38B-231 58 FORT ST BP-2019-1071
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 38B-231 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category renovation BUILDING PERMIT
Permit# BP-2019-1071
Proiect# JS-2019-001738
Est.Cost,$58525.00
Fee,$380.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group HAYDENVILLE WOODWORKING & DESIGN INC_
Lot Sin(sa. e.): 34325.28 Owner. MUZIO CHERYL&ANDREA FISKE C/O CHERYL A MUZIO
Zoning, SC(56)/URW44)/ Applicant: HAYDENVILLE WOODWORKING & DESIGN INC
AT: 58 FORT ST
ApplicantAddress: Phone: Insurance:
P O BOX 1070 (413)253-3229 Workers Compensation
AMHERSTMA01004 ISSUED ON:4/312019 0:00:00
TO PERFORM THE FOLLOWINGWORIKKITCHEN, BATH AND LAUNDRY ROOM RENO
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:
FeeTvoe: Date Paid: Amount:
Building 4/3/20190:00:00 $380.00
212 Main Street.Phone(413)587-1240,Fax: (413)5874272
Louis Hasbrouck—Building Commissioner
File M BP-2019-1071
APPLICANT/CONTACT PERSON HAYDENVILLE WOODWORKING& DESIGN INC
ADDRESS/PHONE P O BOX 1070 AMHERST (413)253-3229
PROPERTY LOCATION 58 FORT ST
MAP 38B PARCEL 231 001 ZONE SC(56)/URB(44)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid yt�
Building Permit Filled out 'Ll
Fee Paid
Tvoeof Con tructiom KITCHEN BATH AND LAUNDRY ROOM RENO
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 F9LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF MATION PRESENTED:
t. Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§ —
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Sita Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit_ __ Variance---
Received
ariance' _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 Architecmre Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demob _ q- 3- Zoiq
Signabre of Building 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 40A.Contact Office of
Planning&Development for more information.
City of Northampton POR
WDWELLING Building Department212 Main StreetRoom 100Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A O
SECTION.1 -SITE INFORMATION
1.1 Property Address: q Tlhl#w to be com*/pleted by oi�e
P
U Q h �d�Unit
MAR 28 019 � Overlay DW
58 Fort St .-,+—>--
DEPTOPBUILDING INSP in.. alstrlct CB Dwid;
SECTION 2-PROPERTY OWNERSNIPI .MA oloso
2.1 Owner of Record:
Cheryl Muzio 58 Fort St
Na id(Print Current Mailing Address: 413-626-1088
Telephone
Signature
2.2 Authorized Acent:4JAyvWvi� y. w� �,F.} �fa1Ji LNL
-[[ � '1 PO Box 132, South Deerfield, MA 01373
FSi
ame(Pont) Current Mailing Addressatum Telephone
t;
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by perinfit so licant
1. Building 39,375 (a)Building Permit Fee
2. Electrical 7,250 (b)Estimated Total Cost of
Construction from 6
3. Plumbing 11,900 Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection 0
6. Total=(1 +2+3+4+5) 58,525 Check Number 3'
This Section For Official Use Only
@ulWing PermDates Number .Issued:
Signature:
Building Commissionedinspedor of Buildings Date
zinnia HaydenvilleWD.com
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
Tbis adumn ,,be filled in by
Building Department
Lot Size ) _
Frontage
Setbacks Front a .....i
Side L.I 1 R.i I L:,, R:!
Rest
Building Height
Bldg.Square Footage % I r i
Open Space Footage _ a
(Lot area minus blue&parent
parking)
#of Parking Spaces
Fill: _
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O YES
IF YES, date issued j
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 O DON'T 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 O
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 O
IF YES, describe size, type and location:
E. Wil the construction activity disturb(Gearing grading,excavation or filling)over 1 acre or Is it partof a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S•DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteralion(s) 0 Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [1-3] Decks [p Siding[01 Other[a
Brief Description of Proposed Kitchen,bathroom and laundry room renovation.
Work:
Alteration of existing bedroom_Yes tx No Adding new bedroom Yes 'a No
Attached Narrative Renovating unfinished basement Yes it No
Plans Attached Roll -Sheet
a. Useofbuilding One Family Two Family Other
b. Number of rooms m each family unit: Number of Bathrooms
c. Is there a garage attached?
it 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 0of 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 Ta-OWNER AUT14ORLZATION-TO BE COMPLETED=
OMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I, �,4U")_ ^ =bh , as Owner of the subject
property
Haydenville Woodworking& Design, Inc.
hereby authorize
tto ct o be alf, in all ere elativ to work aujhorized by this building permit application.
SI ature of Omer
/ ""`� Dale
I, /AL�.�+-�T/,y+� � //i(/7t1� as Owner/Authorized
Agent hereby declare Nal the stateme�din &tion on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
r&A;Y0/��O 3&QX
Print Name S
Signal of a ant Date
SECTION 8•CONSTRUCTION SERVICES
8.1 Licensed Construction
Supervisor:
'ny��, Not Applicable
Name of License Holder'. li'I><fKla�r VYr N� L. br.c"p oY10p•3
License Number
/2 23 22_
Atltlress Expireti�—r
Si nature Telephone
�i ��"o" xw Fr(M ar, ujH,H) r Not Applicable ❑
fl�� V V't 1 iWlxa �J�jVY��i Dt �fi1�, �ti c ;!6 x-32
Compo ame Registration N ber
PO 60& ) -,2 Sn IF1A�Ma�1��3 INM
Address Expiration Date
--- Telephone
SEC 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.1512 0))
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 Vas....... No_.... ❑
City of Northampton
Massachusetts s'Z
" 1
DEPANTNENT OF BUILDING INSPECTIONS
212 Mein ath a a Nuiciauiltling
Northevpton, a010.l OlOfiO �
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:7jthe homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: V171-NEjxl,..t. ejjt� Est.Cost:
Addressof Work: f5 s�
Date of Permit Application:
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 GUARANTV 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 hereby apply for a building permit as the t of the owner:
P`[��3�
Date t ntract r ame HICRegistration 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
Massachusetts
is
DEPARTMENT OF BUILDING INSPECTIONS
212 Mein Sweet • Municipal Huiltli.,
a
,
Northampton, 1N 01060
Massachusetts Residential Building Code
Section 110.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 11o.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 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
MassachusettsW
DEPANTMENT OF BUILDING INSPECTIONS 212 Mein Street *Municipal Building
Norttampton, 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:
�� R r, n�vr�lr'
(Please print house nu ber and street name)
Is to be disposed of at:
yv_�c�c�,�.r6 134 �as�tltn�vr�N �A, �4� Awbroiv
(Please p int name an location o acility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Sig�ry of Pern it pplicant 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
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address: Tbibb/. `31.- —C
City/State/Zip: %jg{b JX ,pg�7jtllA DVt?,Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
LX I am a employer with A� 4. ❑ 1 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. + y Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. q, ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §](4),and we have no 12.❑ Roof repairs
insurance required.] employees. [No workers'
comp, insurance required.] 13.❑ Other
"Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy automation,
t Homeowners who submit this affld.,it 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 their workers'comp policy information.
I am an employer that is providing workers'compensation insurance for my,employees. Below k the policy and job site
information.
Insurance Company Name:
Policy is or Self-ins. Lic.#: t^Vbll -`$Qp-ADo�`�23'��/.��I> Expiration Date: 12- )7-D,11)
Job Site Address:�5.SS' Fpf $T, r City/State/Zip: NA[� 1}MD[J Miq 3M
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 perjury that the information provided above is true and correct
Si nature: Date: 2 -
Phone#: i 467-
-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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their cenificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be tilled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax# 617-727-7749
www.mass.gov/dia