetbacksFront
Side R:
Rear C
BuiIding 11 ight
Bldg.Square
Open Space Footage . ..... %
(Lot arov minun bldg&pave(i . ...........
parking)
#of Parking SRaces
Fill:
(volunic&JAx
A. Has a SpPcIal Permit/Variance/Finding ever been issued for/on the site?
NO t& DONT KNOW 0 YES 0
IF YES, date issued:F'—
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
i.. . ...................
IF YES: enter Book t Pagei -
and/or Document#[ -
............... .... .............
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained0 Obtained 0 Date Issued:
............ .....-J
C. Do any signs exist on the property? YES NO 1(7)
0
IF YES, describe size, type and location:
.......... .... ....
D. Are there any proposed changes to or additions of si R n s i n ten d e d for r the property? YES 0 NO
.............
IF YES, describe size, type and location: . ...
E. Will the construction activity disturb(cloaring,grading,expavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acro? YES 0 NO %
IF YES,then a Northampton Storm Water Management Permit from the DPW Is required,
f000/z000[n f 0 OD STddns jolovjj, 99LLLZ9CTf XVJ KV TT:9 OZOZ/9T/5()
CTI N 5-n gt'R(PTION OF pmOMED WORK fchack ai!anpllcablel
New House Addition Replacement Windows Alterations) 7R0C)flng
Or Doors d
Accessory Bldg, d Demolition t_I New Signs [ice] Decks
(Q Siding J�], Other[�
K
Brief Descri tion f Propod 1
��d
Work: '
Alteration of existing bedroom yes
Attached Narrative -_4k4 No Adding new bedroom Yes ,No
Renovating unfinished ba
Plans Attached Roll -Sheet sement Yes No
6r�, if flew":'�ouee,;end'oar'addifiion to"eXIMi�9::h'oii6160,come.Tete fte 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? &-Q -
d. Proposed Square footage of new construction- Dimensions x C) )L /
e. Number of stories?
f. Method of heating? t �� Fireplaces or Woodstoves
Number of each
g. Energy ConservationComplia a. /V 7� _Masscheck Energy Compliance form attached?
h. Type of construction
i- Is construction within 100 ft- of wetlands? Yes —G�—No. Is construction within 100 yr. floodplain_YesNo
j. Depth of basement or collar floor below finished grade /
k. Will building conform to the Building and Zoning regulations? • Yes No.
I. Septic Tank A,— City Sewer /W Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, � �) TCS
property as Owner of the subject
hereby authorize
to act on my beh If, in al att relative to work authorized by this building permit application.
Siflneture of w r41
Date
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,
� (-A - �1't t�G{'�`
Print Name
Si naluro of O r/A onl /�o
Date
fi000/m0ln fi09 OD TddnS JoaDeal 99LLLZ9CTfi YVi KV TT:9 0ZOZ/9T/90
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensod Corl9truGtion, L oryl9or:
Not Applicable
t�lrr►D of Llcon6Q Holder:
Lleense Number
I
Address
piratlon Oato
Slgnaturo
ExTel hone
.rG,. ,:. ,.. ...... Not Applicable
Company Name
Registration Number
Address
Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§25C(6))
Workerson. Failure to provide this
Compensation Insurance affidavit must be Completed and submitted with this applicatiaffidavit will result
In thepf the issuance o
denial f the building permit.
Signed Affidavit Attached Yes..,•,., Q Na
fi000/t'000ln tog OD .11ddnS ,101013.11 99LLLZ M YVd WY ZT:9 OZOZ/9T/50
'`�`. E .�partrt�ettt-usg_ottly
City of Northampton
Building Department
P + € ;Curd Ct°i�c3vt�w,+v•�'Hrmit,
212 Main Street
( valalll
t t
Room 100 ~., VV r11h�elt kvatiabitity
Northampton, MA D( 3�. �T ?Cats cftr r .ura!Plane
Phone 413-587-1240 Pax 41:5= Mr 2 0}ot sits plans
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENUV O�2 DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1,1 Pra2tq Addrkss: 1 _(�'0 Q� .�5 �' This,604:ton to be completed by office
/A) /"! Map ." Lot: Unita.
Zone Overlsy District
Elm St Dlvrict Ca DIfirtrict
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Qwnerof Rec r
Name(Pr t) Current Mailing address,
_. �. -7
Ssgr t e
Telephone
2.2 Authorized Atom:
Name{Prl�t) Current Melling Addrew
SGgnature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item ]estimated Crest(Dollars)to be Official Use Only
eom Ietod bypermit applicant
1. Building
2 V (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
J Construction from
8. Plumbing -7
Building Permitlees
4. mechanical(HVAC)
S.Fire Protection 1VIi�
6. Total=(i +2+3 Check Number
This Section For Official Use Orel
Building Permit Number: Date
Issued:
Signature:
Building Comrmissionertinspector of Buildings, Date
EMAIL ADDRESS (REQUIRED, EITHER HOMEOWNER OR CONTRACTOR)
F004'TOOt)i T09 U -iTdd11S 1010ell 99LLL99CTf XF3 ;iV OT:S OZ09•'8T'�O
Seaton 4, ZONING All infprrnaiton Must Bc Contpietcd.Permit Can Be Denied Due To incomplete information
Existing Proposed Required by Toning
This column to be Aitt+ti in by
Building[kptutnrcnt
l,,ot size _.
Frontage
Setbacks
Frrsrtt
Side t
f 4 �`
R:
Real
Building Height X
t
Bldg.Square Footage °!n
open Space Footage ( ora qq
(Lat era+minus bldg&Paved
parkin
y
#of Parking Space,,
Fill:
(Yt)lnMC int.IA)=ipn
A. Has a Spvcfat Permitfbariance/Finding ever been issued forfon the site?
NO DONT KNOW 0 YES 0
IF YES,date issued: _...___
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enterbook 1
x Page,d � and/or Document#;!
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0
Date Issued: i m�
C. Do any signs exist on the property? YES NO 9
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO v
IF YES, describe
I—.
size, type and location: I
s
E. Will the construebon activity disturb(ctoaring,grading,excavation,or filling)over t acre or is it part of a common plan
that Will disturb over 1 acro? YES 0 NO 6k
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
t0o0iZ0000 tog OD STddnS 102091y 99LLLZ9CTf lYd Its% TT:9 0Z0Z/9T S0
S=Tl PROPOSED WORK(cheek AM2LJcabft)
New House F-1 Addttlo,
tZ PoPlacerritint!Windows Alteration{s} F-1 Roofing
Or Doom r71
Accessory Bldg. D Demolition C New Signs f0j Docks 1EM Siding P� Other(CX
Brief Descri tion f�Propoq.^A
Work:- V!
41
Alteration of existing bedroom_yet; No Adding now bedroom yes
Attached Narrative ---'ZN0
Plans Attach"Roll -Sheet Renovating unfinished ba-"—ment _yes t-4'—No
640f-9iWh' 44":'A11id'1*-lr4 IdKon lhi f6116i4l!j4.
a, Use of building:One Family Two Family_Other
b- Number of rooms in each family unit:--9— Number of Bathrooms
c. Is there a garage attached?
W
A
d. Proposed Square footage of new construction,-
e . I �i� 4,4—Dimensions
. Number of stories? )L
f. Method of heating?AA-"'i,'kfX X'I Fireplaces or Woodstoves Number of each
g, Energy Conservation Compli
A)A MaSSCheCk Energy Compliance form attached?
h. Type of constructioni. : J W,
Is construction within 100 ft.of wetlands? Yos 41-No. Is con3trUCtion within 100 yr. floodplein_Yes
j. DOPth Of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? yes_No.
1. Septic Tank-�L City Sewer A) Private well /
t/13 City water Supply
SECTION 78-OWNER AUT14ORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r, t-')
property as Owner of the subject
hereby authorize
to act on my bel lf,
,in al att rel five to work authorized by this building pemjit application.
Signature of
FQste
as Owner/Authorized
Agent hereby declare that ths statements and info tion on the foregoing appficationare true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of peo-
Print Marne
Signal roof to t Date /�o
row'v000 tog 03 sTddns Jolopli 99LLLZ9VTf XVJ KV TT:9 OZOZ,19T/SO
SECTION 8-CONSTRUCTION SERVICES
8.1 Uconipd Construction Supervisor- Not Applicable
ftw*of Uconcs Hottis+r
UCense Number
Address Expiration Onto �
J ff
Signature Te hone
9 Rs�lcserrad Heine lriiareveiRtet<#Cciti7i+Ctor' Not Applicable
Cornpanv Name Registration Number
Address Expiration Date
Telephone
SECTION 16-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152,§25C(6p
Workers Compensation insurance affidavit must be completed and submitted with this application.Failure to provido this affidavit will result
In the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... O No—...
fi000%f 000
1-09 Q STddnS J030 JL 89LLLZ9f:Tf yvj K' ZT:9 0Z0Z/9T/S0
Z i
RECEIVES
f
2020
DEPT-OF SUILDINr INSPECTIONS
NORTHAMPTON.PAA 0105
IIL
i
i
�fu
l CSS a \V\
City of Northampton
Massachusetts .. f{
F DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building
Northampton, MA 01060 �sdw•• ���3
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 constructi`on11 work being performed at:
- ;�l(Please print house number and street name)
Is to be disposed of at:
VCA�� RRLN/ C I f—
(Please rint name and I cation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
;ganaturoPermit 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.
City of Northampton
Massachusetts �ss s'Q f{�
DEPARTMENT OF BUILDING INSPECTIONS a
1
212 Main Street • Municipal Building '. tr
'� Northampton, MA 01060ryr its
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 pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the 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): T'�° f�`'��W )dLm wor[`
Building not owner-occupied
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 RESPONSIBILITES 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 ow r f the above property:
Date Owner Name and Signature
The Commonwealth of Massachusetts
= Department of Industrial Accidents
a I Congress Street, Suite 100
tw Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Avililicant Information Please Print Le ibl
Name (Business/Organization/Individual): �[-ox 44eX d jm 1 e c
Address: a 1
City/State/Zip:1U4;nvt A,4 C LQ(20 Phone #: ly —7 3 a9
Are you an employer?Check the appropriate box: Type of project(required):
1.[]I am a employer with employees(full and/or part-time).* 7. ❑ New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
3.��,[am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
— a 10 64Building addition
4.❑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 11.❑Electrical repairs or additions
proprietors with no employees.
12.F]Plumbing repairs or additions
5.[]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 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.Lic.#: 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.
l do hereby c fy un er a pains and penalties ofperjury that the information provided above is trues and correct.
Si ature• Date:
Phone#: L` 1
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#:
O(0k
x
..t r
77,