22B-020 (2) 13 MEADOW AVE BP-2019-1251
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mia :Block:22B-020 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-2019-1251
Project# JS-2019-002016
Est Cost$210000.0
Fee $1365.00 PERMISSION IS HEREBY GRANTED TO.-
Const.
O.Const. Class: Contractor: License:
Use Group: DOUGLAS THAYER 107699
Lot Size(sp.ft.): 17816.04 Owner: HDLBINK TOM
Zonjna:URB(100)/ Applicant: DOUGLAS THAYER
AT. 13 MEADOW AVE
Applicant Address: Phone: Insurance:
P O BOX 60322 (413) 530-4755 0
FLORENCEMA01062 ISSUED ON:5/9/2019 0:00:00
TO PERFORM THE FOLLOWING WORKRENO OF ENTIRE STRUCTURE
**SEE NOTES***
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: 21 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 5/9/2019 0:00:00 51365.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File d BP-2019-1251
APPLICANT/CONTACT PERSON DOUGLAS THAYER
ADDRESS/PHONE P O BOX 60322 FLORENCE (413)530-4785 O
PROPERTY LOCATION 13 MEADOW AVE
MAP 22B PARCEL 020 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLIC TIO EC
'CLOSED EQUIRED DATE
ZONING F RM FILLED OUT _
Fee Paid
Building Permit Filled out
Fee Paid
TyricofConstruction. RENO OF ENTIRE STP UCTU
New Construction
Non Structural interior renov tions
Addition to Fxisting
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:
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
4e
Signa rte 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.
Department use only
- City of Northampton Status of Permit:
Building Department Curb CubDrivei ay Permfi
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
� Northampton, MA 01060 Tiro Sets of Stmchmal Plans
\� phone 413-587-1240 Fax 413-587-1272 Plol/Sits Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pro-oierIv AAddressem: This section to be completed by office�f / 1-d w Ave Map �a i Lot h Unit
Flo,evid AA
010612 Zone Overlay District
-OolilQS(1 l v LD wl i CO n'1 Elm SL parcel CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record: y
TOW : I PAlc 13 he.dGt„ Ayf Floved«
Name(Print) Current Mailing Address: %l 3 9l S 773
Telephone
Signature
2.2 Authorized Agent:
neuA�aS 7�'1a t� P c r xT
Nems(P' t Current Mailing Address:
y0530 - V783Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmd applicant
1. Building l q0
(a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
7/G Construction from 6
3. Plumbing (L Building Permit Fee
4. Mechanical(HVAC) 10 1 l�
5.Fire Protection 16
6. Total=(t +2+3+4+5) 1 ILI Check Number
This Section For Official Use Only
Building Permit Num r: IIsssued,
Signature:
Building Commissionerrinspedor of Buildings Data
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 nllcd in by
Building Deportment
Lot Sim 1Loi
4 I
Frontage P10% L0 1
Setbacks Front
Side L: R: L:_R:
Rear
Building Height
Bldg.Square Footage 6 Z 1707
Open Space Footage %
(Lot oma minus bldg&paved
parking)
#of Parkin S aces
Fill: r
volume&location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW �D YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES
IF YES: enter Book Page ���fTTand/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 9 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 ,yyyyDattt(te Issued:
C. Do any signs exist on the property? YES 0 NO "1
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 IK
IF YES, describe size, type and location:
E. Will the construction activity disturb((ctg�aging,grading,(excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 7 acre? YES L5 NO k
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION tF DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition JZ Replacement Windows Altered n(s) Rooting ❑
Or Doors O
Accessory Bldg. [11 Demolition E] New Signs [0] Decks [p Siding[O] Other[a
Wo Description of Proposed Re*0Vstl tan O T C M 1ii
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: -Is Not Applicable 0
Name of License Holder: UL I Q S 16)"v lpp7 ' 10-10101
License Number
lPC) �� c Gq1o712 o
Add Expiration Date
yl3
Sao- y-7S r
Signat Telephone
9.Reoiatered Nome Improvement Contractor,Contractor, Not Applicable 0
C&).&). r -1hge 1-790SS
Company Name Registration Number
�lrf�av
Address Exp, io Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted Wth this application. Failure to provitle Mis a%davit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... 0
s'
� •� " Massachusetts
DEPAR1fffiiT OF BGILDIRG IRSPECrIOBS
212 Main etzaet • �cipa Building �d V. �s`c
aortha ton, Mx 01060
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 .orto structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est.Cost:
Address of Work:
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 owneroccupied
_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:
1 hereby apply for a building permit as the agent of the owner:
Date Contractor Name 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 Signal=
' f Massachusetts
p d z
' ,I _ lJ&PAN24II:NT OF HOZLDxaG xaSPEC1ZON5
212 Nein Sti t • Municipal Building Sof CD
\,. NontTenptan, N 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 110.R5.13.1
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.
> Massachusetts
' 1. DEP➢R1flEaP OF BpiLO1aG ZFSPECTIOES 2 .
212 Nein Street •Nun 1c 1 Building i CA
, .Nort 't.' M 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:
ne4t. Ave
(Please print house number and street name)
Is to bbe disposed of at:
ct00S�n
(PI ase print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature it 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.
ALN The Comrnonweahh ofMassachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass gov/dla
WVwskers'Compecountion Insurance Affidavit:BuilderstContmetors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/OrgmizalioNlndividual): // [�g� 'Thup
/
Address: a) 116y Q 5l).i
City/State/Zip: F-I cw Phone#:
Are you an employer'Check the appropriate box:
Type of project(required):
LE]I am a employer wah employees out and/or part-time)." 7. ❑New construction
I am a sole proprielor or partnership and have no employers working for me in S, Remodeling
ity.No workers comp.insurance required.]
3.❑ m 1 aahomow
ener doing alt work myself No workers'comp.insurance required.)t 9. Ohtl00
4.❑I am a homeowner and will be hiring contractors e,conduct all work on my property. I will IU❑Building addition
ensure that all commctom either have workers'compemetlon insurance or are sole 11.❑Electrical repairs Or additions
proprietorswith no employees. 12.❑Plumbing repairs or additions
5. I am ageneral contactor and I have hired the sub-contrecters listed on the couched sheet.
These sub-corionsors have employees and have workem'comp.insurence.t 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§I(4),ared we have no employees.[No workers'comp.insurance required.]
•Any applicant Nat checks box 41 most also fill out the section below,showing their workers'compensation polity information.
t Homeowners who submit this affidavit indicating they are doing all work and 0.hire outside emmumos must submit a new affidavit indicating such.
=C.ortutors that check this box muss attached an additional sheet showing the name of the sub-contractors and some whether or not Nose entitles have
employees. If me mb�onbacmrs have employees,they most provide theb workers'comp.policy number.
I am an employer that is providing workers'compensation imumuce for my employees. Below is the policy andjob site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job 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 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 fate of up to$250.00 a
day against the violator.A copy of this statement may he forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby eer]a the pains andpenalfies ofperimy that the information provided o is true and correct
Sime tur��Daw 5 I
Phone#:
Ojjiclat use only. IM 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#:
n CITY OF NORTHAMPTON
BUILDING DEPARTMENT
These plans have been reviewed
And approved. wrrH tioTeS
Date 5- q- Zojq -
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172.85 11 .26 2L2 Signature _
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