28-048 93 CAHILLANE TER BP-2018-1075
GIs n: COMMONWEALTH OF MASSACHUSETTS
M=Block:28-048 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category:renovation BUILDING PERMIT
Permit# BP-2018-1075
Proiect8 JS-2018-001938
Est.Cost $29500.00
Fee:$192.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use Group: DAVID JAGODZINSKI 106068
Lot Size(sq.ft): 12806.64 Owner: MOTAMEDI MATTHEW
Zun_ ine: Applicant: DAVID JAGODZINSKI
AT. 93 CAH ILLANE TER
Applicant Address: Phone: Insurance:
P O BOX 204 (413) 230-9160 WC
NORTH HATFIELDMA01066 ISSUED ON:4/1912018 0:00:00
TO PERFORM THE FOLLOWING WORK KITCHEN, BATH, REMOVE OLD HEAT ADD NEW
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 R 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 4/19/20180:00:00 5192.00
212 Main Street,Phone(413)587-1240,Fax: (413)5874272
Louis Hasbrouck-Building Commissioner
File#BP-2018-1075
APPLICANT/CONTACT PERSON DAVID]AGODZINSKI
ADDRESS/PHONE P O BOX 204 NORTH HATFIELD (413)230-9160
PROPERTY LOCATION 93 CAHILLANE TER
MAP 28 PARCEL 048 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out :Iq
Fee Paid
Tpeof Construction' KITCHEN BATH,REMOVED EAT ADD NEW
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106068
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Stonn Water Management
�$emolition Delay
Aqacme of Building, tircial Dale
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.
City of Northampton NONE
RDWELLING Building Department
212 Main StreetRoom 100Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR
SECTION t -SITE INFORMATION
1.1 Property Address: This saedon to�
Map e2 ^ lot d—i .
Unit
lcrence1 A"l S. O(O(c+D- Eons WbpbY Dlabie#
Elan St.pukka_ CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: el
6y prosy t- }ue/ � r aw�lvnlJ�sS
Name ring `, Current Mailing Address A// j..d19 - QJ38)
/ Telephone
Signature
2.2 Authorized A e t:
f64 �or sox ')6 iv, �� �� Jl�
Name IT,- t) ` Current Mailing Address,
y/3-ago- SIG)
Sign re v Telephone
SECTION 3-ES ED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
cpm leted b ermit applicant
1. Building 'l �� CIO (a)Building Permit Fee
2. Electrical 4 SQor "� (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) Ir�
5. Fire Protection
B. Totsi +2+3+4+5) Check Number
This Section For Official Use OnIv
Building Permit Number: Date
ssued-
Signature:
Building Commissioner/Inspector of Buildings Date
C&
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doom ED
Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [M Siding[C]] Other[
Brief Description of Proposedo c�m
Work: �.r l-cl -v1 l e�F� 2ew.oyP 0IJ 1—ern.E Jcdyyekl
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.1E ... S eBlk #m
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
A
I, / 'ifG% + '`6k Avv�Cyl as Owner of the subject
property
hereby authoriz �AZI'7 I< Y
to act my alf, in all mir,r relative to wor thonzed by this building permit application.
Sig/nates vmer gtlt(,he
I, 1/klfd as Owner/Authorized
Agent hereby declare th t e statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the p 'ns anryrypenalti s of perjury
u( 76 Zerr�G
Print Name
1111f//9
Signat a of Owner) nt Da
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
I his column to be filled in by
Building Department
Lot Size _.. .....
Frontage
Setbacks Front
Side L R-1-1 L___ R-
Rear
L--j _J
Building Height
Bldg. Square Footage /a
Open Space Footage _ 'N -
(Lotareaminusbldp&paves
arkiu
#of Parkin S aces
Fill:
I
volume ffi
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ' DONT KNOW O YES O
IF YES, date issued:[--,---
IF
ssued:_ _IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES
IF YES: enter Book Page and/or Document#�
B. Does the site contain a brook, body of water or wetlands? NO 'Q 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:
� _ v
C. Do any signs exist on the property? YES O 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,L�valion,or filling)over t 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.
SECTION 8-CONSTRUCTION SERWCES
8.1 Licensed Construction Su rvisor. Not Applicable ❑
Name of License Holder' Wl (cl, K r s(I J(0 60
License mber
1C /1S I %
Addre .,,sior'nee
SiliKeture Telephone
R:Reuti Fid NB>a� r 1ihiY rT5a�e6aeBon '** 149 Not Applicable El
V /ti C�croykt vl.`I ti ,g'1OP`7
Compafiv Name Rei rati n N mber
5 a
Address / >> $' ExpiraE n D e
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....... x No...... ❑
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Si eet a Municipal Guild ngia
Northampton, Ma 01060 "'• ^�C
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation,repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-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:Ifthe homeowner has contracted with a corporation or LLC,that entity must he registered
Type of Work: Est.Cost:
Address of Work:
Date of Permit Application: �8
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I her apply for a building permit as the agent of the owner:
�llF s 13ut it ws a F �,��%� 1� /TQ
0 S y
D t c Contractor N-510' HIC 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
City of Northampton
l
Massachusetts
1
DEPARTMENT OF BUILDING INSPECTIONS
212 Main St eet • Municipal Building
MorNa ton, !R 01060
Massachusetts Residential Building Code
Section I IO R5.1.2
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 IO.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a persons)
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 persons) you hire to perform work for you
under this permit.
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main St eet oMunicipal Building(a
NoxNampton, NA 01060
Debris 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.
The debris from construction work being performed at:
9 � C?17, 114,1e le iRc2
(Please pant house number and street name)
Is to be disposed of at:
VAlipI ec�ff/r7
(Plea print name a d loc io of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Av,,Iw-3') V'uCi( Kz�\
(Company Name an Address) ry'
/ ,�
Sig u e o Per t (cant 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.
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Type: Corporation
Registration: 187884
A&S BUILDING AND REMODELING, INC Expiration: 05/23/2019
P.O.BOX 204
N. HATFIELD,MA 01066
Update Address and return card. Mark reason for change.
scA1 o 20M 05/11 n AAA-- n Q---o n =—u,,m r n i —+r.--A
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
TYPE Oomora[on before the expiration date. If found return to:
c� Reelstraton Expiration Office of Consumer Affairs and Business Regulation
L., r 187884 05/23/2019 10 Park Plaza-Suite 5170
A&5 BUILDING AND REMODELING,INC Boston,MA 02116
DAVID JAGODZINSKI Ap—c&-I—
123 DEPOT ROAD
NORTH HATFIELD,MA 01056 UndereeCretar Not valid without signature
Commonwealth of Massachusetts
'_t®t Division of Professional Lc sure - £
Board of Building Regulations and Standaeds
Co nst nIctbn'3upe ry iso r
CS-106068 . ! Esplres: 11/12/2019
DAVID JAGO&INSKI vizi
P.O.BOX 204
NORTH HATFIELD MA 4066
r N`
Commissioner