30A-024 (6) 42 LEXINGTON AVE BP-2017-0383
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-024 CITY OF NORTHAMPTON
Hot:-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-2017-0383
Project# JS-2016-002492
Est.Cost:$65000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor License:
.Use Group DOUGLAS GOODNOW 082188
Lot Size(sq. ft.): 10410.84 Owner: Debra Truskinoff
toning:URB(I00# Applicant: DOUGLAS GOODNOW
AT: 42 LEXINGTON AVE
Applicant Address: Phone: Insurance:
225 OLD CHESTERFIELD RD (413) 296-4387
WILLIAMSBURGMA01098-9318 ISSUED ON:4120/2016 0:00:00
TO PERFORM THE FOLLOWING WORK FINISH RENOVATIONS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.F.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: tire Department Fireplace/Chimney:
Rough: 01: 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 9/20/2016 0:00:00 $65-00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0383
APPLICANT/CONTACT PERSON DOUGLAS GOODNOW
ADDRESS/PHONE 225 OLD CHESTERFIELD RD WILLIAMSBURG (413)296-4387
PROPERTY LOCATION 42 LEXINGTON AVE
MAPA PARCEL 024 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Pai(F
Typeof Construction: FINISH RENOVATIONS
New Construction
Non Structural interior renovations
Addition to Exislina
A.cccessory Structure
Building Plans Included:
Owner/Statement or License 082188
3 sets of Plans/Plot Plan
THE FOL ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
dY' Vlay
Sip . . e riding Mich 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 Irons 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 Statusof Permtf�` " "1r`r '_
:uilding Department Curb Cut/DnvewayPermit
/ S 13 AY, 212 Main Street Sewer/SephcAvailablhty
`l. �,��� Room 100 Vdater/We&IAvallabilRy
'D ..:2,2'2, �'` Northampton, MA 01060 Two -Structural Plans
f ps+done 413-587-1240 Fax 413-587-1272 Plot/Site Plans
a oP Other Specify
-P ATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: 4.../(c9Las
\c vO� This section to be completed by office
QVC Map Lot Unit
C-l c-SV a 1J LC 1. .—A
Zone Overlay District
0\OCCO
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner^� of Record:
t �r�
V =Z \�SXAkK\Ur C YV L2XlalltJ Nie oCv -r€ atp,b -u
Name(Print) Current Mailing Address
/ utt3 3O CAFA-1-3
A. / _ amu/ N . . . Telephone
Si na ure / t : y
2.2 Authorized Agent: lap
R f-+:JWk�
1Th- , (702;10130t-,-- Q C10 CNrS,TE.V- 1 1 I a-y cnkoeiC0
Name(Print) Current Mailing Address
3 5y6 gS40I
Signature .p-Ort....--- X11Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by permit applicant
1. Building , ' —lT (a) Building Permit Fee
2. Electrical �y J (b)Estimated Total Cost of
SCDOCD Construction from(6)CCO /`�,
3. Plumbing S Building Permit Fee / 5
4. Mechanical (HVAC) —� 007
5. Fire Protection COO
6. Total=(1 +2+3+4+5) (Ti Check Number C7s,
r7 9y
This Section For Official Use Only
Building Permit Number: Date
Issued.
Signature:
•
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning i
This column to be filled in by
Building Department
Lot Size _...- __ _' L_ _ ._ _-
Frontage i I .
Setbacks Front - _- - '
Side L R:'.-- - —
_
i
Rear i _ii ,___i ___...
Building Height --
Bldg. Square Footage n ------
".----
Open Space Footage % —
(Lot area minus hldg&caved I I ___ I -
parking)
d of Parking Spaces .—._.._ 'I
Fill: I'
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O YES O
IF YES, date issued: i
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book i Page and/or Document #,
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 O , Date Issued:
C. Do any signs exist on the property? YES O NO 0
IF YES, describe size, type and location: L—
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing,grading,excavation,or filling) over 1 acre oris it pad of a common plan
that will disturb over 1 acre? YES O NO O
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 ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks 41Z1 Siding 57:11 Other[01
Brief De cription of Proposed /
Work: \ M± y\\ "Q5l..X' 3evtr"b 3 ^ P-/ - , tog°
Alteration of existing bedroom * Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea. 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
a 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
( --
J'a r . tei- 1'q
.- • ,- as Owner of the subject
grope y
hereby authorize f
to�aacctt)on my behalf, in II mats re alive • +.rk authorized by this building permittaaapplication.
Signature of Owner , Date
I, (C (ha),cc. 1 k„acie;-Z , as Owner/Authorized
Agent hereby declare that the statements an i ormation on the foregoing application a— true and accurate,to the best of my knowledge
and belief.
Signed under the pains an. penalties of perjury.
•nnt Name -
� a�i�
ignature of Owner/Agen ' 0 to
SECTION 8-CONSTRUCTION SERVICES
8'l-Licensed-Construction-Supervisor: --- - --- -- _ - / a NotlApplicable(❑ G�G _
Name of License Holder: MACS V\.tc XD LiO s pr 1] IS
License Number
2AS otd Qt aF,t=. X) Vc7 wa••,*LOSS IAA 10 — kCa, —
Address OAax Expiration Date
eiry(3 C1L-(r7IS leo l
Signet drepp Telephone
Fe3Sarl : ab 90061A. / @ yo-k'0
9.Registered Home Improvement Contractor: Not Applicable ❑
/ 5S4h
Company Name Registration Number
Address Expiration Date
Telephone
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 I .
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 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 permit.
As acting Construction Supervisor your presence on the job site will be required from time to time,duringand 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 de State Building Code,City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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.
ctOV—C4V( 1
Address of the work: t,{a \ccoc\-0\3 pito, O\CJCdO
The debris will be transported by: Pc( n e_ Cc-CAI-4"i
The debris will be received by: v LI nr (Ta-<-7uftn
Building permit number:
Name of Permit Applicant Y o° ' I 4-5G o
*7*
Date Signature of Permit Applicant
The lh of Massachusetts
�_ Department of la ialAccidents _
_ t. _: -
h= Office of Investigations
�
1- 1 Congress Street, Suite 100
�_r Boston, MA 02114-2017
, www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): G b''C,-II-4) I'd CV SC /
Address: a as o{4 c41---c-Fax- fte-- A,. rc ,
City/State/Zip: by1U,% o-r4 S 6 -" h14 Of 'tLPhone #: V/3 - .3y e — cl'g (
Are you an employer?Check the appropriate box:
lam ageneral contractor and I Type of project(required):
4
I.D am a employer with ❑ 6. ❑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 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp.insurance comp. insurance?
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 17 ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.n Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.n Other
comp.insurance required.]
'Any applicant that checks box KI 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.
: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.
7 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. 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 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 certift
thepains and penalties of perjury that the information provided above is true and correct.
Siunature::�� 6.-597.7.2# �— Date: 9/ '/A:
Phone#: ?L ti X ,u S'-‘,.Official use only. Do not lwrite in this area, to be completed by city or town official
City or Town: Perm it/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#:
•
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to he an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-7274900 ext 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 7-2013
www.mass.gov/dia
^u=o
City of Northampton
•
212 Main noBe Massachusetts•nMunicipal6Building :.2. Ti�s
w '✓` 14, —DEPARTMENT-OF BUILDING INSPECTIONS-,
amp , Hry 1..4
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
E $WN_'L EXEM•TlON ACKNOWLEDSiEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. The state defines"Homeowner" as, " Person(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s) who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages,which include
f• :on/foo r• befo zbackfilll. sonotube holes tbeforgpour) a rough building inspection
(before work is concealed), insulation inspection (if recall red) and a final building inspection.
The building department requires these inspections before the work is concealed, fai ..re to securre
these inspections can result in failure to obtain acertificate of occupancy unfit the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule ail required building inspections necessary for the building permit issued to me.
Date
Address of work location
To: Northampton Building Department
1 Deborah Truskinoff am writing this letter of termination for Kevin Cook, at my property on 42 Lexington
Ave. Florence,MA. By doing so I am aware original building permit will be terminated,allowing for a new
permit to be opened by Douglas Goodnow,of Goodnow Construction.Doug will be finishing out the
remainder of the project. As of this moment I will be keeping the plumber who also has a permit open for
me,on this project to continue with his part of the renovations.
Thank you,
Deborah Trusk'noff
September 20 2016