18C-176 (2) -
------ i
/ / .0
1 V
_ IV i 1/ -7 -4 i
il (,_
t t
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, 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 sub- contractor(s) name(s), 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 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 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE
Revised 4 -24 -07
Fax # 617- 727 -7749
www.mass.gov /dia
J 2
The Commonwealth of Massachusetts
y ,d Department of Industrial Accidents
r. = 4 Office of Investigations
= h 414, 600 Washington Street
"! Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information / Please Print Legibly
Name (Business /Organization/Individual): pi U4 t .,r.
Address: 1 - . S (,? KAT(I t.,1) .sue 2 k"irvE- sr
City /State /Zip: /r.4 'f )eLI) /44 o is Z£; Phone #: y! /3 9Z
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
employees (full and/or part-time).* have hired the sub - contractors 6. ❑New construction
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. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12:0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
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.
1 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 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:
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 fy
L.. e pain nd penalties f perjury that the information provided above is true and correct.
' `-_' Date: 1 2 '2c >l0
Signature: rol, �.."_ '
Phone #: 9''5 :Z';' - 4'2 S'.?
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 o1 Health 2. Building Department 3. Cityfl'own 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, 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 sub - contractor(s) name(s), 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 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 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 bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE
Revised 4 -24 -07
Fax # 617- 727 -7749
www.mass.gov /dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
.".. "411=711 Office of Investigations
600 Washington Street
=10= AI Boston, MA 02111
`° "'VA www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): t /`'t /¢ S /4 gvi ��f''t
Address: 1 ,i6;c1 f'
City /State /Zip: , 7,4f Cr 4 /g o/..3 Phone #: 'f / 3 ` L
Are you an employer? Check the appropriate box: Type of p ject (required):
1. [1 am a employer with Lt 4. [] I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ew construction
2. I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. [] Demolition
working ca employees and have workers'
g for me in any capacity. t3' $ 9. 0 Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
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 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: Cit it/ ,t t I S ,u 3
Policy # or Self -ins. Lic. #: s L(..3 6. 3 / Expiration Date: — 7/ / /` //
Job Site Address: 7 7(( 6c 74 i C ( Z) City /State /Zip: Aa T r4RAu rw /109, U/ G 66
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains d penalties of perjury that the informa provided above is true and correct.
Signature: pa �'° Date: ?/ 7//
Phone #: t"/ 5 4 7 - 5` C ,
Official use only. Do not write in this area, to be completed by city or town offlciaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/'Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
OP
•
•
i .` * i ,. �. r 11441,, a -
.
..,..,,,,,,,..4„,,,,,,,..,,,..,
.. v '%,:,,._:,'7,*.h.74,4,' ''.- - at
x a t 1 - ! e '
A
, , i f. jr
L
g
ffir
` - " A ,'* t �� - _� ,�. a� ,
iif { ' s : 4 4 i) . w o
t
• i
h .
h ex r,�.. w �# f }. f .;f v
..%,,,,
i t f �
s '
,,,,O$
'04 x
Ift
a 0
a ` 7,
y y
i ''''14'. a t fi r ,
r ,s�
* ' 4 k 40 ' 41 :,' .1"-A „x:i'... ',:l't °41 :(} ) , ' t ; '''',4 4— ''''''''. ‘ i ,/ `-,' — /
litli N. wi , ; ,. s
liIj''I' III w .. . s.
i I ii ,,,
q
■ .f ' i f ' , Y , � r 'WfM . r
1 .,
1 1 1' I t i l' ' � � t'11 1 a � h
,.,_. ;1 , ''' , i ,
v
s ii �
lilt 1 iil 1 1 `° �
iil 5
i 1 Ili { i l 1 i ;15; U ;
rr r
'i 1 ''� I 4- i i . I ° ' ' , , -: ,, a ir , - 'ix 7444L- difir 1141 i f + ��`I [ I ' , ' ' i ~_ 1 I � i 1 I # . r
INI
I ••`1114I 1 . 1ii ii f .11 11111111211 1 [1
I ll i l i l 1 i 1 i r # i 111' l Q r
l 1 i r r r1 H I i "°
+ ,..3 -.11- `f a 1`3_ i . , ... Z r '
! �' I
i ii i i , II '1 -4::-1,1-'—}421-17-.:1-2. �. < (,�
!hill / ti l l' 1 I Ri. - 1 1 I ij -4 I ° , t. ,
g 1 t # , y N 'i I 9i! *!'�!' X 1 ! r i • ,» .,
1 I'ii i ill 1
1 1 1 1 1 1 I C I I i ,�.i 1 1 1 Li .1.14,.'.0.',5_ , , ti , w
�.tr*I
10. All disturbed areas shall be graded, loamed and seeded, or stabilized with erosion control
blankets or netting, and a covering of straw mulch prior to November 30, of each year. No
disturbed areas or stockpiled materials will be left unprotected or without erosion control
after this date.
11. No disposal of soils or other materials shall be allowed within: a 100 -year floodplain; 40
feet of the 100 -year floodplain elevation; any wetland; or any area within 100 -feet of a
wetland, unless such areas are specifically approved by the Commission, in accordance
with 310 CMR 10.00, and City of Northampton Ordinances - Chapter 337.
12. Upon completion of the work covered by this Order, the applicant shall notify the
Conservation Commission.
"ATTACHMENT A"
1. Prior to the initiation of any work, the applicant /owner shall submit a letter of
understanding to the Commission stating that he /she has received, read, understands and
shall comply with these conditions. The applicant, and, his or her contractor, foreman
and /or construction manager shall sign the letter of understanding.
2. The applicant shall notify the Conservation Commission after silt fence is installed and
before work begins for inspection.
3. The silt fence shall be installed as shown on the plans, and shall serve as the limit of work
line.
4. All required permits must be obtained from applicable federal, state and local agencies and
departments prior to the start of any project.
5. A copy of these conditions and associated plans shall remain on site during all construction
and /or building activities. The project manager and all equipment operators shall be
familiar with the approved plans, and shall be informed of their location on the site. This
location shall be accessible to all contractors whenever work is occurring on site.
6. All revised plans shall be approved by the Conservation Commission and incorporated into
the pen by reference and shall be followed during the course of construction.
7. The areas of construction shall remain in a stable condition at the dose of each construction
day. Erosion control measures shall be inspected at this time, and maintained or reinforced
as necessary. All such devices shall be inspected, cleaned or replaced during construction
and shall remain in place until such time as stabilization of all areas that may impact
resource areas is permanent. These devices shall also be inspected to assure that the
maximum control has been provided. Any entrapped silt shall be removed to an area
outside the buffer zone and resource areas, and maintained or reinforced as necessary.
Erosion controls shall be inspected after every rainfall to assure that maximum control has
been provided.
8. An adequate stockpile of erosion control materials shall be on site at all times for
emergency or routine replacement and shall include materials to repair or replace silt
fences, straw bales, erosion control blankets, riprap, filter berms or other devices planned
for use during construction.
9. Soils exposed for periods greater than two months shall be stabilized with erosion control
blankets and netting, a covering of straw mulch, or a temporary cover of rye or other grass
to prevent erosion and sedimentation. Drainage ditches shall be stabilized and seeded with
a native perennial grass mixture. Any stabilization materials such as jute netting shall be
firmly anchored to prevent them from being washed from slopes by rain or flooding.
Preference should be given to biodegradable materials.
•
. *
Massachus D epartment of Environmental Protection
\) , --
- Bureau of Resource Protection - Wetlands
WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
D. Appeals
The applicant, owner, any person aggrieved by this Determination, any owner of land abutting the land
upon which the proposed work is to be done, or any ten residents of the city or town in which such land is
located, are hereby notified of their right to request the appropriate Department of Environmental
Protection Regional Office (see http: / /www. mass. qov /dep /about /region.findyour.htm) to issue a
Superseding Determination of Applicability. The request must be made by certified mail or hand delivery
to the Department, with the appropriate filing fee and Fee Transmittal Form (see Request for
Departmental Action Fee Transmittal Form) as provided in 310 CMR 10.03(7) within ten business days
from the date of issuance of this Determination. A copy of the request shall at the same time be sent by
certified mail or hand delivery to the Conservation Commission and to the applicant if he /she is not the
appellant. The request shall state clearly and concisely the objections to the Determination which is being
appealed. To the extent that the Determination is based on a municipal ordinance or bylaw and not on the
Massachusetts Wetlands Protection Act or regulations, the Department of Environmental Protection has
no appellate jurisdiction.
wpaform2.doc • Determination of Applicability • rev. 1016/04 Page 5 of 5
•
1�
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Determination (cont.)
❑ 5. The area described in the Request is subject to protection under the Act. Since the work
described therein meets the requirements for the following exemption, as specified in the Act and
the regulations, no Notice of Intent is required:
Exempt Activity (site applicable statuatory /regulatory provisions)
❑ 6. The area and /or work described in the Request is not subject to review and approval by:
Northampton _
Name of Municipality
Pursuant to a municipal wetlands ordinance or bylaw.
Wetlands Ordinance C 337 of the General Code
Name Ordinance or Bylaw Citation
C. Authorization
This Determination is issued to the applicant and delivered as follows:
❑ by hand delivery on ❑ by certified mail, return receipt requested on
May 14, 2010 .
Date Date
This Determination is valid for three years from the date of issuance (except Determinations for
Vegetation Management Plans which are valid for the duration of the Plan). This Determination does not
relieve the applicant from complying with all other applicable federal, state, or local statutes, ordinances,
bylaws, or regulations.
This Determination must be signed by a majority of the Conservation Commission. A copy must be sent to
the appropriate DEP Regional Office (see http: / /www. mass. qov /dep /about /region.findyour.htm) and the
property owner (if different from the applicant).
Sf • natur=
JS a 0 I D
Da e
wpaform2.doc • Determination of Applicability • rev. 10/6/04 Page 4 of 5
r � �
Massachus Department of Environmental Protection
Bureau of Resource Protection - Wetlands
s .
1 WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Determination (cont.)
❑ 6. The following area and /or work, if any, is subject to a municipal ordinance or bylaw but not
subject to the Massachusetts Wetlands Protection Act:
❑ 7. If a Notice of Intent is filed for the work in the Riverfront Area described on referenced plan(s)
and document(s), which includes all or part of the work described in the Request, the applicant
must consider the following alternatives. (Refer to the wetland regulations at 10.58(4)c. for more
information about the scope of alternatives requirements):
❑ Alternatives limited to the lot on which the project is located.
❑ Alternatives limited to the lot on which the project is located, the subdivided lots, and any
adjacent lots formerly or presently owned by the same owner.
❑ Alternatives limited to the original parcel on which the project is located, the subdivided
parcels, any adjacent parcels, and any other land which can reasonably be obtained within
the municipality.
❑ Alternatives extend to any sites which can reasonably be obtained within the appropriate
region of the state.
Negative Determination
Note: No further action under the Wetlands Protection Act is required by the applicant. However, if the
Department is requested to issue a Superseding Determination of Applicability, work may not proceed
on this project unless the Department fails to act on such request within 35 days of the date the
request is post- marked for certified mail or hand delivered to the Department. Work may then proceed
at the owner's risk only upon notice to the Department and to the Conservation Commission.
Requirements for requests for Superseding Determinations are listed at the end of this document.
❑ 1. The area described in the Request is not an area subject to protection under the Act or the
Buffer Zone.
❑ 2. The work described in the Request is within an area subject to protection under the Act, but will
not remove, fill, dredge, or alter that area. Therefore, said work does not require the filing of a
Notice of Intent.
❑ 3. The work described in the Request is within the Buffer Zone, as defined in the regulations, but
will not alter an Area subject to protection under the Act. Therefore, said work does not require
the filing of a Notice of Intent, subject to the following conditions (if any).
Please see Attachment A
❑ 4. The work described in the Request is not within an Area subject to protection under the Act
(including the Buffer Zone). Therefore, said work does not require the filing of a Notice of Intent,
unless and until said work alters an Area subject to protection under the Act.
wpaform2.doc • Determination of Applicability • rev. 10/6/04 Page 3 of 5
•
•
Massachusetts Department of Environmental Protection
Bureau of Resource Protection - Wetlands
WPA Form 2 - Determination of Applicability
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
B. Determination (cont.)
The following Determination(s) is /are applicable to the proposed site and /or project relative to the Wetlands
Protection Act and regulations:
Positive Determination
Note: No work within the jurisdiction of the Wetlands Protection Act may proceed until a final Order of
Conditions (issued following submittal of a Notice of Intent or Abbreviated Notice of Intent) or Order of
Resource Area Delineation (issued following submittal of Simplified Review ANRAD) has been received
from the issuing authority (i.e., Conservation Commission or the Department of Environmental Protection).
❑ 1. The area described on the referenced plan(s) is an area subject to protection under the Act.
Removing, filling, dredging, or altering of the area requires the filing of a Notice of Intent.
❑ 2a. The boundary delineations of the following resource areas described on the referenced plan(s) are
confirmed as accurate. Therefore, the resource area boundaries confirmed in this Determination are
binding as to all decisions rendered pursuant to the Wetlands Protection Act and its regulations regarding
such boundaries for as long as this Determination is valid.
❑ 2b. The boundaries of resource areas listed below are not confirmed by this Determination,
regardless of whether such boundaries are contained on the plans attached to this Determination or
to the Request for Determination.
❑ 3. The work described on referenced plan(s) and document(s) is within an area subject to
protection under the Act and will remove, fill, dredge, or alter that area. Therefore, said work
requires the filing of a Notice of Intent.
❑ 4. The work described on referenced plan(s) and document(s) is within the Buffer Zone and will
alter an Area subject to protection under the Act. Therefore, said work requires the filing of a
Notice of Intent or ANRAD Simplified Review (if work is limited to the Buffer Zone).
❑ 5. The area and /or work described on referenced plan(s) and document(s) is subject to review
and approval by:
Name of Municipality
Pursuant to the following municipal wetland ordinance or bylaw:
Name Ordinance or Bylaw Citation
wpaform2.doc • Determination of Applicability • rev. 10/6/04 Page 2 of 5
Bureau Massachusetts of Resource Department Protection of EnvironWetlands mental Protection
-
WPA Form 2 — Determination of Applicab
Massachusetts Wetlands Protection Act M.G.L. c. 131, §40
A. General Information
Important:
When filling out From:
forms on the Northampton
computer, use Conservation Commission
only the tab
key to move To: Applicant Property Owner (if different from applicant):
your cursor -
do not use the Richard E. Jaescke
return key. Name Name
774 Bridge Road
rah Mailing Address Mailing Address
Northampton MA 01060
II City /Town State Zip Code City /Town State Zip Code
1. Title and Date (or Revised Date if applicable) of Final Plans and Other Documents:
Wetlands Delineation & Proposed Work 3/22/2010
Title Date
Title Date
Title Date
2. Date Request Filed:
April 2, 2010
B. Determination
Pursuant to the authority of M.G.L. c. 131, § 40, the Conservation Commission considered your
Request for Determination of Applicability, with its supporting documentation, and made the following
Determination.
Project Description (if applicable):
Replacement of wooden piers on an existing garage with a concrete foundation, and construction of
a 160 sf addition to the garage on an area that is currently gravel. Area is located within the 100 foot
buffer zone to an intermittent stream.
Project Location:
774 Bridge Road _ _ _ Northampton
Street Address City/Town
18C 36 and 176
Assessors Map /Plat Number Parcel /Lot Number
wpaform2.doc • Determination of Applicability • rev. 10/6/04 Page 1 of 5
..d:
•
4 '' k; t. PLANNING AND DEVELOPMENT • CITY OF NORTHAMPTON
AA ,, planning • conservation • zoning • northamptonGIS • historic • community preservation • central business architecture
-ji1
■ � r ( Sarah 1. Lavallev, Conservation, Preservation, & Lind Use Planner • slavallcy<'- !NorthamptoniMA.gov • 413- 587-12G3
May 14, 2010
Richard Jaescke
774 Bridge Road
Northampton MA
oto6o
RE: Determination of Applicability, 774 Bridge Road, Map 18C, Lots 36 and 176
Dear Mr. Jaescke:
Enclosed please find the original signed Determination for the above referenced project.
The Determination confirms the boundaries of the resource areas shown on your plan, and finds that the
work shown is in the Buffer Zone; and will not require the filing of a Notice of Intent. The Determination
is valid for three years.
Please read the document carefully, as it contains conditions that must be adhered to before, during, and
after work on the project.
Please feel free to contact me with any questions or concerns.
Thank you,
q v-to a dav
Sarah LaValley
Conservation, Preservation and Land Use Planner
City Hall • 210 Main Street, Room 11 • Northampton, MA 01060 • www.NorthamptonMa.gov • Fax 413-587-1264
original printed on recycled paper
of "
,
10. ; Do any signs exist on the property? YES NO
IF YES, describe size, type and locations
Are there any proposed changes to or additions of signs intended for the property? YES NO
d
IF YES, describe size, type and location:
11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common
plan of development that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
This co res el-a ed
for use by the Building
e ..,
EXISTING ,-.4.4- �^ " . `k _ ® v
. iiill ih°4?-: l c:'; 2 7- 77- 11:i 1; :''''''‘.-14
iiiIIIIII
Frontage
Setbacks Front 3' 0 . ; x :-
Side L: R: L: 2.0 R:
Rear Le
Building Height
Building Square Footage -''
% Open Space (lot area r
minus building Et paved 8 S7 kr"; ,, x 4
# of Parking Spaces - . - Im,' - q� ;,
# of Loading Docks ' .-
Fil {:
(volume Et location) kg
13. Certification: I hereby certify that the information contained herein is true and accurate to the best of
my knowledge.
Date: - ZJ Zi CO Applicant's Signature .1'L 261.ia.r...4
1
NOTE: T E issuance of a zonin permit does not relieve an applicant's burden to comply with ail zonilrig
requirements and obtain all required permits from the Board of Health, Conservation Comission,
Historic-and Architectural Boards, Department of Publi m
c Works and other applicable permit ranting
authorities.
W:\Documents\ \ o rigmalTuilding- lnspector2oning- Permit - Application- passive.doc 8/4/2004
O�
File No. /971
WAY.; �. _�,,� ��,».. .«�:; <..� -�n .,.�.�a � ,...� .,:sE±.n. a - �..xe- ..,.tee -_ � " � . c , �o._ . ? r .. ,ate
Please type or print all information and return this form to the Building
Inspector's Office with the $15 filing fee (check or money order) payable to the
City of Northampton
1. Name of Applicant: 'j t Char d . J C e s e- Ke
Address: 7 7 , -/ e ea Telephone: 6 4 .1 7 r9 IF
2. Owner of Property: can
Address: Telephone:
3. Status of Applicant: Owner V Contract Purchaser Lessee Other (explain)
4. Job Location: % 74 x3v c 1
5. Existing Use of Structure /Property: ' V > r 1 a' tt, , ` S yre
6. Description of Proposed Use /Work /Project /Occupation: (Use additional sheets if necessary):
fie 6'1- to 4c d e h e i it vide, 6 's4 r s fi I cr i feho
rTi it t Gt .*1 Ate f •
/vane/ 014,g O) rrn ii tDIT(cr,rA 1.- VEY / ATH 6 3
7. Attached Plans: Sketch Plan Site Plan Engineered /Surveyed Plans
8. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW YES IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and /or Document #
9.Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained date issued:
(Form Eonlanries Or Other Side)
W:i Documents \FORMS \originallBuilding InspectorlZoning- Permit- Application- passive.doc 8/4/2004
ie
f
File # MP- 2010 -0049
APPLICANT /CONTACT PERSON JAESCKE RICHARD E & SANDRA H
ADDRESS /PHONE 774 BRIDGE RD (413) 584 -7898 ()
PROPERTY LOCATION 774 BRIDGE RD
MAP 18C PARCEL 176 001 ZONE SR(100) / /WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
( FORM ILLED OUT - , r 1:.
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction: ZPA - ADDITION
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 V 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
C.Permit from Conservation Commissicsn Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
3 /lil
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 the Office of
Planning & Development for more information.
File # MP- 2010 -0049
APPLICANT /CONTACT PERSON JAESCKE RICHARD E & SANDRA H
ADDRESS/PHONE 774 BRIDGE RD (413) 584 -7898 0
PROPERTY LOCATION 774 BRIDGE RD
MAP 18C PARCEL 176 001 ZONE SR(100) //WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out a??
Fee Paid
Typeof Construction: ZPA - ADDITION
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
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 the Office of
Planning & Development for more information.
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
iermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, 'r- v( (1- understand the above.
(Home owner /reside s signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date Sr /-err 6 i
Address of work
location 77'/ !(fir , el y r �(
J( rf-17o,11 / ' an 114 . °eke
7.
The Commonwealth of Massachusetts
Department of Industrial Accidents -
f1
= _ 1= Office of Investigations '
- =:-.:81.--x: 600 .' 600 Washington Street
Boston, MA 02111
.„ • ' • www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name (Business/organization /Individual): / � •;11 e
• - Address: •
City/State/Zip: Fro - d Phone. #: .-2
Are you an employer? Check the appropriate box: • . Type of project (required): /
1.0 I am a employer with 4. 0 I am a general contractor and I
employees (full and/or par time). s have hired the sub- contractors 6. ❑ New construction
t
2.. [] I am a sole proprietor or partner- listed on the attached sheet. 7. ❑. Remodeling
ship and. have. no. e loyees These sub - contractors have. S. 0 Demolition
• working for me in any capacity. employees and have workers' g 7.7: uilding'addition
romp, mSnranrA_#
workers' comp-. 2ns>I
r e 5. We are a corporation and its 10.0 Electrical repairs or additions
ms I officers ve4xercsed their . 11. Piumbm r
3. h i i
I am a homeowner doing all work f ❑ g epairs or additions
myself workers' co right of exemption per MGL
Y � o workers comp. 12:Q Roof repairs
insurance required.] t ' c. 152, § 1(4), and we have no •
em ployees. [No workers' 13 .LJ 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 state wbetheror not those entities have •
employees. lithe sub - contractors have employees, they must provide their workers' comp. policy number.
ram 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 ta secure coverage, as required under S ection ofMGLc. 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 $25000 a day against the violator. Be advised that a copy of this statement may be_forwarded to the Office of
Invest eatiotis of the DIA for instance coverage verigaition _ .. , . _ _ -w..
_ td---"a hereby_ certify under the pazns.and penalties ofperjury that the information provide d.above_rr_true aadrorrecL_ _
Signature: Dare:
Phone it:
- . Official use only. Do not write in this area, to be completed by city or town offciaL
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
iL'#tegisteredI ottrre'lrrtt►roveirieiit ai i ? tra tt t°` . �_`. F E:Zt "g .z .,r, . Not Applicable ❑
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 ❑ No ❑
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of 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.
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 the job 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 person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
JH orthampton Ordinances, State Local Zoning L and State of Massachusetts General Laws Annotated.
omeowner Signature ,,e,�Ji a-4
t'
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House D Addition [l Replacement Windows Alteration(s) ❑ Roofing J
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [O] Other [0]
Brief Description of ,*pi /lei') Ccileret vrclert u
, c.1 rrc/�`. ex Is hey AK( /Airy 4i( ex 15/ I"
Work: b /k .J.• ve rt6Jife 5fre ce,t
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
pit*iu ors a dW c i4Mi i t c . i tI ac tft . fc Iic W:r :
a. Use of building : One Family Two Family Other OelPvIC-
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Pf /l S. L-- Dimensions /0 I Pi
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 G,.'C4 4 /rt m t, /?7 e t / S a n,
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
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
, 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 under the pains and penalties of perjury.
Print Name ,, f
i� �%u.�Tl f ,
Signature of Owner /Agent Date
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 1
Setbacks Front F. -Rj i } jp 4 i
Side L:P,m , R:? J L: 201 R:
--d0 I
Rear i
Building Height Tri .
Bldg. Square Footage ( -- % M
t
Open Space Footage %
(Lot area minus bldg & paved 9_ ,* ....
parking)
# of Parking Spaces
Fill: i -
(volume & Location) s
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book I ( Page #
I and /or Document '
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES ef
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained j`ii Obtained el , Date Issued . /4 /0
C. Do any signs exist on the property? YES Q NO ef
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, ex vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
City of Northampton
-Building Department
212 M Street e - ¢ -
� f
� � r oom X00 ��
pi MA 01060
,
\ ` � � ,. � s ,E,y di
Northam
�l phone 413- 587 -1240 Fax 413- 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Propertv Address:
This section to be- completed by office
7 7'1 i '- c c' Map Lot Unit
Zone Overlay District
EIm St District CB District
SECTION 2 - . PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
itkepi z1,( SaMllr , esc 771 L f h ,�'Lyl�iu,�p�n
Name ( p�'nt) Current Mailing Add
114.4 Telephone
Signature 57 " 7Y9F
2.2 Authorized Agent:
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 1 .55'a tD (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) 9 a - Sep. c Check Number 69,5'i --
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
I I
ti I '
File # BP- 2011 -0254 '
r r ( L
APPLICANT /CONTACT PERSON JAESCKE RICHARD E & SANDRA H
ADDRESS/PHONE 774 BRIDGE RD NORTHAMPTON (413) 584 -7898 O FI :kJ Pi'Ii (c)J
PROPERTY LOCATION 774 BRIDGE RD
MAP 18C PARCEL 176 001 ZONE SR(100) //WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid _
Building Permit Filled out :Cr
Fee Paid
Typeof Construction: CONSTRUCT 10 X 14 ADDITION TO GARAGE FOR VEG STORAGE & NEW
FOUNDATION TO EXISTING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owne Statemen or License
3 sets of Plans / Plot Plan
THE F LLOWING r/ AC TION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RM ATION PRESENTED:
A 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 Peen It 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
Cam% 9 d 7 /its
Signature of Building 0 i cial 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
774 BRIDGE RI) BP- 2011 -0254
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block:18C -176 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit # BP- 2011 -0254
Project # JS- 2010- 001112
Est. Cost: $5500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 33105.60 Owner: JAESCKE RICHARD E & SANDRA H
Zoning: SR(100) / /WP Applicant: JAESCKE RICHARD E & SANDRA H
AT: 774 BRIDGE RD
Applicant Address: Phone: Insurance:
774 BRIDGE RD (413) 584 -7898 0
NORTHAMPTONMA01060 ISSUED ON :9/27/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK :CONSTRUCT 10 X 14 ADDITION TO GARAGE
FOR VEG STORAGE & NEW FOUNDATION TO EXISTING
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 9/27/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner