17C-064 (2) 167 CHESTNUT ST BP-2017-0913
GIS n: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-064 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL
c.142A)
PERMIT
Category: demolition BUILDING
Permit# BP-2017-0913
Project# JS-2017-001560
Est.Cost:$5000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DOUGLAS THAYER 107699
Lot Size(sq. ft.): 14984.64 Owner: DOUGLAS THAYER
Zoning: URA(100E Applicant: DOUGLAS THAYER
AT: 167 CHESTNUT ST
Applicant Address: Phone: Insurance:
P O BOX 60322 (413) 530-4785 ()
F L O R E N C E M A01062 ISSUED ON:2/6/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMO OF KITCHEN AND 1/2 BATH
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 2/6/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck- Building Commissioner
•
File 4 BP-2017-0913
APPLICANT/CONTACT PERSON DOUGLAS THAYER
ADDRESS/PHONE P O BOX 60322 FLORENCE (413)5330-4785 0
PROPERTY LOCATION 167 CHESTNUT ST
MAP 17C PARCEL..064 001 ZONE URA(I00)/
THIS SECTION FOROFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid B ld a P h Fifed outFee Paid
TvpeofConstruction: DEMO OF KITCHEN AND 1/2(1663
'
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 107699
3 sets of Plans,`Plot Plan
THE FOLLOWING 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: §
FindingSpecial 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 Sweet Commission Permit DPW Storm Water Management
D- ' ' ion Dela
Ai
Si_ ceding 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 40k Contact Office of
Planting& Development for more information.
Department use only
�� City of Northampton Status of Permit:
,L'1� Building Department Curb Cut/Driveway Permit
("� - . % 212 Main Street Sewer/Septic Availability
` Room 100 Watermell Availability
Northampton, MA 01060 Two Sets of Structural Plans
�. phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
G 7 (112.. /]y'y,//)'µ ,I .J Map Lot Unit
I `Otey(( ` [F / 1� Zone Overlay District
CO G Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Douglas Thayer
Name(Print) Current Mailing Address: PO Box 60322,Florence MA 0106:
A / Telephone ('77 778.5
Signature V IC 51 0 -
2.2 Authorized Aaent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building S 000 — (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 .(/
6. Total=(1 +2+3+4+5) Check Number ii..2 37 ab
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: O(7 Q(t�UJ /14f,DV 7 9 999
U License Number
fo hoic 11 f 0(06)
Address Expiration Date
7(3 S30 - Y7ci5
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
1 , rfg,45 hhoist% 1790 5
Company Name Registrati m n Nur
PO fou Ao K 6717 ���
Address Expiration Date
-DM"?
"
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 0 No 0
11. ome Owner Exemption
he 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,oris 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 Oficial.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
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): Do a ) (tt 5 771.t1/4\e J
Address: n� 577(7�n 60-) UFhNeKst fr/ A
LJ
City/State/Zip: Phone#: 7 _ 5'7 7U- (-77 _,S
Are you an employer?Check the appropriate box:
general contractor and I Type of project(required):
1.❑ I am a employer with 4. ❑ I am a g
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
ip and have no employees These subcontractors have g. 0 Demolition
working for me in any capacity. employees and have workers'
9 0 Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. 0 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.] r c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
'Any applicant that checks box a I 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 him outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the subcontractors 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:
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 the pains and penalties of pedury that the information provided above is true and correct.
Simature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License I
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 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) C] Roofing ❑
Or Doors ❑
Accesso Bldg. ❑ Demolition El New Signs fl Decks [❑ SidingnLI] Other[CI
Brief Description of Proposed f1
Work: j_./ 0 Oe F `0.14 ( Q✓( !9- 62""
1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. If N house and or addition to existing housing, complete the following:
a. a of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
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 aryl Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SEION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
0 NERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, rf
,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
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.
Signedfunder the pains and penalties of perjury.
ed
I Oac ri S 111Q .,
Print Name f
Signature M• -0A:1111W Date
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 filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: It: L: R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage °b
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/FindingD � ever been issued for/on the site?
NO 0 DONT KNOW '1g) YES 0
IF YES, date issued: i/�
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO It�� 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 \6 A
IF YES, describe size, type and location: �X\'
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,gradin e 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.
City of Northampton 212 Main. Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, 854, 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!lIby MGL c 111, S 1150A.
Address of the work: I 6 7 Oh 0,174 W Ho-nice
The debris will be transported by: I'J n nl u s -Tr I k l P f
The debris will be received by: Vc& I L _ P,xOl '14 r
Building permit number:
Name of Permit Applicant 9C 4c,1c15
7.711q
/ e v
Date Signature of Permit Applicant