11A-004 (4) 17 EVERGREEN RD BP-2020-0617
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 1 I-004 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Zoning Permit BUILDING PERMIT
Permit# BP-2020-0617
Project# JS-2020-000831
Est.Cost:$45500.00
Fee: $470.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: ALLEN GUIEL 054248
Lot Size(sq. ft.): 22041.36 Owner: HOBBS DAVID B
Zoning: URA(102)/ Applicant: ALLEN GUIEL
AT. 17 EVERGREEN RD
Applicant Address: Phone: Insurance:
63 CHESTERFIELD RD (413) 268-9200 O WC
WILLIAMSBURGMA01096 ISSUED ON.11/15/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO EXISTING GARAGE AND BUILD NEW
24X28 GARAGE
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 11/15/2019 0:00:00 $470.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2020-0617
APPLICANT/CONTACT PERSON ALLEN GUIEL
ADDRESS/PHONE 63 CHESTERFIELD RD WILLIAMSBURG (4 13)268-9200 Q J
PROPERTY LOCATION 17 EVERGREEN RD
MAP 1 IA PARCEL 004 001 ZONE URA(102)/
THIS SECTION FOR OFFICIAL USE ONLY: n r�
PERMIT APPLICATION CHECKLIST
E OSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out
Fee Paid
T_ypeof Construction: DEMO EXISTING GARAGE AND D NEW 24X28 GARAGE
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/Statement or License 054248
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF90MATION 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
I TLW/ 1 A6 )
Sign ture of Building Official 10 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 Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
; ,. Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION RECEIVED
1.1 Property Address:
This section to be completed by office
NOV - 6 201 lap Lot Unit
Zone Overlay District
DEPT.OF BUILDING INSPECTIONS
NORTHAMPTON.MA ct CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
X a,J," -k �A v -, ri= ,1 Lza►h j �1 r� �3i E
Name(Print) Current Mailing Add ss:
Telephone
Signature
2.2 Authorized A ent:
Ayi 6u •P C�S e Pl. � �)JIIA 6l
Nam t) Current Mailing Address:
yl
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building -13 � `0 (a)Building Permit Fee
i
2. Electrical -a (b)Estimated Total Cost of
9 Construction from 6
3. Plumbing Building Permit Fee
T-4K 2-4 X ,2m�S'f CzQ1P, -7A 1
4. Mechanical (HVAC)
5. Fire Protection '&rx2`I X ` &0 � u v� Ftop
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
all
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
rIK2I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House E] Addition Replacement Windows Alteration(s) 0 Roofing 0
Or Doors l]
Accessory Bldg. Demolition 417=11 New Signs [Ell Decks [M Siding[p] Other[lam]
Brief D -e\Lk of rop sed G 2r e v 1 $�
Work: //
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, 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
®Ao"' as Owner of the subject
property �1 //
hereby authorize !"�I 1 k VL 61 t�#-► e-
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date _T
I, lura �V(-� 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 pe alties of perjury.
U -Q
Print Name
. I1
Signature of Owner/Agent Date �J /
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
e Building Department
Lot Size
Frontage
Setbacks Front
Side L:�11 R: Z76 L15— R:
Rear `� a
Building Height `
Bldg. Square Footage % 1
Open Space Footage { OX
(Lot area minus bldg&paved I y ! &:7 j`I f(�
parking) 1 I
#of Parking Spaces
Fill: 11
volume&Location i t A Q 2 v
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW O YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 9 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
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
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder: O y�P V
License Number
A s Expiration Date
13a�g �a�
Sign ure Telephone
9.Re istered Home Im rove ent Contractor: Not Applicable ❑
4— �OWV y
Company Name Registration Number
1u Ili L: fin D) 13. 06
Addie*. // Expiration Date
Telephone L ' o6
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 �
�f. 4 DEPAR2MNT OF BUILDING INSPECTIONS
!' 212 Main Street a Municipal Building
C_--' 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, modemization, 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: W� JlC7y� — qa
1A,-((77 Est. Cost:
Address of Work: 1 F)E6-P �
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 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 hereby apply for a building permit as the agent of the owner:
&vI �U)_4 pggq�
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 Signature
City of Northampton
*JUV
MassachusettsDEPARTiNENT OF BUILDING INSPECTIONS
212 Main Street •Municipal BuildingNorthampton, 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:
-1 6\,J�(4 gE-,-r-70 poq�=Q
(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:
(Company Name and Address)
Sig ature of Perm t 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.
\ 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:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print i.ellibly
Business/Organization Name:Allen Guiel
Address:63 Chesterfield Road
City/State/Zip: Williamsburg MA 01096 Phone#:413 268 9200
Are ou an employer?Check the appropriate bog: Business Type(required):
1. I am a employer with 2 employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers'comp.insurance required] 8• Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers'comp.insurance required]* 11.❑Health Care
4.E3 We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp.insurance req.] 12.❑Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy in formation.
Insurance Company Name: HARTFORD UNDERWRITERS INS CO
Insurer's Address: P O BOX 1450
City/State/Zip: MIDDLEBORO, MA 02344-1450
Policy#or Self-ins.Lic.# 6S60UB-9F66069-2-19 Expiration Date:04-27-20
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 herebyc under ains enaldes ofperjury that the information provided above is true and correct.
Si ature: Date:
Phone#: 413 268 9200
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.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia