36-215 (2) 20 BIRCH LN BP-2017-0335
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:36-215 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath reno BUILDING PERMIT
Penna# BP-2017-0335
Project JS-2017-000549
Est.Cost:$37000.00
Fee: $259.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouo: SOUP TO NUTS CONSTRUCTION CORP 004599
Lot Size(s9.ft.): 60112.80 Owner: MALEK THADDEUS B&EUGENIE A
Zoning: Applicant: SOUP TO NUTS CONSTRUCTION CORP
AT: 20 BIRCH LN
Applicant Address: Phone: Insurance:
10 MCKINLEY AVE (413) 527-5359 Liability
EASTHAMPTONMA01027 ISSUED ON:9/14/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:RECONFIGURE EXISTING MASTER
BATHROOM
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 9/14/2016 0:00:00 $259.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File H BP-2017-0335
APPLICANT/CONTACT PERSON SOUP TO NUTS CONSTRUCTION CORP
ADDRESS/PHONE 10 MCKINLEY AVE EASTHAMPTON (413)527-5359
PROPERTY LOCATION 20 BIRCH LN
MAP 36 PARCEL 215 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyneof Construction: RECONFIGURE EXISTING MASTER BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 004599
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I F 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 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
7/5—lam
Sig' . ire of.uildifig O';cml 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 Status of Permit:
Building Department Curb Cut/Driveway Permit
„j,,;: et 212 Main Street Sewer/Septic Availability
,`.../ \� "sr Room 100 WaterM/ell Availability
v,4 Northampton, MA 01060 Two Sets of Structural Plans_.
e)' `�? phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
o° °r' Other Specify
I LIGATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
N
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit,
2_0 -2> r ac c^t +c sto
f- -SZ. Fes I riFit 0i 0(ci7� Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
o—E. 1 L MALER :LC 1-312CI't 1—ANL rLokE ,44 olof. ,
Name(Print) ma Current Mailing Address:']
\'
/ telephone 3 •
I • • •
Signature
2.2 Authorized Agent: -Cl/ fk1a%. -3 C>� I}`)p MC,KI i.aC£.. i/C-.+
<� .. " rra, k)c>i,l OklYrri ,kJ E� `tk-NnA)-foi. [✓'eft 0lot 7
Name("• Current Mailing Address:
i
qt3 `1 c7ricf
ignamre ,-11/ Telephone
ZT ...
ION 3 STIMATED C i NST:' ON COSTS
Hem Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection (7
6. Total=(1 +2+3+4+5) `z, OCZ..>. Lk, Check Number It 25 j
This Section For Official Use Only
Building Permit Number: Date
al etl:
Signature:
Building Commissioner/Inspector of Buiklings Date
Z ink. L_ JrS Se'1L 25ACJarr(ia,c-, - e_0(4
Section 4. ZONING AU 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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %o
Open Space Footage `Xu
(Lot area minus bldg&paved
parking) ___...
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW O YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds? /"�
NO O DONT KNOW O YES 0
IF YES: enter Book Page and/or Document k
B. Does the site contain a brook, body of water or wetlands? NO O 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 l..J , Date Issued:
C. Do any signs exist on the property? YES O NO CO
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 filing)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House I I Addition ❑ Replacement Windows Atteration(s) Roofing n
El
Or Doors 0
Accessory Bldg. Demolition ❑ New Signs [p] Decks [0 Siding fl] Other[p
Brief Descripti n of Proposed
Work: F- CJN ILcd1.5— 4xtsc/.,y- (k tit ?Krtt2uo'
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 Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes_No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
,K I. CU G E N I L' / PL ,4 t k , as Owner ofthe subject
property /
hereby authorize Soul' 1-C !� U S C01U S T--c? U C- OA/
to act on my beha 'n all m ers relative to work authorized by this building permit application.
9
Signature of Owner Date
I, 4,1, 1S , Ca: 'S001? k)l 7fSI ciIUtT/Ztcci>si , as Owner/Authorized
Agent hereby declare that the stt ments 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-
1J - �0,�
Printar-
Q z, TOIL
Signature of 0 er/Agent \ Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
.t p
Name of License lblder' ftN �. --16,1 Cl - OOUy--s
real
C License N tuber
b fi I(. IN(Y, II'r.. � Ell\-1l-0(1A rOY-) �Ifc 0(CRL7 c I (rC'i / Z c�(Y.
Add - Expiration Date
1-113 53g --CYTH,
S'e . are Telephone
9. - - .• Home Impro - ent Contractor: Not Applicable 0
�biaN 3 . "1'5;A 12.3644
Company Name /+ Registra'on Nu ber
r - K31.-At I rrirr� ccioJ 3/L8 /20i7
Address <I �^ �, \ (+ Expiradddon Date
)1/4_, N�y/ \L , C ksTKIVa.r7lQ(Telephone4 t s 073
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 B No 0
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 hire who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 10835.1.
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 shah 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 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.
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 Massachusetts
Department of industrial Accidents
Office of Investigations
l Congress Street,Suite 100
Boston,MA 0211 4-2 01 7
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Please Print Legibly
Name (Business/Org(anization/Individual): �(yq 9c) tiers ezi- -rrrco rtc*J
Address: )D J �� K i LI1 p A ,
City/State/Zip: iiatkF1 y., I . 0 2:7 Phone#: l — _ —673
Are you an employer?Check the app}opr ate box:
Type of project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.0 I am a sole proprietor or listed on the attached sheet. 7. ® Remodeling
partner-
shipand have no employees These sub-contractors have g
❑ Demolition
working for me in any capacity. employees and have workers'
comp. insurance. 9. 0 Building addition
[Noworkers' comp. insurance
required.] S. 0 We are a corporation and its I0.0 Electrical repairs or additions
3.❑ 1 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
y c. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]
employees. [No workers' 13.0 Other _
comp. insurance required.]
*Any applicant that checks box!II must also fill out the section below showing their workers'compensation policy information.
'Homeowners 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 art employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: -.I 14Gyn'�r-Ltxt--•
Policy#or Self-ins. Lic. #: 1 1, 54 B/Bc(r. (fig Expiration Date: 1 3 /-7
G
Job Site Address: City/State/ZipLca,25.i.LF.) (4A �J I(34,
t-
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.
do hereby ce an, e pains and pen• f of perjury that the information provided ab ve is a and correct.
$imature: Date: 9�r z�-u'tCo
Phone#: 4 iq ` a
Official use o I t not write in • a,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 S.Plumbing Inspector
6.Other
Contact Person: Phone#:
ACRO CERTIFICATE OF LIABILITY INSURANCE ns61o' 6' T Rd CERTIFICATE OF LIABILITY INSURANCE �wsolTe r
THIS CERTIEICATE IS Losueo AS A morrEn OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MOLDER THIS THIS ceonnorn IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO ROOTS UPON TME CERRFIGATE HOLDER.THIS
POUCIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN TME ISSUING INSURCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE ER S,TAUTHORlzEo DOGGIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY A CONTRACT BETWEEN THE ISSUING INSUEXTEND OR ALTER THE COVERAGE RER),AUTHO AUTHORIZED
REPRESENTATIVE CC IMPORTANT. X Its GAMS.%rU PRODUCER,AND nHE nAOOIRiNAL INH0.DERI REPRESENTATIVE OR PRODUCER,p0RIiI Aww.nwmmtIT SUBROGATION m.SUBRlOGATIN IS WAIVED,IVJ dIto Rader ADDITIONAL INSUND THE CERTIFICATE RED,the ISISb anions*
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INDICATED NOTAATHSTANDI NO ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED NOIVAIN9TANOIND ANY AREA EuENr TERM of CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO IAHICH THIS
CEA INSURANCE AFFORDED BY THE POLICIES xTERMSKATE MAY PERTAIN THE INSURANCEu eS DESCRIBEDHEREIN IS SUBJECT
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City of Northampton
Bnilding:epartment
EXISTING EXISTING Plan Review
212 AlOn Street
BEDROOM BEDROOM Northamp , MA 0106)
O L� _ O O
41 ci
CL EXISTING CL MODIFIED
MASTER BATH 13'-8" MASTER BATH
13'-8'
[ o i
CL
Ko
a -___A
SHOWER SHOWER
Lr0 \ o
12'-9" 12'-9"
EXISTING EXISTING
STORAGE STORAGE
EXISTING BATH BATH REMODEL:
ADD CLOSET
EXPAND SHOWER
EXPAND VANITY WALL
INSULATE NEW WALLS
BATH REMODEL
JOY/MALEK, 20 BIRCH LANE, FLORENCE MA 413 539-0734
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:
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
City of Northampton 212 Main Street, Northampton, MA 91060
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: 20-0 r F ' F _: 2. 1)%
The debris will be transported by: W s Ck1.cH—TEAi{„tiV
The debris will be received by: F26 le&A�c r „ C- iv »F.4>%_-
Building permit number
� n
Name of Permit Applicant
D. e 9 l4, 2x d< Signatur-/f P-rmit Applicant