31A-241 BP-2021-2038
57 KENSINGTON AVE COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31A-241-001 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-2021-2038 PERMISSION IS HEREBY GRANTED TO:
Project# DOOR Contractor: License:
HAYDENVILLE WOODWORKING &
Est. Cost: 6500 DESIGN INC 116208
Const.Class: Exp.Date:04/13/2025
MANSEAU PATRICK M&JACQUELINE LIZETTE
Use Group: Owner: RICHARDS
Lot Size (sq.ft.)
Zoning: URB Applicant: HAYDENVILLE WOODWORKING &DESIGN INC
Applicant Address Phone: Insurance:
35 CONZ ST (413)665-7402 0 WMZ-800-8007423-2020A
NORTHAMPTON, MA 01060
ISSUED ON:10/15/2021
TO PERFORM THE FOLLOWING WORK:
REPLACE FRONT DOOR
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.
Signature: I
• t . y2 - 'I •
r
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
,
('C Department use only
,of:H City of Northa pto ECER/ rmit:
-,.�. Building Dep rtme t _ ut/Dri eway Permit
t_ t 212 Main tree OCT l Sew /Sept Availability
0 ! ki 1 . Room 00 5 2021 Wat r/Wel Availability
' Northampton, MA Tw Sets f Structural Plans
phone 413-587-1240 -Fa c_4 +t PI Site lans
A Mr,ToN'01�q oECT er S City
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR D ISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: ?� Thisy section to be completed by office
Map (/(/ Lot (/ti',,/�/ Unit
57 Kensington Ave Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Patrick Manseau 57 Kensington Ave,Northampton
Name(P Current Mailing Address:
/ /' A� 413-923-8133 ,
(-0 O ole�N,�` Telephone
Signature
2.2 Authorized Agent:
Haydenville Woodworking&Design, Inc.(Zinnia Stetson) 35 Conz Street Northampton, MA 01060
Name(Print) Current Mailing Address:
3413-665-7402
nat a Telephone
TION 3- STIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building $6,500 (a) Building Permit Fee
2. Electrical N/A (b)Estimated Total Cost of
Construction from (6)
3. Plumbing N/A Building Permit Fee
ii)
4. Mechanical(HVAC) Ur)
5. Fire Protection N/A
6. Total=(1 +2+3+4+5) $6,500 Check Number 425344
This Section For Official Use Only
g0 2t/-• Date
Building Permit Number: .�/ - Issued:
Signature: //. JO 'I S-ZOZ i
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 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES Q
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 Q
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 Q
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Ci?Name of License Holder: Zinnia Stetson
License Nu er
35 Conz Street, Northampton, MA 01060 �(
Address Expiration Date
i'1�Zz 04/13/202 '
SOnatu a Telephone
\, 413-665-7402
9. Registered Home Improvement Contractor: Not Applicable ❑
Haydenville Woodworking & Design, Inc. (Zinnia Stetson)
Company Name Registration Number
35 Conz Street, Northampton, MA 01060 110732
Address Expiration Date
-- �. ,� Telephone413-665-7402 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...... ❑
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) l i Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[0] Other[CI]
Brief Description of Proposed Replace front door
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
I, l lT--t4--i/1Ak(UA0 , as Owner of the subject
property
Haydenville Woodworking& Design, Inc. (Zinnia Stetson)
hereby authorize
to act on my b I in al atters relative to work t}ior• ed by this building permit application.
• /14, ��
Signature or wner Date
I, 2/lUAf%►/{ g7t1j)r i �-14Af (/lC.[E L4,0iQ4(jri-IGr/�Fac4 L 26iN ?Az. . , as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing ap lication are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
7:11JAIIA Sn SO►v
Print Na
La/'1 72 a: I
Si na erlA ent Date
The Commonwealth of Massachusetts
1, Department of Industrial Accidents
C-v
;�,I_ � 1 Congress Street,Suite 100
14_:�_� Boston,MA 02114-2017
, v=� www.mass.gov/dia
Corkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Haydenville Woodworking& Design, Inc.
Address:35 Conz Street
City/State/Zip:Northampton, MA 01060 Phone#:413-665-7402
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 8 employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 El Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.1=1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.Q other
152,§1(4),and we have no employees.[No workers'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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:A.I.M. Mutual Insurance
Policy#or Self-ins.Lic.#: WMZ-800-8007423-2020A Expiration Date: 12/1/2021
Job Site Address:57 Kensington Ave City/State/Zip:Northampton 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 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 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 pai and penalties of perjury that the information provided above isis true and correct.
Signature: . e� Date: 494/70Phone#:4(ii
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#:
City of Northampton
` �:`� Massachusetts c
c
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street •Municipal Building Jti Cb
.' Northampton, MA 01060 'Psi* \'"."
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:
57 Kensington Ave, Northampton
(Please print house number and street name)
Is to be disposed of at:
Valley Recycling Center, Easthampton St Northamptia
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
/ Sig attic
r o Permit Applicant 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.
City of Northampton
„ H M j„ .tij, S . • sk,
F •.,-r- Massachusetts ,, '`e� -
t
I 1 K. a 1i DEPARTMENT OF BUILDING INSPECTIONS ;'
_. 'i. r ` 212 Main Street • Municipal Building y`�. c'
,N - Northampton, MA 01060 ssfn, ‘^J
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: Replace front entry door Est. Cost:$6,500
Address of work:57 Kensington Ave, Northampton, MA 01060
Date of Permit Application: 10/06/2021
I hereby certify that:
stration is not required for the following reason(s):
i IWork 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: ' , A'
10/06/2021 Haydenville Woodworking & Desi n, In (Zi Ta F. Stetson) HIC 110732
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