30B-051 (4) BP-2021-2289
189 RIVERSIDE DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
30B-051-001 CITY OF NORTHAMPTON
Permit: Addition
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-2289 PERMISSION IS HEREBY GRANTED TO:
Project# 2 STORY ADDITION Contractor: License:
Est. Cost: 333400 DOUGLAS THAYER 107699
Const.Class: Exp.Date:04/07/2022
Use Group: Owner: SMITH JASON S
Lot Size (sq.ft.)
Zoning: URB Applicant: DOUGLAS THAYER
Applicant Address Phone: Insurance:
P O BOX 60322 (413)530-4785 6HUB-9F79609
FLORENCE, MA 01062
ISSUED ON:12/17/2021
TO PERFORM THE FOLLOWING WORK: •
2 STORY ADDITION
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.
Signature: Qr
itm
Fees Paid: $2,167.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 •
Office of the Building Commissioner
File #BP-2021-2289
APPLICANT/CONTACT PERSON:DOUGLAS THAYER
P O BOX 60322 FLORENCE, MA 01062(413)530-4785
PROPERTY LOCATION 189 RIVERSIDE DR
MAP:LOT 30B-051-001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $2,167.00 I
Type of Construction: 2 STORY ADDITION V
New Construction ,
Non Structural Renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFISRMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Perm it 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 Perm its 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
, cf: 3-/1 NVai
Si_i ature 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.
/ ( .
V
i
The Commonwealth of Massachu/ttsOrF �t"'"
W Board of Building Regulations/and andardc 1 4 20 FORI PALITY
Massachusetts State Building{Code; ,,,T oa CMR 2/ USE
Building Permit Application To Construct,Repair; eky ' olish evised Mar 2011
�spti
One- �o,
or Two-Family Dwelling ' 1 0,cr oN
This c 'on For Official Use Only -
Building Permit Number: _be. a 1" ;2-1 Date Applied:
! ;) R
_ ��i�\ . y.11 i
13ui1ding Official(Print Name) I Signature • D to
SECTION 1: SITE INFORMATION
1.1 Property Ad ress: 1.2 Assessors Map& Parcel Numbers
iCSq .ter,,s:da fir log — OS/
1.1 a Is this an accepted street?yes )( no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
MR R9$% 9 I a-61 .AMS c 7,S
Zoning 'strict Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
110' t 5 ' 9 0'
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: Q 1
31xSoe, 5,�t, Plave,y �� A
Name(Print) City,State,ZIP
50I Rivet/ SadP dv
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition,
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work':
g S I-0 vo add,: .1-1‘c1, A I to,i o 1 x..'s-,‘4)
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1-7 0 y0o 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ 1 0 Standard City/Town Application Fee
4 j 00 0 0 Total Project Cost3 (Item 6)x multiplier x
3. Plumbing $ `a i 0 0 0 2. Other Fees: $
4. Mechanical (HVAC) $ a v 000 List:
5. Mechanical (Fire $
Suppression) Total All Feitli a4)
Check Nd 1.W I Check Amount*.Z 67 'Cash Amount:
6.Total Project Cost: $ J 900 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisoru License(CSL) CS— 10701
U 07 2q.
V 0&t1 Q S 11101411 License Number Expiration Date
Name of CSL Holder
�7 List CSL Type(see below)
�U •',1) 6 6 3 01 x No.and Street Type Description
oyQ B C t J1A 000 U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
(� I_ RC Roofing Covering
1JO Olr S i Lay (. f#ta; .CCIt WS Window and Siding
u 7 v u SF Solid Fuel Burning Appliances
'f 7' S I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
0 a l�s �"h� � HIC �qo s s iv � /
Q Registration Number Expiration Date
HIC Company Nar'or HIC �egistr Name
No.and 'Oet Got66 ria,eu�� Doa 11sthaiNts rtr.� . mIn
Email address g
City/Town, State,ZIP Telephone
SECTION 6: 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 . ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 0341 ft S 1).144 4
to act on my behalf,in all matters relative to work authorized by this Building permit application.
Print Owner's Name(Electronic Signature) / Date
SECTION 7b: OWNER1 OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understandin
(AC dyk S
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count 6
Number of fireplaces / Number of bedrooms "3
Number of bathrooms Q. Number of half/baths d2
Type of heating system /h;4; 5a(. Number of decks/porches
Type of cooling system /'1; ; 54 I(1- Enclosed — Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
cO e 0° I Qlao
Y�d\` -
4
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton
gJt\ y1ri. Sf4'
Massachusetts # :.(4 *3 41;
ttY
z' DEPARTMENT OF BUILDING INSPECTIONS a
212 Main Street • Municipal Building
° Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: V a II k 62o C k c�
The debris will be transported by:
Name of Hauler: AlAA0v5 �I/ u C lCc 14
1
U C
Signature of Applicant: Date:
.Z\ The Commonwealth of Massachusetts
. Department of Industrial Accidents
• .,.- ,,,„_„. •
I Congress Street,Suite IN
0 Boston, MA 02114-2017
..4, .....',. . .,
wwwmass.gov/dia
44 0.1,
— Workers'Compensation Insurance Affidavit:Builders/ContractorstEkctricians/Plumbers.
TO HE FILED WITH THE PERMITTING AtTlItIRITE.
Applicant Information Please Print Letibtv
1 ....i_i
Nance I Business,OrganizationAndiviciunii: 61 ( 5 1 rvtlfir
Address: i)0 _VI 41_ .6±0,21 1_ Flmig 4 11 „A
City/State/Zip: Phone#: i'll - G 3 0 - Y7iS
,tre CIO WI employer?Clerk the appropriate box: Type of project(required):
t tip am a empkrya with employetit(full incise part-tirriel.. 7. New construction
2C3 I am a sole proprietor or p.nmership and have no employees working for me In B. Remodeling
any capacrty,(No vvorkers'comp.insurance required]
9. Demolition
I 4M a homeowner doies all work myself.(No workers'comp.west:vice manual°
I 0[]Building addition
1.0 i sm a homeowner and will be hiring saminsetors to conduct ail work on my property_ twill
CILSigtr dam all contractors either have mete's°compensation insurance tie arc sole 1 1.0 Electrical repairs or additions
proprietors with no employees,
i 2.0 Plumbing repairs or additions
50 I ant a general contractor and I have hued the sub-contractors listed on the:sturdiest sheet
These sub-contractors have employees and have workers'comp.insurance.: 1313 Roof repairs
14.0 Other
ba We are a corpocation and its officers have exercised their right of exemption per MGL c.
152.§1(4).and we haw no employtta.[No*utter.'comp,insurance required.)
'Any applicant that checks box al must also fill our the reetion below showing Mee worker.s compensation policy information
f ihnneowners who wham this affidavit indwatmg they are dostss all work and than hire outside contractors mum'about a new affiaiatv ti Indicating such.
1Coratractors that eiseek this box mum aturded an additional sheet showing the name of the erocs and mate w heater or not those moues hese
employees, If the nub-ClArArsciurs have emplitytet,they must preside their workers'comp.policy number
lam an employer that is providing mothers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 1 Yav a 14.1 V064, d
Policy a or Self-ins.Lie. a: 6 I-)ttb 6 k6s 6 Expiration Date: 10 I li A R,
Job Site Address, 1 c5 1 (-ki-eosi‘ *Le i City/StateJZip:
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 punishabk by a tine up to SI.500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 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 cerd ,under the pain penaltio of perjury that the Information provided a re is foe and correct.
Signature: / .
Datc- )(2 /1 0Z. I
Phone a: 1/4/ I I - Sc' - 97 1"
Official use only. Do not write in this area.to he completed by city or town official
('ity or Town: Permit/License a . .
'!
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.CityiTown Clerk 4.Electrical inspector S. Plumbing Inspector
6.()flier
[ Contact Person: Phone a:
.--.1