04-003 (7) 521 AUDUBON RD BP-2019-1008
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:04-003 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category:Bath rano BUILDING PERMIT
Permit# BP-2019-1008
Project# JS-2019-001661
Est.Cost:$21150.00
Fee: $137.00 PERMISSION IS HEREBY GRANTED TO.
consL Claw: Contractor: License:
Use Group: DANIEL HATHAWAY 081793
Lot Size(w. Rl: 718740.00 Owner: ANSALDO ROBERT L&KELLY I
Zoning: RR(100) WSP(54)/WP(15v Applicant. DANIEL HATHAWAY
AT.- 521 AUDUBON RD
ApplicastAddress: Phoned Insurance:
2OLD GOSHEN RD (413) 695-2937 0
WILLIAMSBURGMA01096 ISSUED ON:3/19/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:RENO BATHROOM
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 Find:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: 001: 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 3/1920190:00:00 $137.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2019.1008
APPLICANT/CONTACT PERSON DANIEL HATHAWAY
ADDRESS/PHONE 2 OLD GOSHEN RD WILLIAMSBURG (413)695-29370
PROPERTY LOCATION 521 AUDUBON RD
MAP 04 PARCEL 003 001 ZONE RR(I00)/WSP(54VWP(15V
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvveof Construction: RENO BATHR OM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 081793
3 sets of Plans/Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF_004ATION 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 Pian AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registryof Deeds Proof Enclosed
_Other Permits Required:
_Cub 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
� 3- Iq- Wj?
Si of Building Official Date
Now: 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.
r Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
RECEIVED
Depar ynom use only
City of rlortn mpt NAA 18 20 §law of Pe nel
.r Building Dep rtme t curo utfDd way Permit
212 Main reef Septi Availability
Room 110 DF'T OFouItfHNf.IH==,C,tlpy�ell Amiability
�\ NOnTHAMPTON.'"< TMFf"
Northampton, K A 0 1060 Plans
phone 413-587-1240 Fax 413.587-1272 Plot/Site Plans
Other Spedfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION
1.1 Prooerh Addrse: This section to ba rompladegd by
office
52/ 4v4lo �
ve)aw "*,o Lisp — aunit
bcrl� Zone Oni DIMAc
Elm at mablut CB District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2./ Owner of Bill
KGuy 41VD rLo /h✓Sm o /kV
VtgjAl &19 LEll
Name Firp Current Newo
T.I.,l ne /V
Si wre
Name(Fid) Currant Mailing Address:
Signature Telephone
SECTION a-ESTIMATED CO11>;1iilIC710N L'03T8
Item Estimated Cost(Dollars)to be Official Use Orgy
.irnplatedbmetapplicant
1. Building 11115-b (a)Building Penned Fee
2. Electrical 2 O O d (b)Estimated TOMI Cost of
Conatructon from(6
3. Plumbing y10 o a Building Permit Fes
4. Mechanical(HVAC) 6-100
1 ✓ /
5. Fire Protection
6. Total=(1 +2+3+4+5) 1 Check Number Q
This Section For Official Use Only
Building Permit Num n Date
etl: (ryy �^ p
Signature: 3" j'y" &j
Buft g C rvnssbrwrllnspacter of Buildings One
I�tiibL y-qj'�j*"Al-Y @ Gdmcarr, Na�j-
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
J3
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Womptete Information
Existing [`mjx,cd Required by Zoning
Tao Mama a D<BBcd a by
BmId.,lle'roin.l
Lot Sian
Ronin e
Setback Prom
Sidi, L R: L R
Rear
Building Height
Bldg,Square Footage
O'n Space I Mirage
(W au ma-bldg a peal
#of Parki ng Spares
res -
Fill:
volume a lacmiaa
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW !I�61- YES O
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 DONT KNOW ® YES O
IF YES, las a permit been or need to be obtained from the Ci servation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO lar
VY
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 ID
IF YES, describe size, type and location:
E. Vdll ted construction activity disturb(d nrg,grading,excavation,or filling)over 1 acre or is H part M a common plan
that will disturb over 1 am? YES ( NO Q
IF YES,than a Northampton Storm Water Management Permit from the DPW is required.
DESCRIPTION OF PROPOSED WOR check alle lice le
Have Nowa ❑ Addition Replacement Windows ANarattun(s) ® Roofing
Or Doors
AacassorYBldg. ❑ Demolition ❑ New Signa [01 Decks [p Siding[01 Other[E:4
Brief WorkDescnPtion of Proposed /6 "� �A'DN'UJNLYL
Alteration of existing bedroom_Yea No Adding new bedroom Vas No
Atached Narrative Renovating unfinished basement _Yes _ No
Plans Attached Roll -Sheat
ea.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 raw mrrstrucOon. Dimensions
e. Number of stones?
t Method of heating? Fireplaces or Woodaloves Number of sack_
g. Energy Coraervation Compliance. Massdack Energy Compliance form a ached?
h. Type of construction
I. is construction within 1 D R of wetlands?_Yea _No. Is corsnwron within 100 yr, floodplain_Vas No
I Depth of basement or cellar Boor below fin islad grade
It 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,— K tZ.L •' /M/3/YL A O as Owner of the subject
property
hereby authorize DA-"/C:1 L/"Ri -K'•v/
toactoffin behalf,in all lative to udonzed by this buiIdng nmit a Plication.
ruhaa Qvnarv Dan,
I, / i [�ilatl,4-AWI��// ,as Owner/Authorized
Agent hereby Madame that the slatemente and info lion on the foregoing application are true and accurate,W the bast of my Imowledge
and belief.
Signed under the pains and penalties of perjury.
h4wcL
Print
s
slgnaWe dQuer/Agent CAN
SECTIONS-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: G. ^� Not Applicable ❑
Name of License Holds: YJ' m)f-7/ CS OiU M
Laceme KS r
2 O1.0 yv3r(t�l ,9,17 k1w/�'Shc/✓GG! �{� /l • Z0
Add E�eation Dab
Sipneluro Tabphorre
i.ReaN[ered hams Imvovenent Cor4rocbr. Not Applicable ❑
mWICi dw-nt,tQ -y /1/ / 6 98
Comnrw Name Registration Num
see 05/6N;7 Z o
Atldies; Expiration Dab
Tetepho.
SECTION 10,WORKERS•COMPENSATION INSURANCE AFFIDAW(M.C.L o.154,$75C(S))
WorkersCompensation Jr.ance aflMavit nxret be completed and sIDrniltetl with this application.Failure to provide this affidavit vnll result
in the denial of the issuance=buiki rmit.
Signed Affidevk Attached Ves....... No...... ❑
City of Northampton
a
t4aasachuaetta
D6PAn7MENT OF BUILDING
Ma]n INSPECTIONS
212 stxaet " Mv,idal Bvl
pldlog
i
lbitba pR , M 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 most be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction,alteration,renovation,repair,moderwatuxi, conversion,
improvement,removal, demolition, or construction of an addition to any preexisting ouneroccuoied budding cardaining
at least one but not more than four dwarfing units....orto structures which are"acent to such residence orbuftrig'be
done by registered contractors.
Note.Iftke kion o er kas combatted m&k a carpordramr or LLC,akar exi*y mast be regisroed
Type of Work: /. er?t(90Z) 4 9A5-W 0VVZ_ Est.Cost: 9 Z 17 6D
Address of Work: 5?,I >YuDui3sAi A0 CM6
Date of Permit Application: ..3 ' t
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 owcerbccupied
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 RESPONSIBIL ITES 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 buildingmut as the agent of the owner:
� NIL"
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
Y
City of Northampton
� 6 _
Massachusetts
h ` 4
` fp � OF H=DII G INSPECTIONS
213 lLip sth¢ n ipal Building
tbt
�.., tTaWtmon,, tM 01060 -'\9
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:
52/ 90od8ou &" GGZVS
(Please print house number and street name)
Is to be disposed of at:
lr94LL 4WO6jy4 /n4XdF7�P .
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
LL—
Signature of Permit Applican 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 oflndttstrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
VII.rken'Compeanation Insurance Affidavit: Builders/Conlnctors/ElecMclans/Plumbem
TO HE FILED WOH THE PERMITTING AUTHORITY.
A licaat
Information Print
NmHe(BusnewOtganizatioMvdividuel): 8'♦`wlw4yU/Kz
Address:_ Z OL-,O &r,&5 tfAJ IP.o141J
City/state/zip: (AAIl.f Yl 004 MN 0 4hoae u 3
Are you an enpbyw?CTmkl6e apprapriYe h:: of rare
Type P 1ecl(required):
I.��,�aIamae�bva wah mglay�ffoa mdimpart-timel' T []Neweanstruetion
20-1--
0-1--asok Fopk mpt hipa�luvemo loy waking["mein 8. ❑Remodeling
��Y W—tY.INowoknn'cemp.wnmmce"000A.l
3.Olamahwnawna doing all wok myneV No woken camp.hummcerWwtW.l' 9. ❑I)enuolition
a.�I am a M1mnmwnaavd wJl h M1mvg comracl"sb aMrtdl w"k nn my peapMy. [oil] 10❑Building addition
me
not d]covtndom crthah.,seders,cmnpewation ins"an"e so—k 11.0 Electrical repairs in additions
pmpiene,wish m empbYee.
12.[]Plumbing repairs or additions
S.0Them gammicanhachnandilove hwan the eAterson,.invathe anactwd sheet 13.nRoofrgmirs
1h®e.ub-contr+b-tom have emploY«e and hrve wokas'Amp.msmmw.+
6,E]We area wtporation and fts.[Geos have exemimd their right of—".pm—MGL.. 14.❑Othm
152,§i(A) aM we have no employees.[No woken come.itumanec mxsme ]
'My appiium that chap box#1A.also 0 on Ne"dim below showing thew wohms empmuatiov policy infamution.
t Hmneownem who submit this ATMandr indict ing they all doing At wok aM Nen him oubidc aohadon mast submit a sw.w•6daviti Akwng such.
TC toaotn that cher*this bin Amt AtsNd s s&hfi ul shat showinglee wineof am sobcmanadms andstate whdha"not thorn news hrve
employee. If Ne aub�antnamn haveenryloYeee,N)'mustFwidc Ncir wofo- comp.00hc,—u ,
I am anemployer Wra isproviding workers'winpensation insurimmfor my ennplopees. Below is thepoUcy andjob site
information
Insmance Company Name:
Policy N or Self-ins.Lic.p: Expiration Date:
Job Site Address: City/Statelzip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure 0 secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or tmayear imprisonment,as well m civil Families;in the than ofa STOP WORK ORDER am a fine of up to$25000 a
day against the violator.A copy of this shatemem may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification
I do hereby under rite pains and penalties of peduq ling the information provided abosv is true and carred
Si.tme -�/ \ Date3 1
Phone H: 413 615 2437
Official use only. Do not tv70e in this area,to he omnpleled QI'cot'or town ajJlclal
City or Town: Pernil/Liceme 8
Issuing Authority(cloche one):
1.Board ofHeallb I Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone a:
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