31B-314 (11) 15 PARK AVE BP-2017-1426
GIS ft: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 318-314 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bathreno BUILDING PERMIT
Permit# BP-2017-1426
Project# JS-2017-002367
Est.Cost:$7000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ERIK VAN NATTA 104203
Lot Size(sq.ft.): Owner: MIEHER STUART
Zoning: URC(100)/ Applicant: ERIK VAN NATTA
AT: 15 PARK AVE
Applicant Address: Phone: Insurance:
403 S MOUNTAIN RD (413) 834-0054
NORTHFI ELDMA01360 ISSUED ON:6/7/20I7 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM ***NO PARTITION
CHANGES****
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:
FeeTvpe: Date Paid: Amount:
Building 6/7/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1426
APPLICANT/CONTACT PERSON ERIK VAN NAFTA
ADDRESS/PHONE 403 S MOUNTAIN RD NORTHFIELD (413)834-0054
PROPERTY LOCATION 15 PARK AVE
MAP 31B PARCEL 314 000 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
,-----7i CLOSED REQUIRED DATE peof CZONING FORM FILLED OUTFee Paid 6,05
Building Permit Filled outFee Paid ^
Tyonstruction: REMODEL BATHROOM
New Construction
N Et
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plansl I ded;
Owner/Statement or License 104203
3 sets of Plans:Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOR ION PRESENTED:
proved 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
Signa rd. g0 wial 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 eon i
ezy a City of NorthamptonNORMIStat of r sa IMON VACIlsO°N9
,� . ) Building Department Cu veway whit
4` L' ,t• I 212 Main Street Sewer/Septic Availability
t f 4- Room 100 Water/Well Availability _
•:.'+e i1. °' Northampton, MA 01060 Two Sets of Structural Plane__,_
:.a-yr phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
,.-- Other Specify
1 APPLICATION TO CONSTRUCT.ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address. yn�
I v FA", A1/f.. Map 31 e Lot...._ .))// ._.._Unit
iriefsatssowati 044 01 OIJG Zone Overlay District
G,_
Elm St District_ _ CB District_ _
_.......
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
I STvµr $4IENCR Ir efrAk 4. Nosnr,ia.ror. i"/' 0 / 06
Name(Print) Current Mailing Andress. Y/3 bTr int
—......
UL�
Teltpl a e
Synalure
2.2 Authorized Anent: I
� E r/k. v4r7 ge r7re— f 7C Pat/tier/bor Ad (Sae '!
Name(Prins) Current Many Address: /ask (T,'33 7
i
Denature Telephone I
i SECTION 3-ESTIMATED CONSTRUCTION COSTS
)tern I Estimated Cost(Dollars)to be - Official Use Only
com•teted by permit a••licant
1 Budding f3 0 00 (a)Building Permit Fee
( 2. Eiectrlcal
It o 01/Estimated Total Cost
Of
Construction from(6)
iPlumbng Building Permit Fee
i__ I > aed —
14 Mechanical(HVAC)
( .Fire Protection i
' —�—}-
I i_Total=(1 «2r. a.a+B) "'Ot Check Number -,3'j �(J ria�Oj
This Section For Official Use Only
Budding Permit Number_ Dale
Issued: —
signature: _..... _ ._..._ _�.
I BulIding Commissionerilnspector of BuiWlnys Date
Ihasbrouck @ northamptonma.gov
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Completed.Permit Ca'i Be Denied Due To Incomplete Information
[Aiding Proposed Required by Zonirg
Ills column to he rued in in
Building Depanment
lot Sze '1-( 400 a 4, WOO 4. j.
Frontage /0e l0r --
Setbacks Front it' 11.
Side L 0 R: 3� L: 0 R: 31-
Rem-
Building
1-RearBuilding Height LW LY
Bldg. Square Footage too L4 'n }.o '1.4 /.
Open Space Footage nb,
(Lin arca minus bide sported 1}00 .I I}PD 3t 7
parkinm
ir of Parking Spaces L L
racisme,n tucudom
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW ® YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW Q YES O
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO fie DON'T 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 NO
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 filling)over 1 acre oris it part of a common plan
that will disturb over 1 acre? YES O NO S
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 n Replacement Windows Alteration(s)Si Roofing n
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [O Siding E D] Other[01
Brief Descsption of Proppsed
Work- 546,tar', ei (.i4 (r toy i1(.e ebtry b.4is .._
Alteration of existing bedroom Yes ?ib.. Na Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes jC No
Plans Attached Roll -Sheet tt
6a,If New house and or addition to existing housing, complete the following:
ik a. lige of building: One Family Two Family Otber_
h. Number of rooms in each family unit: „ Number of Bathrooms
o. Is there a garage attached?__ _
_ Prom-sed Square footage of new construction. —Dimensions
v. Number of stories?
t Method of heating? _ Fireplaces or Woodstoves _Number of each__
g Energy Conservation Compliance. Masscheck Energy Compliance torn attached'
It. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No, Is construction within 100 yr. floodplain Yes No
1. Depth of basement or cellar floor below finished grade f
k. Will building conform to the Building and Zoning regulations? Yes No.
I
Septic Tank City Sewer Private well City water Supply
F...._
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
VA p
I S�n�r ....k _. _;as Owner of theru,bject
.+oPeM1y � /
hereby authorize 4114VlM AMA
to act s i . ml( in ais
s, elative to work authorized by this building permit application.
/ _. r ?Jr
Signal e of Owner Date
I Eir1 h Vin J1-4.ribs— Owner "Ambo:iced
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the host of al my knowledge
and belief.
Signed under the pains and penalties of perjury.
Er ji Vito
/Iris, --._—
i
Print Name _.. __...... .._._.— .._–
a
,.
LSI,�f°who;Agent Date
City of Northampton
r :
g Massachusetts
A ®
,,, DEPARTMENT OF BUILDING INSPECTIONS
(Ut
y 2i2 Main Street • Municipal 1 Building
Northampton, MA 01060 r1
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation ("OCABR") regulates the registration of contractors and
suheoniractors performing improvements or renovations on detached one to four family homes. Poor to
performing work on,such homes.a contractor must be registered a,a Home improvement Contractor i"I ti{tet_
M.G.L. Chapter 142A requires Thai the"reconstruction, alteration, renovation, repair,modernizationconversion,
improvement, removal, demolition. or construction of an addition to any pro-existing owner-occupied building containing
at least one but not more than four dwelling units_..or to structures which are adjacent to such residence or building" be
done by registered contractors.
.Note:If the homeowner has twntracterl with a corporation or LLC,that entity nurst be registered.
Type of Work:_ tyy Thd .t-a4... ½ C _Est Costa_4( 42
Address of Work l S ( al s fv'e r''7i. `f ,ren;
Date of Permit Application: /7/1Z.
I hereby certify that:
Registration is not required for the fbllowing reason(s):
Work excluded by law(explain);
Joh under S1.000.00
_Owner obtaining own permit texplaina
_ Buitdirts,not s,wmcr-irccupicx7
Other(specify):_
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH tSI REGIS
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBi.E FOR ANt)DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY Ft'NO
UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME'I'IIE RFSPONSIBII,ITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT. SEE NEXT PACE FOR MORE INFORMATION.
Stalled Undo-the penaItics of perjury:
1 hereby apply for a building permit as the agent of the owner:
171 7 k " a LLI� I1 cR
Date Contractor Name WC Registration No.
OR:
Notwithstanding the above notice. I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: � " Not Applicable ❑
Name of License Helder: i�'� /•..n
-7h
fiPLO- _._ S--- Ct`i.2('55
Licen^.e Number
Pat, rO✓ K1) 13aernard5 /144- a)61/_>
Address c-._... Expiration iration Date
eeep ✓r( i g 3'r - Y
5�nawra Telephone
9.Registered Home Improvement ConIr ctor: Not Applicable ❑
Vt. 0 ILC.- _ _ _ F 1 12
Company Name Reiistration Number
I-7{_ P r ... tt Aantani5-tarl frliff 7115
Address Expiration ate
cc3(,/'_,�7GVIJ . Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(0))
Workers Compensation Insurance affidavit roust 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 Si No ❑
City of Northampton
Massachusetts
(Ett . DEPARTMENT OF BUILDING INSPECTIONS
• . 212 Main Street • Municipal Building
SNorthampton, MA 0106D
Massachusetts Residential Building Code
Section I10.R5.12
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.
Section I I0.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions 01'780 CMR 1 10.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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.
City of Northampton
Massachusetts E`
a
y Ifs, 4' DEPARTMENT OF BUILDING INSPECTIONS
't 1' tAi 212 Main Street eMnnicIpai Building
Northampton, MA 01060 t.0i
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowlecge 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.
The debris from construction work being performed at:
P''K�� �/P...........—
(Please print house number and street name)
Is to be disposed of at
Vv//e u. ^ G 71 ,
(^ ease print name and ocation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Appl can or Owner Date
if, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
L1
_r,
4 f=, us, Office of Investigations
@" !jam,y 600 Washington Street
"" t'- Boston, MA 02111
,:tazar www.neass.gor/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Basiracsvr/rgant/alion Individual): I,/veil Web, ,^s'-04'.. tic/
Address: 1.7 �" _fd/}+-vii. 'i5Y-_...P
City/State/Lip: fjvrfv;Ki S 71,11 y'/' 4 Phone ': t-713 '_ 93 . ` (,`,;'Ci
Are you an employer?Check the appropriate box: Type of project(required):
I.Vi. I am a employer with _3_ _ 4. LI I am a genet al contractor and I 6. E New soon eruct on
employees(full ardor part-time).* have hired the sub -contractors
ug
2.❑ I am a sole propricr or partner- listed on the attached t .sheat. # 7. fri-RmnodeI
ship and have no employees These sub-contractors:have S. n Demolition
working for me in any capacity. workers' comp. insur.flce.
Y ! 0. ❑ Buddm addition
INu oyatkerg' comp. msn-anee 5. We are a corporation and its
required.] officers have exercised their 10.[ Electrical repairs or additions
b.Ur 1 am a homeowner doing,all'nor'k right of exemption per MGL I LQ Plumbing rend=s or additions
myself. [No workers. comp. c. 151, I(4L and we have no 12.[ Roof repairs
insurance required.)` employees. [No sorters'
comp, insurance required,]
I3.❑ Other
Nilo aerkeitm tan ebecns bcx. i r eels°ill onoth ectien'xl vrteur nolo- mntpcamoa po c. ntornanon.
I lianctrAners who submit this anhvi, indicating 0 . :dour all work and then hire outside:eont- mrs nasi submit J nc,. id tali; ni Ili inning Midi
t ontractors that check this box inae attached adtioal shut sh yin he name of thesoh-contractors and th:tr svor r mppOiis R:mzrna.
I am an employer that is providing workers's'compensation insurance fir my employees. Below is are policy and lob site�
infin-motion.
Insurance Company Name: P(er _-> I✓fStrG/ip e_.
Polley„ or S If-ins, Lie Co � (>A b ----- L1(/ 0 )66'-/_0 Expiration Dat.: ([5/,[611,43 _
_
.lithSite Address: L P'yr K iT i City/Stateszip: _f IC"?M P*7f_L fr
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage us required under Section 25A of MCI, c. 152 can lead to the imposition of CFI ill inal penalties of a
line up to S1.500.00 author one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the ()Ince of
Ir'estigations 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.
4ienamre f4.��'w'� .. __.... Dula: V7 / 7__._...._....
Phone 4:Id B ` g33+ut " c(2617
Official use only. Do not write in this area. to be completed by city or town official.
Citi or Town: Permit/License#
Issuing Authority(circle one)
1. Board of Health 1 Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: