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31A-147 (8) BP-2022-0312 16 FORBES AVE COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31 A-147-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-0312 PERMISSIONIS HEREBY GRANTED TO: 2022 RENO LIVING ROOM & Project# LAUNDRY Contractor: License: HAYDENVILLE WOODWORKING & Est. Cost: 27930 DESIGN INC 116208 Const.Class: Exp. Date:04/13/2025 Use Group: Owner: GILBERT BORER, JEREMY& EMILY Lot Size (sq.ft.) Zoning: URB Applicant: HAYDENVILLE WOODWORKING & DESIGN INC Applicant Address Phone: Insurance: 35 CONZ ST (413)665-7402 WMZ-800-8007423-2021A NORTHAMPTON, MA 01060 ISSUED ON:04/04/2022 TO PERFORM THE FOLLO WING WORK: LIVING ROOM REFRESH AND MOVE LAUNDRY TO 2ND FLOOR 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: . cga • r 6 Fees Paid: $182.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner Department use only o�H at: . City of Northampton Status of Permit: ? i. .. Building Department Curb Cut/Driveway Permit ;I, 212 Main Street Sewer/Septic Availability _ ; ;� Room 100 Water/Well Availability • .. - ` '' I 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 1.1 Property Address: This section to be completed by office Map 31 A Lot I#7 Unit 0 O ( 16 Forbes Ave Zone UR,3 Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Emily Gilbert+Jeremy Borer 16 Forbes Ave Northampton Name(Print) Current Mailing Address: 917-816-0690 Telephone Signatur efilA e_._.------ 2.2 Authorized Agent: Haydenville Woodworking&Design,Inc. 35 Conz Street,Northampton,MA 01060 Name Print) Current Mailing Address: /<� 413-665-7402 n r Telephone ION 3-ET1ll 1ATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 15,970 (a)Building Permit Fee 2. Electrical 8,600 (b)Estimated Total Cost of Construction from(6) 3. Plumbing 3,360 Building Permit Fee 4 . 4. Mechanical(HVAC) I Z- c 5. Fire Protection 0 6. Total=(1 +2+3+4+5) 27,930 Check Number )*2y-2_2. This Section For Official Use Only 2b 2 2-6312 I s te Building Permit Number: Issued: Signature: 1 Li-11" Z Z2- 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 Side L: R: L: R: Rear Building Height Bldg. Square Footage 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 DONT KNOW O YES 0 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 O DON'T KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O NO O 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 O 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 O NO O 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) n Roofing a Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[DI Other[0] Brief Description of Proposed living room refresh and move laundry to second floor 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 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 • Emily Gilbert+Jeremy Borer , as Owner of the subject property Haydenville Woodworking& Design, Inc. hereby authorize to act on my be , in all matters relative to adLauthorized by this buil ing permit application. Signature of Owner D I, lA ,CAN Kzi I'leiwil((d&ow 49JJlf IA/C as Owner/Authorized Agent herby declare that the statements and information dn the foregoing'application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ,/rY/4/A Print Name SiSi a e O er/ gen Date 9 � SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: Zinnia Wu Stetson License Number 35 Conz Street, Northampton, MA 01060 116208 Address Expiration Date 413-665-7402 04/13/2025 gna ure Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Haydenville Woodworking & Design, Inc. " ..� 110732 Address Expiration Date 35 Conz Street, Northampton, MA 0106 Tel-.17M65-7402 11/2/2022 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 0 City of Northampton Massachusetts ��� • 'e ' 1/4. ' N $eadir, DEPARTIONT OF BUILDING INSPECTIONS y 212 Main Street • Municipal Building Northampton, Mil 01060 st' .3,-p‘\`' 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: living room refresh and move laundry to second Est. Cost: 27,930 Address of Work: 16 Forbes Ave Northampton 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: Haydenville Woodworking & Design, Inc. 1 0732 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 /,,,, , , „4,. City of Northampton r* ,.,„, :: ,,(• Massachusetts �4? S N DEPARTMENT OF BUILDING INSPECTIONS 1. en ^,. W a; 212 Main Street •Municipal Building vs cD� ' r "`-, Northampton, MA 01060 'SPA, N'�`� 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: 16 Forbes Ave (Please print house number and street name) Is to be disposed of at: Valley Recycling, Northampton (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) //Z riat of i �'31. ( -Sig u e perm' pplicant 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 lr�;lill= i Office of Investigations E =tlln_ § 600 Washington Street t'.11= Boston,MA 02111 Y'tlf 1, www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Haydenville Woodworking & Design, Inc. Address: 35 Conz Street, Northampton, MA 01060 City/State/Zip: Phone#: 413-665-7402 Abe you an employer?Check the appropriate box: Type of project(required): 1 I am a employer with j 4. 0 I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ ?•IiII Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. 0 Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.0 Other *Any applicant that checks box#1 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for no,employees. Below is the policy and job site information. Insurance Company Name: A.I.M. Mutual Insurance Policy#or Self-ins.Lic.#: WMZ-800 8007423-2021 A Expiration Date: 12/1/2022 Job Site Address:16 Forbes Ave city/state/ziJorthampton, MA 01060 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 provided above is true and correct Signature: _ / ' %� Date: Phone#: 413-�65-/402 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#: t ,.\ 1 1 . _. . 1 1 1 I 9Iilit „r, EXISTING 1 1 DOOR I ii � TO I I BEDROOM I 1 _ \\ 0 1 t I -00 . •�ff 1 ` I I — 10,5 /610 I It I ) „, MOVE WASHER AND DRYER TO THE BEDROOM CLOSET DIRECTLY ABOVE EXISTIING WASHER AND DRYER LOCATION. / , ,., x ADD DRIP PAN UNDER WASHER ADD DOUBLE BARN DOORS TO CLOSET. INSTALL ADJUSTABLE SHELVES NEXT TO THE LAUNDRY REVISIONS II Haydenville Woodworking & Design, Inc. MM/DD/YY REMARKS '� LAUNDRY Lvyp Desi¢u4 Build-General Contractors-•Residential Constru-tion-Since 14S4 r u3/30/22 7S O 3 --/--/-- ... GILBERT 16 FORBES AVE NORTHAMPTON 4 /_ / Q' 5 --/— /-- ...