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25C-053 (12) 51 LINCOLN AVE BP-2017-0756 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-053 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-2017-0756 Project JS-2017-001265 Est.Cost: $4.000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq,tt.): 10062.36 Owner: MEERBERGEN CHADD Zonine:URBJQQY Applicant: MEERBERGEN CHADD AT: 51 LINCOLN AVE Applicant Address: Phone: Insurance: 51 LINCOLN AVE (508)221-4609 O NORTHAMPTONMA01060 ISSUED ON:12/12/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL POWDER ROOM ON 2ND FLOOR TOILET & SINK 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: Smo e: Finan 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 12/12/2016 0:00:00 $65.00 212 Math Street, Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner Filen BP-2017-0756 APPLICANT/CONTACT PERSON MEERBERGEN CHADD ADDRESS/PHONE 51 LINCOLN AVE NORTHAMPTON (508)221-4609(3 PROPERTY LOCATION 5I LINCOLN AVE MAP 25C PARCEL 053 001 ZONE URB(100)1 THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONINQ FORM FILLED OUT Fee Paidtb Building Permit Filled out lTT Fee Paid Typcof Construction; INSTALL POWDER ROOM ON 2ND FLOOR TOILET&SINK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Not Plan THEE LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I MATION 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 I- .y • / Signa Ire of Buil. ng / lcial 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 40k Contact Office of Planning&Development for more information. . ... a-„ .ii,'- .. rime - fd� r- y.. �" City of Northampton roti : ` -" `�.�,,"" bra �` �„ Building Department pf i'lliYs IalIfil v rT �`yj "r+ �h - f a`'�� e 212 Main Street ��,,ne �f(� vTr aa' ,,; ' , Room 100 IEnnfq"a['1 t 1,4 Northampton, AAA 01060 , ,a ; ,. hone 413-587-1240 Fax 413-587-1272 "reqq ' "" V'"" Cyt Q ; •.7iir ,� t '. p tticV •,..r.4-t7 t7'6•yet- AP' !CATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property AddressThis section to be completed by office le;r.�aS V7 Map Lot Unit I4©C 7'l',Gep'l'O 7M, / #14 Zone Overlay District a a bo Elm St District CB District SECTION 2-PROPERTY OWNERSH'I/P/AUTH,O-RIIZED,AGENT 2.1 Owner of Record: IJC!*`Q F-2Nt.' �+r- y } • . . !/ . 'SI Lincoln ay t Name(Print) Current Mailing©©ddress: O11 � � SO Z2r-' , eq gt{Lq(� __ Telephone Signature "��" �� �mr.t f: C tic F.�tf}'l.r - ' �:« - il.. . .YY3T 2.2 Authorized Agent: Name(Print) Current Matting Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building I l� e G (a)Building Permit Fee 2, Electrical I O 00 (b)Estimated Total Cost of $ r r Construction from(b} 3. Plumbing L000 Building Permit Fee r 4. Mechanical (HVAC) 5. Fire Protection L 6, Total=(1 +2 +3+q+5) /-G 0°° Check Number Yoe Gr") , This Section For Official Use Only / 4/ Building Permit Number I IIsssued. Signature: Date Miffing CommissionetAnspector of Buildings Section 4. ZONING All Information Must.Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filed in by Building Department Lot Size r /0,ot.42._.' t-I LI j Je . A+ta- I_ _..__ .....___1 Frontage .__�0q __�., tar f..._. Setbacks Front ! Z,S j [liii I - _., Side LL4ai R:JQU L:TFO. R:LQ,.H I _f I _-.I Rear ( �"a _____ Building Height Z6.f Y z "r F I Bldg.Square Footage jty [ i Open Space Footage 7 . _._ M & rrrfpppp---��t area minus bldg raved C7Cor l I M Lr..Gv_% LI. .1 parkinjr& ._ —_ #of Parking Spaces — Z1 -� Pith I tfJa✓Lo..- IF 61f"ti' .. —ij —__� (volume&Cocoon _ ._.__. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Or DONT KNOW Q YES CJ IF YES, date issued:. I IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW © YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Of DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: 1 C. Do any signs exist on the property? YES 0 NO 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 0"., IF YES, describe size, type and location: E. WII the construction activity disturb (clearing,grading,excavation, or filling)over 1 acre or is it pad of a common plan that will disturb over 1 acre? YES 0 NO yr 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) n Roofing n Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs ]O] Decks [p Siding[O] Other[O] Brief Description of Proposed . kit 1 Work: tri SFa-Ll ,4'�m.Jcla-v- revwv M Sccl..� flour +C��-�- S.n1� Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes V No Attached Narrative --T1 Renovating unfinished basement Yes l�p Plans Attached Roll {Shy ca. 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 I, ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1111111111111111111.1111111111111.1 I, ,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. Print Name 1/ �t/i /Z 7t/ii Signa of a n: /Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder ....... _..i License Number Address Expiration Date Signature Telephone 9,Registered HOmeSlmprovoment Contractor: ::. ;. Not Applicable 0 .... Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.c.15Z§25C(80 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 0 It -Home Owner Exemption The current exemption for"homeavners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an indiridual 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 be/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 acre able to the Building Officials 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 he 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 maybe liable for person(s) you hire to perform sunk for you under this permit. The undersigned"homeowner"certifies and assumes responsibility for compliance with fie State Building Code,City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature , / a ar Q• IS•fr a- f i.... 4 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: Si L, r. coin A-„c The debris will be transported by: Cwru v—s --rtcic The debris will be received by: C11-, of k)e-nivto. f, +S s Building permit number: Name of Permit Applicant C f1 ^ { eer-be vd e..fri /ZRI Z_o[ re Mo.dd 214 ee-i-fr)e tr Date Signature of Permit Applicant U The Commonwealth of Massachusetts Department of Industrial Accidents l i= b Office of Investigations Shia. a 1 Congress Street, Suite 100 ..p-r_ Boston,MA 0211 4-2 01 7 .� www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Cheek the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 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 workingfor me in anycapacity. employees and have workers' P R 9. 5 Building addition req workers' comp. insurance comp.insurance.: re aired. 5. ❑ We are a corporation and its 10.5 Electrical repairs or additions q ] officers have exercised their 11. Plumbingrepairs or additions 3. I am a homeowner doing all work ❑ P myself [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other 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. [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'comppolicy 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 if or Self-ins.Lic. #: Expiration Date: lob 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 thee •� 'ns and penalties of perjury that the information provided above is true and correct. 7 Suature: (/ / Date: /2 / 7/h Phone If • 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 h: +/ma a s 1/eac`'iv /2 -9-76/ City of Northampton Building Department Plan Review 212 Main Street - Northampton, MA 01060 OF, N BELOV4 '-5":7,,..711, 1111 pa6B _ BEDROOM 10'-1 1/2" " I :Ct "-49 BEDRC9 "lM 10'-0" x 1r-5" dAIvajI 'I 2_v\a dart i— Rats-- RALQ.,4