24C-047 (2) 17 WOODLAWN AVE BP-2019-0764
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24C-047 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: KITCHEN RENO BUILDING PERMIT
Permit# BP-2019-0764
Project# JS-2019-001261
Est.Cost: $112825.00
Fee: $733.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: ROBERT WALKER
Lot Size(sq. ft.): 36808.20 Owner. EPSTEIN NOAH
Zoning URA(100)/ Applicant. ROBERT WALKER
AT. 17 WOODLAWN AVE
Applicant Address: Phone: Insurance:
36 Service Center (413)584-1224
NORTHAMPTONMA01060 ISSUED ON.11412019 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN, REMOVE BEARING
PARTION WALL
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 1/4/2019 0:00:00 $733.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019-0764
APPLICANT/CONTACT PERSON ROBERT WALKER
ADDRESS/PHONE 36 Service Center NORTHAMPTON (413)584-1224
PROPERTY LOCATION 17 WOODLAWN AVE
MAP 24C PARCEL 047 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
NCL D REQUIRED DATE
ZONING FORM FILLED OUT
Eee Paid
Buildinp,Permit Filled out
Fee Paid
T eof Construction: REMODEL KITCHEN REMOVE BEARING PARTION WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
l y c8
Signature of Building O cial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Department use only
City of No ha pton tatu of Permit:
Building D part enAN _ 3 201$ urb ut/Driveway Permit
/ 212 Mai Str et ewe Septic Availability_
Roo 100 ater ell Availability
U11_r)iN�INSPFCTI
Northampton, MRIP AWTON.MA 0106,0 wo S is of Structural Plans
phone 413-587-1240 i^43-561-1212 Plot/Site Pians
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 0 (� 1 l N—S
1.1 Property Address: This section to be completed by office
1'7 U00 y,r�w ;�, p�-,y� Map ` tG
fi, Lot D`7 7 Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Accent:
k-�U`� 'r�l� iA�.h� r c UL N-jCV 'N
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building (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= 0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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' y
Building Departme
Lot Size -�
Frontage
Setbacks Front
Side L:= R:0 E::jl 0
Rear
Building Height 0
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spa C� U
Fill: IF
-�F
v e&Location)
A. Has ar Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW ® YES
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book F_I Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YESlO NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exc ion,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.
SECT z � §R PTION OF PROPOSED WORK(check all;applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[d]
Brief Description of Proposed
Work: z t-
Alteration of existing bedroomYes No Adding new bedroom Yes � No
o
Attached Narrative _ Renovating unfinished basement Yes
Plans Attached Roll Sheet
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms < V
c. Is there a garage attached? �
d. Proposed Square footage of new construction. f Dimensio
e. Number of stories?
f. Method of heating? F' laces or I toves Number of each
g. Energy Conservation Compliance. Mas h �nergy Compliance form attached?
h. Type of construction
I. Is construction within 100 ft. of ands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement ellar floor below finished grade
k. Will build' conform to the Building and Zoning regulations? Yes No.
I. ptic Tank City Sewer Private well City water Supply
SECTION 7a-'OWNER AUTHORIZATION-TO BE COMPLETED WHEN
tiWNERS AOE 17 CONTRACTOR APPLIES FOR BUILDING PERMIT
Av�_ P'�;;Tl c_{.1i`-) as Owner of the subject
property
hereby authorize es-)!6 I*- y
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 0� )')'�•(z`— � 'a 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.
l w g fp
Print Name
Signature of Owner/Agent Date
SECTION_$_-CONSTRUCTION-SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �'�-� �C i�� �✓✓ `� 4�LS — 03A-763
License Number
T- ,,.q
Address C�'� Imo_ C ,fi 1L ��- - �{ ()N� V�rT ExpirationDate�
C.e,..,l�.�c.�(.�--- �—t�i "r�• r1 — l2 fid...
Signature Telephone
Not Applicable ❑
1-7 Zee i �
Company Name Registration Number
sl I71z�
Address Expiration ate
Telephone
SECTION 1D-WOOERS'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 buildin,g-permit.
Signed Affidavit Attached Yes....... No...... ❑
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print LeeiblV
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are yo n employer?Check the appropriate box:
Type of project(required):
1. I am a employer with 10 employees(full and/or part-time).* 7. N onstruction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Ei;Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.a I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.-
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.Q Other
152,§1(4),and we have no employees.[No workers'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'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: t/1.�i�q 6%A V 7U 141`..- 7:X7 t_., S v!tom 1�
Policy#or Self-ins.Lic. (0 IV- -7-7 Expiration Date:
Job Site Address: 1-7 le�.x 140a,.)ti AcQf i City/State/Zip: Oiu(sa
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby cern under the pains and penalties of perjury that the information provided above is true and correct.
Signature: — Date:
Phone#: — 1
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#:
City of Northampton
Massachusetts
`G
N;
y ` DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street *Municipal Building
Northampton, MA 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:
(Please print house number and street name)
Is to be disposed of at:
VP!2t� ACV (-A- !-�'C,
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
A-tyx ax'r I-T' v cy,1 1.. Q-
(Company Name and Addre s)
Signature of Permit Applicant 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.