23A-178 (4) 24 PINE ST BP-2020-0166
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mo.-Block:23A- 178 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Bath reno BUILDING PERMIT
Permit# BP-2020-0166
Proiect# JS-2020-000279
Est.Cost:$25500.00
Fee: $166.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: HAYDENVILLE WOODWORKING & DESIGN INC 112863
Lot Size(sa.ft.): 6185.52 Owner. MARY F ALBERT
Zoning. URB(100)/ Applicant: HAYDENVILLE WOODWORKING & DESIGN INC
AT. 24 PINE ST
Applicant Address: Phone: Insurance:
35 CONZ ST (413)665-7402 O
Mnorthampton MaMA01060 ISSUED ON.811212019 0.00:00
TO PERFORM THE FOLLOWING WORK.-BATHROOM 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:
FeeType: Date Paid: Amount:
Building 8/12/201.9 0:00:00 $166.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2020-0166
APPLICANT/CONTACT PERSON HAYDENVILLE WOODWORKING&DESIGN INC
ADDRESS/PHONE P O BOX 1070 AMHERST (413)253-3229
PROPERTY LOCATION 24 PINE ST
MAP 23A PARCEL 178 001 ZONE URB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: BATHROOM RENO
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 112863
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 Storm Water Management
Demolition Delay
// 9 9-I Z-2619
Signa 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 Northamptort- .tatus-of~Permit:
Building DepJirtmk EC E 1 V Cuti riveway Permit
I 212 Main S'treet(� a er/S ptic Availability
t Room 1 0 I a er/W II Availability
Northampton, A 0 J066 ' 9 2019 Tw Sets of Structural Plans
phone 413-587-1240 ax 4113-587-1272 Plo/Site sans
DFPT OF CiUILDING INSPEC �@r Sp cify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE ORD A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map 3 Lot 7 O Unit
24 Pine St, Florence Zone Overlay District
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Mary Albert 24 Pine St,Florence
Name(Print) Current Mailing Address: 413-374-3488
Telephone
Signature
2.2 Authorized Agent:
Haydenville Woodworking& Design, Inc. 35 Conz St, Northampton, MA 01060
Name(Print) r Current Mailing Address:
413-665-7402
Signatur Telephone
SECTION 3-ESTIMAXCD CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 16,000 (a) Building Permit Fee
2. Electrical 3,200 (b) Estimated Total Cost of
Construction from 6
3. Plumbing 6,300 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection 0
6. Total = 0 +2 + 3+4+5) 25,500 1 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: 2"Zd1
Building Commissioner/Inspector 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
This column to be filled in by
Building Department
.........
Lot Size �.
Frontage
Setbacks Front µ �
Side L:= R:=] L:`.. � R:
Rear
Building Height — —'
Bldg. Square Footage ozo
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
_.... _.
Fill:
volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:l �
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW e YES
IF YES: enter Book ... Page. and/or Document#�
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO G
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO Q
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 ❑ Replacement Windows Alteration(s) EZ] Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other[p]
Brief Description of Proposed renovate bathroom
Work:
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll -Sheet
If rll►house aind or additl+on to existing housina, complete the following:
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
Mary Albert as Owner of the subject
property
Haydenville Woodworking & Design, Inc.
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
8 g �
Signature of ner D to
Haydenyille Woodworking&Design, Inc.
I, , 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.
ct1,�/•S�ioh� ��'y
Print Name '
Signature of Owner/ gen Date
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder Christopher J. Daley
License Number
35 Conz St, Northampton, MA 01060 112863
Address 4,2W Expiration Date
12/23/2022
Signature Telephone
413-665-7402
9. Registered Home Improvement Contractor: �, Not Applicable ❑
Company Name Registration Number
Haydenville Woodworking & Design, Inc. - 110732
Address ` Expiration Date
35 Conz St, Northampton, MA 01060 Telephone 11/8/2020
11/8/2020
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....... No......
City of Northampton
Massachusetts °�r4
DEPARTWNT OF BUILDING INSPECTIONS Ht °
212 Main Street • Municipal Building O�
Northampton, MA 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....or to 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: Renovation of bathroom Est. Cost:24,650
Address of Work:24 Pine St, Florence
Date of Permit Application:
I hereby certify that:
stration 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 he eby apply for a building permit as the agent of the owner:
Z Haydenville Woodworking & Design, Inc. 110732
Dak I Contractor Name HIC Registr tion
tA
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
g
DEPARTMENT OF BUILDING INSPECTIONS #�
s I4
212 Main Street • Municipal Building
Northampton, MA 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.R5.1.3.1
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
Massachusetts
w
'. DEPARTMENT OF BUILDING INSPECTIONS Z
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:
24 Pine St, Florence, MA 01062
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
Amherst Trucking, PO Box 39, North Hatfield, MA 01038
(Company Name and Address)
ignat r of e if Applicant or Own r ate
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.
Ln 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): Haydenville Woodworking & Design, Inc.
Address.35 Conz Street
City/State/Zip: Northampton, MA 01060 Phone #: 413-665-7402
Au x on an employer?Check the appropriate box: Type of project(required):
I. Z I am a employer with 6 4. [:l am a general contractor and 1 6 ew construction
employees(full and/or part-time).* ave hired the sub-contractors
2.n1 am a sole proprietor or partner- listed on the attached sheet. $ emodeling
L—Iship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp. insurance. �), uilding addition
[No workers' comp. insurance 5.aWe are a corporation and its III lectrical repairs or additions
required.] officers have exercised their
3❑1 am a homeowner doing all work right of exemption per MGL I I lumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12 oof repairs
insurance required.]t employees. [No workers'
13 her
comp. insurance required.]
*Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 is the policy and job site
information.
Insurance Company Name:A.I.M Mutual Insurance
Policy#or Self-ins. Lic.#:WMZ-800-8007423-2018A Expiration Date: 12/1/2019
Job Site Address:24 Pine Street City/state/zip: Florence, MA 01062
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 provide above is true and correct.
Si ature: Date:
Phone#:4 3-6 -74
Official use only. Do not write in this area, to be completed by city or town officiat
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#: