11C-034 (14) 24 HAYDENVILLE RD-Route 9 BP-2017-0358
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mau:Block: 11C-034 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPAIR BUILDING PERMIT
Permit# BP-2017-0358
Project# JS-2017-000596
Est. Cost: $4000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: LOUIS J GINGRAS 087279
Lot Size(so. ft.): 18730.80 Owner: YERKES DONNA M
Zoning:HB(1001/URA(0)/ Applicant: LOUIS J GINGRAS
AT: 24 HAYDENVILLE RD - Route 9
Applicant Address: Phone: Insurance:
244 HAYDENVILLE RD (413) 586-7420 WC
LEEDSMA01053 ISSUED ON:9/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE EXISTING REAR WALL WITH CODE
COMPLIANT REAR WALL & REPAIR SILLS AS NECESSARY - GUT INTERIOR
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: O1: 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 9/19/2016 0:00:00 $100.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0358
APPLICANT/CONTACT PERSON LOUIS J GINGRAS
ADDRESS/PHONE 244 HAYDENVILLE RD LEEDS (413)586-7420
PROPERTY LOCATION 24 HAYDENVILLE RD-Route 9
MAP I IC PARCEL 034 001 ZONE HBO 001/URA(OY
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT �
Fee Paid (,A. At / 73 Stop
Building Permit Filled out
Fee Paid
TypeofConstruction:_REPLACE EXISTING REAR WALL WITH CODE COMPLIANT REAR WALL&
REPAIR SILLS AS NECESSARY-GUT INTERIOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 087279
3 sets of Plans/Plot Plan
THE FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O 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
� j ' • 7—/‘/C JI
Stu . ure o Bu' •mg 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.
Versionl.7 Commercial Building Permit May 15,2000
RECE"/ C DepartmsluseQtly
----- City of Northampton StabssoyPemut
Building Department Cu14t4AnveamyPerrnit
SEP 15 ?irs 212 Main Street Sew441869114AvaSibi
Room 100 Wat N*%Ava ty:
DEPT or aur - -.0�s Northampton, MA 01060 Two$da of Sb,zturalPhns
NoaTMr n r..mo
phone 413-587-1240 Fax 413-587-1272 Ptof/SsPlans
Wisr,SDetily
APPLICATION TO CONSTRUCT,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address. This section to be completed by office
24 Haydenville Rd. Leeds, MA 01053 Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Donna M. Yerkes 35 Hockanum Rd. Hadley MA
Name(Print) tcsi N A ys7. l/eYZ-✓SGS Current Mailing Address:
���{�'1'1I �,V^fI//,,��-- (413)441-0358
Signature (NCI
S Telephone
2.2 Authotlzed AaeM: L trd r s Ot ‘14-2 Om(9s"
CMIS
/ ^ �y 4 /-/Ay v;1.1 E 2.0
Name(Print) LO Urs T_ Ce 5.0-G,tnS Current Mailing Address:
mos „Al A� oS',�
//// ,( y /3 -. 5'5 _ 9-ea77
Signature #• Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $4,000.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 4)&0
5. Fire Protection
6. Total=(1 +2+3+4+5) '1.000.60 Check Number /7Dj
This Section For Official Use Only
Building Permit Number Date
Issued
Signature'.
Building Commissioner/Inspector of Buildings Date
Version!.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition Repairs El Additions ❑ Accessory Building 0
Exterior Alteration ❑ Existing Ground Sign❑ New Signs 0 Roofing Change of Use Other Et-
Brief Description Enter a brief description here. RaP-.vu_ *C-C
Of Proposed Work: ce'nPL- 4MT REw2 w.g--- tft Pei.t Sic- -5 ,v.,5341 4,.Ly
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 0 A-3 ❑ 1A 0
A-4 ❑ A-5 ❑ 113
❑
B Business 2A ❑
E Educational ❑ 2B ❑
F Factory ❑ F-1 0 F-2 0 2C ❑
H High Hazard ❑ 3A 0
I Institutional 0 I-1 0 1-2 ❑ 1-3 ❑ 3B 0
M Mercantile 0 4 0
R Residential ❑ R-1 ❑ R-2 ❑ R-3 0 5A ❑
S Storage ❑ 3-1 ❑ 5-2 0 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Spedf :
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group'. Proposed Use Group:
Existing Hazard Index 760 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1., \SSS set
7
Zoe god
3rd 3,d
4th 4m
Total Area(sf) gM. Total Proposed New Con lion(t)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public [i Private ❑ Zone Outside Flood Zoned, Municipal [J' On site disposal system
Version!.7 Commercial Building Permit May 15,2000
S. NORTHAMPTON ZONING
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 %
Open Space Footage %
(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 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the/R'e�gistry of Deeds?
ll
NO O DONT KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW O YES 0
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 0 NO O
IF YES, describe size, type and location: FR6rtT r P12cP7Z "-`
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,ex vation, or filling)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.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address.. ..
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiragon Date
9.3 General Contractor
Net Applicable 0
Company Name:
Responsible In Charge of Construction
4 4 HJ qo en/ v l'i,Z E (1-0, l E E& M 9 oloSJ
Address
gig 75-- 02477
Signature � Telephone
Version1.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No 0
SECTION 11 .OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS Donn A4. tt v'k s as Owner of the subject property
r
hereby authorize to
act
D":. Gl~�" tiA5
f6
act on my behalf, in all matters relative to work authorized by this building permit application.
�10,0 4 - 16- i Le
Signature of Owner Date
l Lo d 015 T CIA/6-4.R 5 ,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.
1_, ; S, O, isA s
Print Name
17#4
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10,1 Licensed Construction Supervisor: Not Applicable 0
Hama of License Holder: �.'Ov/5 6i�64, AS Cs— ar -i 49-79
License Number
fly 11# 9,004,1,11--CE nt.ta 1-i'45ti4. 0103:7 1on-111117
Address Expiration Date
if -575- 84 77
Signature Telephone
SECTION 19-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 cg) No 0
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: "-A \-&Av DEN v
The debris will be transported by: AuAµ�tu-c TYLuc.✓sr+�
The debris will be received by:
Building permit number:
Name of Permit Applicant poN N .
q-15 I(D (af/ik to
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
—, — Department of Industrial Accidents
or "ate_fI Office of Investigations
alai1 Congress Street, Suite 100
1. _�_
=' _ Boston,MA 02114-2017
-,V� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): L0vt5 r o-;-'o /LA5
Address: 3. 11 y F) i9kwvt'LL-,E 40
City/State/Zip: 1- '05 A 6/05 3 Phone #: `I 13 ' SB 4 — 7 9 -D
Are you an employer? Check the appropriate box:
4. I am a general contractor and I Type of project(required):
I.❑ I am a employer with ❑
employees (full and/or part-time).' have hired the sub-contractors 6. ❑New construction
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_ ❑ Demolition
workingfor me in anycapacity. employees and have workers'
P tY 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work
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' 1.3.0 Other
comp.insurance required.]
*Any applicant that checks box 41 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: ��.....a:-'41-a-`2-'44L— Date: ei/ Yom/ 169
Phone 4: µl3 574 7 9 9
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#: