17A-214 140 North Maple St 140 NORTH MAPLE ST BP-2018-0046
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-214 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2018-0046
Project# JS-2017-002308
Est.Cost: $21000.00
Fee: $136.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 24611.40 Owner: JASINSKI LISA L
Zoning: URB(100)/ Applicant: JASINSKI LISA L
AT: 140 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
137 NORTH MAPLE ST
FLORENCEMA01062 ISSUED ON:7/13/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:MISC INTERIOR RENOVATIONS
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 7/13/2017 0:00:00 $136.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2018-0046
APPLICANT/CONTACT PERSON JASINSKI LISA L
ADDRESS/PHONE 137 NORTH MAPLE ST FLORENCE
PROPERTY LOCATION 140 NORTH MAPLE ST
MAP 17A PARCEL 214 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: MISC INTERIOR RENOVATIONS
New Construction
Non Structural interior 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
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 Water Management
Demolition Delay
Signature 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.
.' i J it �� l :
, , + .... .....'-11...-L-:-11,, i 1` Department use only
` t of Northam ton
� ' �:o�,�^rro� �j i ?� Y P status of Permit
i ' r i, 3 ilding Department Curb Cut r reway Permif
Z�TZ i
a itf
� 212 Main Street wer/Sept Av lability
f( - , Room 100 V1►ater/WeilAvailabilityrt, :,x >' ` ,c-'Bor hampton, MA 01060 lwo Sets of Structural Plans
` `' ala ,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 6r-tg - t-1-(A0
This section to be completed by office
1.1 Property Address:
�f /� Map ii A-- Lot CQ 1 4 Unit
t'4
190 i('t ST' Zone Overlay District
RL0(4( K-)C- 66 0l0Ct
i Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
K s A l k& i
j r ,� L(o N IIS-Pik ST I�t.i; r��--e- M 'Oc L
il-
Nami'nt) Current Mailing Address:
/ �� Lr 13 L Z z y .S
�. 'Yv'-�"" G^4 �.' -^il
Telephone /) / n z.v
Si nat re
2.2 Authorized Agent: c/
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 5' 0
0 0 (a)Building Permit Fee
2. Electrical - 00 (b)Estimated Total Cost of
02 t� Construction from(6)
3. Plumbingo Building Permit Fee
4. Mechanical(HVAC) ,,y `Pr
5. Fire Protection Imo/
6. Total=(1 +2+3+4+5) v'2 /� 00C) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: ___4,`—`-
...- I aril "q t 3 f("�
Building Commissioner/Inspector of Buildings / Date !
a
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 11 it-
Frontage
Setbacks Front
Side L: R:_
Rear ,
4!'1 )ie ( , t. t
Building Height
Bldg. Square Footage '7-ii
Open Space Footage .., J
(Lot area minus bldg&paved �'"-f L
parking) —
Y
`
#of Parking Spaces � ' ) �'�((ki` v
Fill:
(volume&Location)
A. Has a pecial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:''
IF YES: Was the permit recorded at the Registry of Deeds?
NO IS DONT KNOW 0 YES 0
IF YES: enter Book Page, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO -!4
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 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing E
Or Doors 0 fJja,rui keituo€
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [E] Siding[D] Other[Dl
Brief Description of Proposed.
Work: IY115c, (A1eJL c>- Q,'k"�Vku' �1t%Y
Alteration of existing bedroom Yes INo Adding new bedroom Yes v No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
sa.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
I, ''''flit .,, (+ , as Owner of the subject
property
hereby authorize
to act on behalf, in . :tters relative to work authorized by this building permit application.
Arm It . clk---ij""--.'
Sig atur- of Owner Date
I, )\_,
k ii-• ^ J ( 1A--SL,--") ,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 ugder the pains and penalties of perjury.
Print Name
Signat e o Owner/Agent Date f–fp (( -1.—
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: (c.V!(� 1 J 6ehtte`eu
License Number
(� caMS VA I
Address Expiration Date
Signature Telephone
9.RRegii(steerre ome Improvement Contractor Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
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 0 No 0
The Commonwealth of Massachusetts
Department of Industrial Accidents
=tag=. l Office of Investigations
.11 600 Washington Street
Sile= Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Lts?- /
Address: N U NS i"
��----
h
City/State/Zip: e Vex=-e. 0\6 Phone #: Lit 1t3'
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 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. * 7 ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.JI 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' 13.0 Other
comp. insurance required.]
*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 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 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 ins and penalties ofperjury that the information provided above is true and correct.
Signature. � i
g � 7 Jyt.���__.. Date: ` //3//' 1
Phone#: '/1 d,) Y f
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
7 sHaM"o x
fr
Massachusetts �,�'�� �'��
A # c
11 DEPARTMENT OF BUILDING INSPECTIONS '.
212 Main Street •Municipal Building
Northampton, MA 01060 4SYyrjt`‘
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:
(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:
iivi,t(L1
(Company Name and Address
Signature of Permit Ap• icant 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.
I
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