25C-069 (5) 30 DAY AVE BP-2020-0393
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-069 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-2020-0393
Project# JS-2020-000672
Est. Cost: $5000.00
Fee: $100.00 PERMISSION IS HEREB Y GRANTED TO:
Const. Class: Contractor: License:
Use Group: CHADD MEERBERGEN 103548
Lot Size(sq. 1): 8189.28 Owner: ABDUL-RASOOL HALA&CARL KNERR
Zoning: URB(100)/ Applicant: CHADD MEERBERGEN
AT. 30 DAY AVE
Applicant Address: Phone: Insurance:
51 LINCOLN AVE (508) 221-4609
NORTHAMPTONMA01060 ISSUED ON:9/27/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.RENO 1 ST FLOOR BATH
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 9/27/2019 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
i
File#BP-2020-0393
APPLICANT/CONTACT PERSON CHADD MEERBERGEN
ADDRESS/PHONE 51 LINCOLN AVE NORTHAMPTON (508)221-4609
PROPERTY LOCATION 30 DAY AVE
MAP 25C PARCEL 069 001 ZONE URBOOO)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIREb DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: RENO 1 ST FLOOR BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 103548
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 Watcr Management
Demolition Delay
q a� ► g
Sig ture of Building Official 10 Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to complywith 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.
Version 1.7 Commercial Buildin Permit May 15,2000
Department use only
E� 1/ - - City of Northampton status of Permit:
--- V_' Building Department Curb Cut/Driveway Permit -
212 Main Street Sewer/Septic Availability
SEP Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
iTHq! DTN ItJcpFCTIoNt o, ON$ Other Specify
A Td CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
30 p"'/ AVS Map dS(�, Lot 0('rVUnit
N o r+h"k p}a'\ M A OI D(.o Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
i��' � SS � 7�OCv
Signature c✓� Telephone
2.2 Authorized Agent:
Name(Print) Current Meiling Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Z CXR C7 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
1,000 Construction from 6
3. Plumbing 2,000 Building Permit Fee
_ V
4. Mechanical(HVAC) � n
5. Fire Protection
6. Total=0 +2+3+4+5) S•n� Check Number
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
Versionl.7 Commercial Building Permit May 15,2000
SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations 0 Existing Wall Signs ❑ Demolition Repairs Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing Change of Use❑ Other ❑
Brief Description R¢.�o� IA I s r f hoc':
Of Proposed Work: a-VtL-A-61C 1-1 N ; Ij(oarS ,
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly ❑ A-1 ❑ A-2 ❑ A-3 Cl 1A ❑
A-4 ❑ A-5 ❑ 113 ❑
B Business ❑ 2A ❑
E Educational ❑ 213 I ❑
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 313
M Mercantile ❑ 4 ❑
R Residential R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE
Existing Use Group: Proposed Use Group:
Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34):
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(so
Scar u- Sc..rn e—
1 st I 1 n I
2nd 2nd
------------
3 d _ 3m F
4'h
Total Area (sf) Total Proposed New Construction(sf)
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40, §54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
L � J
Side L: R: L: R: �
r---, �7
Rear 4
Building Height
Bldg. Square Footage � % �—
i
Open Space Footage %.
(Lot area minus bldg&paved
parking)
#of Parkin Spaces
Fill: f
volume&Location) __ _.__.____
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOWO YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOWO 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? YESO 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 0
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? YESO NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Versionl.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
F Name(Registrant):
Registration Number
Address _
F)irabon Dale
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Fiiration Dale
Name Area of Responsibility
Address Registration Number
_l
Signature Telephone Dale
Name Area of Responsibility
-----__.....__
Address Registration Number
IA_
Signature Telephone Expiration Date
Name Area of Responsibility
I
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
0,d C NO Applicable ❑
Company Name:
Responsible In Charge of Construction
L; ✓� c o l v\ iA-y e
Address
Signature Telephone
Versionl.7 Commercial Building Permit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes O No O
SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property
hereby authorize to
act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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 ppdury.
Print Name
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: G 5 _ U 3 S _Y
License Number
C r r < C> j Z1';' l 2
Address F)iration Date
2z ( -4-1Ld9
Signature Telephone
SECTION 13-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 a No O
The Commonwealth of Massachusetts
Department of Industrial Accidents
> 1 Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address: I L t,-1 C_p u.,
op'.-e—
City/State/Zip:____ 01 D Phone#: Sd if Z Z f oc�
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).' 7. ❑New construction
2.�am a sole proprietor or partnership and have no employees working for me in $ remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
4.❑[am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole 1(.Electrical repairs or additions
proprietors with no employees. 12.[R'l umbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet
These sub-contractors have employees and have workers'comp insurance.:
13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#I 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:
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 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 certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: Z.S-A-0
Phone#: 6
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 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: 30 `�M!, 'ILv e
The debris will be transported by:
The debris will be received by: u
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
34in.
25in, 25in. 19in.
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32.5in.
Shower N
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60in.
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35in. 25in.
9in. —-- - 69i6.
Scale:1/16:1