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
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GILBERT 16 FORBES AVE NORTHAMPTON 4 /_ / Q'
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