38B-219 17 FAIRVIEW AVE BP-2019-0226
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man:B1mk:38B-219 CITY OF NORTHAMPTON
Lot-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeom Bath reno BUILDING PERMIT
Permit# BP-2019-0226
Proiect# JS-2019-000359
Est Cost: $20000.00
Fee: $130.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sp.ft.): 4399.56 Owner: MAZZEI CRISTIANO
Zoninx URB(100)/ Applicant: MAZZEI CRISTIANO
AT. 17 FAIRVIEW AVE
Applicant Address: Phone: Insurance:
17 FAIRVEIW AVE (413) 658-8813 O
NORTHAM PTONMA01 060 ISSUED ON.8/23/20180:00:00 ta, -
TO PERFORM THE FOLLOWING WOR%BATHROOM MODEL
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 siunature:
FeeType: Date Paid: Amount:
Building 8/23/20180:00:00 $130.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File 4 BP-2019-0228
APPLICANT/CONTACT PERSON C L FAMILY TRI MT C/O CHPdSTINE G WHALEN TRUTEE
ADDRESS/PHONE 17 FAIRVIEW AVE NORTHAMPTON
PROPERTY LOCATION 17 FAIRVIEW A'/E
MAP 38B PARCEL 219 001 ZONE URB(t001L/
THIS SECTIO,l FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
SED REQUIRED DATE
ZONING FORM FILLED OUT zlw
Fee Paid
Building Permit Filled out
Fee Paid
Tvmeof Construction: BATHROOM MODEL
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-
ReceiveQ&Recorded at Registry of Deeds Proof Enclosed
_Other Permits Required:
Curb ut 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
molitic r Delay q�
C/
Signatu m did fT Da�
Note: Issuance of a Zoni ermit 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.
City of Northampton
Building Department - qv
212 Main Street
Room 100 kva"IaOiky °'
Northampton, MA 01060 V
T 1,i::
phone 413-587-1240 Fax 413-587-1272 N"
APPLICATION TO CONSTRUCT,ALTER, 4E E' ONE OR TWO FAMILY DWELLING
PAI"'
SECTION 1-SITE INFORMATION AUG 2 1 2018
1.1 Property Address Tq I Is se, dean to be completed by offics,
0 F ' wP1N5PPC�1 3Unit
t AI(Zj 0 il-ked, '4 q
Niga-thAAKeldNi MA Zone Overlay District
Elm St District_ CS District;
SECTION 2-PROPERTY OWNERSHIPAUTHORIZED AGENT
2.1 Owner of Record:
N)A7 c ST,pi'� AVF
Name(Prill I Current Mailing Address,
17 �v ot Telephone q
Si
22AJ.th ..tdA
gent:
Name(Prrn 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 (a) Building Pend Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection Ji
6. Total=(1 -2+3+4 5) Check Number
This Section For Official Use Only
Building Permit Numbs Date
Issued:
Signature:
Building Commissionerfinspector of Buildings Date,
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
'ries column bu be fillml in by
Bur ing Depamr.1
Lot Size _ __.
Frontage
Setbacks Front
Side L: R'_ L: R:—
Real
.Rear .. _._.... _.
Building Height -----'
Bldg.Square Footage
Open Space Footage % _ --
(IAt arra minus bld&
If of Puking Spaces -
Fill: ._ ( "....
(volume&Location) I_
A. Has a Special Permit/V/eg
/Finding ev been issued for/on the site?
NO O DOW O YES O
IF YES, date issued:.
IF YES: Was the permit reat the egistry of D s?
NO O NOW 5 O
IF YES: enter BooPage and/or Document#
B. Does the site contain a brdy f water or wetlands? NO DON'T KNOW O YES O
IF YES, has a permit bee to be obtained from the Conse ation Commission?
Needs to be obtainedObtained O , Dat Issued:C. Do any signs exist on the y? YES ONOIF YES, describe size, tylocation:D. Are there any proposed chto or additions of signs intended for the property? YES ONO O
IF YES, describe size, tylocation:
E. VJIII 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.
3
SECTION S DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks fO Siding[[:3] OtherlC:q
Brief Description of Proposed
Work: KIrTF-rc^ ,1 K/
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
Be.H Few hgm and o r a a"don to sodardinka housina. c m late ft followin a :
a. Use of building XCcmplian�. Mass
ily Two Family Other
b. Number of roomch fame nit: Number of Bathrooms
c. Is there a garaghed?
d. Proposed Squaage of new construction. imensicns
e. Number of stori
E Method of heatireplaces or Wootlstoves Number of each
g. Energy Conserompliance. Mass eck Energy Compliance form attached?
h. Type of constru
i, Is constmction 100 ft. of rands?_Yes No. Is constructi within 100 yr. floodplain_Yes No
j. Depth of basemar floor below finished gradek. Will building coto 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
1, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, C(2J ejTI/-D-'U0 rla � ffvN 054 ,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 belie(
Signed under the pains d penalties of perjury.
Print Name
SignaW Date
C k;C' Al P'Z Z4CCA' Q y 4F ' CO I
SECTIORA,CONSTRUCTION SERVICES
6.1 LI nsed C traction Supervisor: Not Applicable ❑
Nam.,f License Haldar:
License Number
Address Expiration Date
Signature Telephone
S.Registered Hi Imorowmsnt CorRauYar: Not Applicable ❑
Company Name Registration Number
Address Expiration te\
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers CompensaLon Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the dental of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
City of Northampton
i
i Massachusetts
i
l' I)212 Gain S OF B* ILUNG*amici al suil1YOna v-
212 Mein Street • Municipal aviltling =c •Ce
nor[hamp[on, !A 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 he 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: rt)A�tq toom rU,,ry )a. 1 Est.Cost: aF coo /M
Address of Work: ppr I �I F oM Yl l�f�N ry? "t
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:
Date Contractor Name HIC Reg'Jb
n No.
OR:
No thst tiding the above notice,I hereb"pply for a building permit as the owner of the property:
CO A-K,'U 114pz7�il
Efate I Owner Name and Signature
t
City of Northampton
Massachusetts
c
DCPARTNENT OF BUILDING INSPECTIONS LJ
212 Main Street • Municipal Building
Northampton. 01060
Massachusetts Residential Building Code
Section I IO.R5.1.2
Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside,
on which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/ or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 1IO.R5, provided that if a homeowner engages a persons)
for hire to do such work, then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she shall be responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on thejob site will be required from time to
time, during and upon completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153
(Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts
General Laws Annotated, you may be liable for persons) you hire to perform work for you
under this permit.
City of Northampton
S 4"J�O
l Massachusetts
/ a 4;
i C DEPAETBENT OF BUILDING INSPECTIONS L
212 Main Straat *Municipal Building
Northampton, M 01060 \ha
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 heiln/g performed at:
A•1 /T
IT rUtEAJ 6/
(Please print house number and street name)
Is to be disposed of at:
A)C'
(Please Irnt name and location or facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Compan ame and Address)
ignature Icant or Owner Date
If, for any rea n, a debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Dep rtment as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 700
Boston,MA 02114-2017
www.mass.gov/dia
W urkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information '�"Please Print Legibly
Name(BusinesyOrgmizationnndividua0: i)'/.� Z761
Address: 1-7 Fq I o i6w f ppy F
City/State/Zip: OocT� P Pok) m A Phone#: 14��J — .b/ 4 <7 U
Are you an employer?Check the appropriate bas:
Type of project(required):
I.[]I am a employe,with employs-fen[]ensure pan-tard.. 7. ❑New construction
L❑[am sole pmpne or pmmership sod have no employee woddmg t,mem g. E]Remodeling
y capacity.[No workos'comp.insurance requite.] s
3gl am ahomeownddodgall work myself[No workens'comp.insumnce¢quved]' 9. ❑Demolition
10❑Building addition
4 1 am a homeowner and will be hhavewnhvetars m condudai work insurance
my e,solety. 1 will
we that all wno-acmrs eimer have wrrkmx'cmnpensation dsmunee or are sole 11.❑Electrical repairs or additions
proprieers with no employees.
12.[]Plumbing repairs or additions
s rl 1 cone general contractor and 1 have hiredsrkaawrs Meted on me attache sheet
Th .These orb-canhacims neve employees and base
workers'comp.insumvice? 13 ❑Roof rePairs
6,E]We are a co tion and it olfiom have exercise their right ofexcmuon 14.❑Other
ryom g p per MGL c.
152,3114),and we have no employees.[No workers'comp,huumtme inquired.]
"Any applicant that checks box#1 must also fill out the section below showing men wortens'compensation policy information.
I Homeowners who submit this andavit indicating they are dying all work and men hire out ids considers must submit a new affidavit Indicating such.
:Contractors mat check this box must nodded au additional sheet showdg the time drove sub-contmemd and slate whether or not those entities have
employed. If the sub contractors have employees,they must provide meth workers'wran.policy number.
I am an employer that is providing workers'rompensadon insurance far my employees. Below is the policy addict,site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. q: Expiration Data
Job Site Address: City/State/Zip:
Attach a copy ofthe 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 punishable by 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.A ma be forwarded to the Office of Investigations of the DIA for insurance
coverage verift n.
I do Is y certify under the pains and penalties ofpetyury thifirrhar4olormaltion provided above is nue and camera
ituni ure' Date
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or PermiNLiceme#
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,amt or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)morels),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be resumed to the city or town that the application far the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 7406 or 1-877-NIASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
Information and Instructions
Mrsix.husens General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However,the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority"
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy
is required.Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of
insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town
that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you
have any questions regarding the law or if you are required to obtain a workers compensation policy,please call the
Department at the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the perniulicense number which will be used as a reference number. In addition,an applicant that
must submit multiple perm Ulicense applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). A copy of the affidavit that has been officially stamped or marked by the city or town
maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit
must be filled out each year.Where a homeowner or citizen is obtaining a license or permit not related to any business
or commercial venture(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number-
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Farm Revised 02-23-15