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AUTHORIZATION:
DATE:i-30`30 /S
NAME: �(Y`g�
ADRESS: ��3 �°4* i/
FIa�M4 bf<Ca
as owner of record authorize Kirk L.Pisani(DBA KLP Builders)to pull permits and
act in our behalf for all matters regarding INSPECTION SERVICES in our town for work performed at the above address.
Sincerely,
X
KLP R r _
FIN I SH CARPEN T ERS SPECIALIZING IN
HOME REPAIR,IMPROVEMENT&CONSTRUC IION 1`10 HOX 7402
WIF1451',MA01004
KIRK L.PISANI GENERAL CONTRACTOR I IC d CS(W4 (411)5:!1.0001
I'ru (41:1)3230918
klrkr@klpbuildert.com
TO: Zack Forray and Lindsay Fogg-Willits DATE:April 7, 2015
43 Beattie Dr.
Florence, MA 01062
Project Description: 1 Car garage addition and Mudroom conversion
Saecifications: approx 16'x 24' 1 car garage addition, 4'foundation PCN w/footings, 2x4 exterior walls on PT plate, Y2
osb siding w/housewrap and white vinyl siding, Roofing to closely match (Woven to existing roof), 1 9'x7'garage door w/
opener over 4" concrete slab with wire mesh. 2 new construction vinyl windows and 1 rear 2'8"exterior swing door.
Conventional framed roof system(2x8 rafters and 2x8 ceiling joists with strong back beam @ mid-span %z COX roof
sheathing w/grace UL Open bay walls and ceiling inside w/5/8"Firecode sheetrock on demising wall up to roof deck.
78" exterior metal door entrance to new mudroom
Mudroom approx 5'x12'created in front of existing dining room within existing garage. 2x8 floor joists w/'/4"advantech
subfloor over R30 fiberglass Insulation. Infill existing garage door with foundation pour, 2x6 wall frame, R21 insulation
and double mullion window(6'x 54"), Ceiling Insulated to R45. Sheetrock, trim, and paint. Tile floor. Create opening to
existing foyer. Electrical, lighting and Heat to code New gutters. Driveway prep(Sub gravel).
(INCLUDED)All materials and labor to complete above project except where noted. Flooring and dust protection
work, debris disposal, daily clean-up, permit work, sub supervision, Inspections.
Allowances (Included in Total below)
Electrical work: M&L $ 256000
Heating work M&L $ 88000
Painting. M&L $ 600.00
Garage Door: (New) M&L $ 1260.00
Windows and Doors. M S 1450.00
Tile work: (Flooring) M&L $ 102000
(NOT INCLUDED) Repair or replacement of any existing defective or unsuitable material(in existing structure)
required to continue contract work,Additional Work created by or requested by Owner or owner's agent or
subcontractors. Permit fee. Light Fixtures Shelving. Landscaping.Asphalt Drive($To be determined) Walkway
Paver salvage. Licensed Surveyor work(Probably required approx$650). UnderGround Utility work ;If required)
Total: $ 44.692.00
Thank you for considering KLP Builders for your construction and remodeling needs. If you have any questions
regarding the above quote please do not hesitate to call. I look forward to hearing from you.
Sincerely,
Kirk L. Pisani
Accepted: X Date/ .l U/ � Deposit: $ G/
�
COVERAGE TABLE
TOTAL LOT 10,458 SQ. FT. 100%
BUILDINGS 1,444 SQ. FT. 13.8%
PAVEMENT 249 SQ. FT. 2.4%
PROPOSED ADDITION 384 SQ. FT. 3.7%
OPEN SPACE 8,381 SQ. FT. 80.1%
TOTAL COVERAGE 10,458 SQ. FT. 100%
co
100.00' M
Dpp
ah
w
m Q
u driveway
o'otaddition
24.5'
21.7'
72.26' V�bt
ACREBROOK DRIVE
"PROPOSED IMPROVEMENT LOCATION"
PLAN OF LAND IN
FLORENCE, MASSACHUSETTS
PREPARED FOR
twa"�l WILLIAM Z. FORRAY
y LINDSAY FOGG—WILLITZ
R SCALE: 1"=40' APRIL 29, 2015
HAROLD L. EATON AND ASSOCIATES, INC.
REGISTERED PROFESSIONAL LAND SURVEYORS
235 RUSSELL STREET — HADLEY — MASSACHUSETTS
413-584-7599 413-585-5976 (fax)
email — hleaton�aol.com
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 defimed 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."
AdditionaIIy,MGL chapter 1521 §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 confn-tnation 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 Investi gations 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
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Revised 7-2010 Fax# 617-727-7749
www.mass.gov/dia
The Commonwealth of Massachusetts
Department of lndustrialAccidents
Office of Investigations
I Congress Street, Suite 100
�+ Boston,MA 02114-2017
xr wwwanass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
f
Name (Business/Organization/Individual): j�/��� / J 5 /
Address: L— C, C, Z
City/State/Zip: L3- Phone #: -3 S .3/ 0 00
you an employer?Check the appropriate box: Type of project(required):
FAre
.❑ I am a employer with 4. I am a general contractor and I 61 ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2 I am a sole proprietor or partner- listed on the attached sheet. 7. F-1 Remodeling
ship and have no employees These suU-contractors have g• Demolition
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp.insurance.1
required.] 5. F-1 We are a corporation and its 10. Electrical repairs or additions
officers have exercised their I L Plumbing repairs or additions
3.❑ I am a homeowner doing all work g p
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13T] 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 thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and ies of erjury that the information provided above is true and correct.
Signature: _ Date
�— _ - _ 1 : .
Phone#: l O G 0
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable(❑
Name of License Holder: ���/ -J�- 02
License Number
Address / Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name _ Registration Number
13,121 A21 /--!Crl
Address Expiration ate
Telephone 3 S•3 --0 06
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. r
Signed Affidavit Attached Yes....... 1S( No...... ❑
11. - Home Owner Exemption
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 1083.5.1.
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
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ® Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [0 Siding M] Other[�
Brief Description of Proposed 7`x'
Work:_.. /l "k —2 1/ C"/��2 C � rt' t it/`?CAL Z h X►S 1 I-ti/ S304c 2
C
Alteration of existing bedroom Yes_X,No Adding new bedroom Yes N
Attached Narrative Renovating unfinished basement Yes 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: C Number of Bathrooms
Sf3 �-��
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions 1i
e. Number of stories?
f. Method of heating? �� L Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction Cz 4 C_ t
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,
FT- 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 a true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
"4<,(IL�'IZ_ L_ i--/--7 //
Print Name /
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 q
Frontage
Setbacks Front f.`7
Side L R: L:2�^/'7 R: ./i/If
Rear C?_
Building Height -1
Bldg.Square Footage %
Open Space Footage % _
(Lot area minus bldg&paved
parkin'-)
# of Parking Spaces Z
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T 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 kC DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
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
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 O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
ow
Department use only
"City of Northampton Status of Permit:
D \V/ Building Department Curb Cut/Driveway Permit
s
212 Main Street Sewer/Septic Availability
MAY —Q ?ij, I; Room 100 Water/WellAvaitability
rthampton, MA 01060 Two Sets of Structural Plans
Eieciric. =.- �4>1s -587-1240 Fax 413-587-1272 Plot/Site Plans
No Other;Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ZA Q,Z— F-O aaA Y L r2
Name(Print) Current Mailing Address: ? j _ G�.L�
Telephone > L
Signature
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 ermit applicant
1. Building L11 z � (a) Building Permit Fee
2. Electrical 5 Ca 60 (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 0 +2+3+4+5) �_ ° �� Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1061
go l� o K-
APPLICANT/CONTACT PERSON KIRK PISANI D(tJ(V6iN
ADDRESS/PHONE P O Box 2402 AMHERST01004-2402(413)323-0918() (Atsv f HaN'6 k PROPERTY LOCATION 43 BEATTIE DR
MAP 29 PARCEL 202 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out �Ji L/ 4L '!✓ i
Fee Paid
Tvpeof Construction: CONSTRUCT 16 X 24 ATT GARAGE&REMODEL MUDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 056494
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
VV 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
i
n Delay
r of ildmg Off ial 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.
43 BEATTIE DR BP-2015-1061
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-202 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: GARAGE BUILDING PERMIT
Permit# BP-2015-1061
Project# JS-2015-002014
Est.Cost: $44692.00
Fee:$267.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KIRK PISANI 056494
Lot Size(sa. ft.): 10454.40 Owner: FORRAY WILLIAM ZACHARY&LINDSAY FOGG-WILLITS
Zoning: Applicant: KIRK PISANI
AT. 43 BEATTIE DR
Applicant Address: Phone: Insurance:
P O Box 2402 (413) 323-0918 ()
AMHERSTMA01004-2402 ISSUED ON.512112015 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 16 X 24 ATT GARAGE & REMODEL
MUDROOM
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 5/21/2015 0:00:00 $267.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner