31B-200 3 G
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 by MGL c 111, S 150A.
Address of the work: / LkelShaW AV-C_ N rfi-,W&l'
The debris will be transported by: `lconS�r�r�t0/�
The debris will be received by:
Building permit number:
Name of Permit Applicant '
- `�-'�_
.r-
Date Sign-at re of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
x 600 Washington Street
r Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information S M� e� Please Print Legibly
Name (Business/Organization/Individual): Z�Y C�/� S��"!/iGJ�IO/1 �4 4.4 G
Address:
City/State/Zip: LOA 01149k Phone#: q13
Are you an employer? Check the appropriate box: Type of project(required):
1 I am a employer with 4. E] I am a general contractor and I
6. F-1 New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g, E]Demolition
working for me in any capacity. employees and have workers' 9 0 Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. F-1 We are:a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers'
13.F1 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors 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. ,,f
Insurance Company Name: i'G C% - C
Policy#or Self-ins. Lic.#: Expiration Date: w
Job Site Address: 2/ 5&yV Ay(/I 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 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 a STOP WORK ORDER and a fine
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 r ' under pains andpenalties ofperjury that the information provided above is true and correct.
Sign afore: Date:
Phone#:
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#:
SECTION 87 CONSTRUCTION SERVICES
8.1 Licensed Construction.Auoerviso, Not Applicable £
Name of License Holder:
License Number
Add O/ Expiration Date
3 o V7 72
Si nature Telephone 1112612O16--
isfered_Homeam'rove"inept Cont actok Not Applicable £
Company Name Registration Num er
a/1 �D/gyp
Address Exp[ratialh D to
Telephone 7
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....... £ No...... £
11 .� dome OwnerEgenption
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 hire 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
structures.A person who constructs more than one home 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 building per
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.
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,
i
SECTION 5-DESCRIPTION OF PROPOSED WORK{checkaR applicable)
New-House ❑ Addition ❑ Replacement Windows Atteration(s) ❑ Roofing ❑
r or Doors
Accessory Bldg. ❑ Demolition D New Signs 101. Decks [Og Siding IC9] Other JC j
Brief Des f Pro as ,L K L 7-S / e QC� 2C 1J�1
Work: Vv�'�� 3 pnia-cK �c,c.ics wf,�.� 1 pD ✓
Alteration of existing bedroom Yes No Adding new bedroom___ _Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
sad( .I�eii'crtandor- dvi'oi t':ta�exstt�cr os't
a:-6. a6 Mt{t7vi�i�tt
a. Use of building.One Family t/f Two Family Other
b. Numberof rooms In each family unit_ Number of Bathrooms 3 t/2-
c. Is there a garage attached?__ —0
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? 2
f. Method of.heating? 9*040 tam T/S aces or Woodstoves Number of each
g. Energy Conservation Compliance. Masschack Energy Compliance Corm attached?
h. Type of construction
t. Is construction within 900 fL of vmfiands? Yes ZNo. Is construction within 100 yr_ floodplain Yes No
j. Depth of basement or C111121'floor below finished grade :5 k
k. Will building conform to the Building and Zoning regulations? ✓Yes No.
I. Septic Tank City Sewer Private well City water Supply V-1
SECTION 7a-OWNPA AUTF(OR1ZATit)N:-1 O.9E COMPLETED
WHEN
OWNERS�AGE�NsTnOR CONTRACTOR Ai'P�LIESF�1�8U[LDiNG PERMiT .
0, ^ [7R6- �5'ln/7H COLLI ^(::5G as Owner of the subject
property h� e
hereby authorize A�/A(,�-+ CoMo2 Tu')A/ �` �
G
to cQaw behalf,In ail matters relative to work authorized by this building permit application.
Signature ofQvW Date
I, TOto ES as OwneVAuthorized
Agent hereby declare that the statements and informatioA on the foregoing application are true and accurate,to the best of my knowledge
and ballet
Signed underthe palins and penalties of perjury.
P-ti `J
Print Name
Signature of 0wner1Agen Date
JV JLJ:lV LV•.aal J�♦
9 ^
.F
9 ^
3
Section 4. ZONING All Information Must Be Completed.Permit Can Be Dented Due To Incomplete Information
Usting Proposed Required by Zoning
TWs-oolwm to be idled in by
Building Daparun:nt
Lot-Size # ,
Frontage C�7 ! �1
Setbacks Front
Side
Rear
Building Height
Bldr,Square Footage
Open Space Footage �-^�-� {'�� %
(Lotmu rairm bldg&paved
#ofParking Spaces Q `
Fill:
si=c&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on 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 YES 0
—z
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ® YES ,
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q • Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO1
i
IF YES, describe size,type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IFYES, describe size,type and location: ,
E. Will the constntction activitSr disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
thdrvdU disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i�
i
Sts�LSytf IzaVYesTNT. WEzts:14a.m. Uts IS—LUI /3
06 City of Northampton
ra
�
AUG °J Bu ding Department
Ele tric,Pi�mbing&Gas Inspections 212 Main Street
Ncrthampicn, MA 01060 Room 100
Northampton,MA 01060
phone 413-587-1240 Fax 413-587-1272
r
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SiTJNFORMApq
1.1 PmpertjAddress: This ec Avc
SEECTION 2-PROPERTY PMERSHJP%AtJTi;iOKIZED
2.1 Owner of Record: n
Name(Print) Current McMn�Address: I`Z
'—t> 58 !
Tetephone
Signature
2.2 Authorized Aaent: Wc-s—i A M C� _ c e\ 126 'JT 4ol4ftP-tu) MA
Name(Print) Current Mailing Address: QIG?63
€ qj-? 566 2q12-
Signature Telephone
5EC1iO9 3-ESTIMATED CONSTRUCT ICiN COSTS: ;'
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ) 76 C -,(a).euiiding'PepnjtFee'
2. EfecIrlcat / J ..tt)F timatedTotai'Cost of :'
-•Cbnstrirctiao'trorn'16 • •
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.fVre Protection
S. Total=.(1+2+3+4+5) -76 Check Number
This Section Fur'011t05i'Use'Onl
pate
Building Permit-NumlAr issued:
Signature: '
• tiu�ding•Commisstonertirlspecfnr."af Buildings,._" ' . .• ;pau:
,w.
File#BP-2016-0188
APPLICANT/CONTACT PERSON ZAYAC CONSTRUCTION LLC
ADDRESS/PHONE 79 HIGHMEADOW DR WEST SPRINGFIELD01089(413) 896-9346
PROPERTY LOCATION 21 HENSHAW AVE
MAP 31B PARCEL 200 001 ZONE EU(100)/URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: REPLACE DECKING&REPAIR RAILS ON 3 PORCHES
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 074881
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO RMATION PRESENTED:
proved 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
e n ela
Si re of B i ding cial 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.
21 HENSHAW AVE BP-2016-0188
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B-200 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-2016-0188
Project# JS-2016-000317
Est. Cost: $15765.00
Fee: $104.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ZAYAC CONSTRUCTION LLC 074881
Lot Size(sq. ft.): 13590.72 Owner: SMITH COLLEGE OFFICE OF TREASURER
Zoning: EU(100)/URC(100)/ Applicant: ZAYAC CONSTRUCTION LLC
AT. 21 HENSHAW AVE
Applicant Address: Phone: Insurance:
79 HIGHMEADOW DR (413) 896-9346 WC
WEST SPRINGFIELDMA01089 ISSUED ON.811412015 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE DECKING & REPAIR RAILS ON 3
PORCHES
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 8/14/2015 0:00:00 $104.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner