29-588 76 WOODS RD BP-2018-1150
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:29-588 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category ROOF BUILDING PERMIT
Permit BP-2018-1150
Project# JS-2018-002070
Est.Cost:$15700.00
Fee: $40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groan Homeowner as Contractor_
Lot Size(so, ft.): 29795.04 Owner. JONES JEFFREY W&MARY E PALISI-SCHUELKE
zoning: Applicant: JONES JEFFREY W & MARY E PALISI-SCHUELKE
AT: 76 WOODS RD
ApplicantAddress: Phone: Insurance:
76 WOODS RD
FLORENCEMA01062 ISSUED ON.51312018 0:00.00
TO PERFORM THE FOLLOWING WORK.NEW METAL ROOF
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: OJ: 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 Sienature:
FeeType: Date Paid: Amount:
Building 5/3/2018 0:00:00 $40.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
RECEIVED
Department use only
of Nort ampton Status of Permit
�r���jjyy
111 - 3 �871din De artment Curb Cut/Driveway Permit
A, 212 ain treat SewedSeptic Availability
CP BUImMG iNSPEC m 00 Watern'Well Availability
R HAMPT0NNMthVfh A 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 619-19- 116U
1.1 Property Address This section to be completed by office
�p
4�(/o/ /)o 41 / Map q Lot 691 Unit
Zone Overlay District
Elm SL District C8 District
SECTION 2.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
Name(Print) .� Cement Mal Address'
T `7
z� �<� - fl I?
elepM1one
Signa re 'a
2.2 Authorized Alent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
cam leted by perni applicant
1. Building 0 O (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) 0 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued
Signature Q �9
Building Commissioneffinspector of Buildings Date
b re y'e ; e ff @ �z ,eg S7, -,-e7
EMAIL ADDRESS (REQUIRED; EITHER( OMEOWNE 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 ev
Petition,Detrainment
Lot Size
Frontage
Setbacks Front
Side L R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot ares minus bldg&paved
puking)
#of Parkin Spaces
Fill:
(valuate&L.emi m)
A. Has a Special Permit/Variance/Finding ever been issue J for/on the site?
NO O DON'T KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds
NO O DON'T KNOW CI Y S O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obta ned from t e Conservation Commission?
Needs to be obtained 0 Obtained 01 , Date Issued:
C. Do any signs exist on the property? YES 0 I NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or addit ons of signs in ended for the property? YES O NO O
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 l acre? YES NO O
IF YES,then a Northampton Storm Water Manacement Permit from the DPW is required.
SECTION S.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Kr
Or Doors D
Accessory Bldg. ❑ Demolition ❑/ New Signs [0] Decks [I� Siding[0] Other[QI
Work Brief Description P�ysed'/ l�rT/}L I — wit-acy(r
AACella / L A001-
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Its. 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
n Is there a garage attached?
J, 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 weflands?_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.
L 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, , 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.
SignatureofOmen/ Date
I, -J�+�7(/ Y ��c�v/'�S , 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.
--I—
Print Name
' C
l Jr cmc®
Sig aide gf Owrter/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Reaistered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Te.ephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed aid 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...... ❑
City of Northampton
•' Massachusetts
�-
DEPARTMENT OF BUILDING INSPECTIONS Z
212 Main Btveat a Municipal Building ��
�.. Northampton, ! 01060 by, .ij0\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 perforating 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 pm-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: Est. Cost:
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perj any
I hereby apply for a building pemtit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner t e_above property: '
i
Date Owner Nam and Signature ,'/j /
City of Northampton
Massachusetts
x
I DEPARTMENT OF BOSLDING INSPECTIONS
212 Main street • .M,nioipal Bnildinq
Northa Vton, MA 01060 pn
Massachusetts Residential Building Code
Section I IO.R5.1.2
Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside,
on which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or fartr structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section I IO.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R1, provided that if a homeowner engages a persons)
for hire to do such work, then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she shall be responsible for all such work performed under the building permit.
As acting Construction Supervisor your presance 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 persons) you hire to perform work for you
under this permit.
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
F
212 Nein Street 'Municipal Building
Norther ton, MA 01060
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:
96 Cl 001f hd {/�✓*ltAwPta�, 010612
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility) / <l/ e"e- /'S Vaz✓y
/
q'�2// /
// p✓LL'is NJ/OST /$
Or will be disposed of in a dumpster onsite rented or leased from: Al�eyt r-YC)4A/W— VY./fry `e-
cpP�y�`� - fItKflc Sf�aps
$j W1Y�ppig5 GA-h -��- in ,4
(Company Name and Address) 1649
?60ur of Permf 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.
'\ The Commonwealth ofMassachuselts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston, MA 02714-10177
www.mass.gole/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Pletise Print Legibly
Business/Organization Name:
Address:
City/State/Zip: _ Phone#:
Are you an employer?Check the appropriate box: Busines ype(required):
1.❑ I am a employer with_ employees(full cnd/ 5. stall
orpart-timet'i 6. RestauramTar/Eating Establishment
2.0 I am a sole proprietor or partnership and have no ❑Office and, Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8- ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per a 152, §1(4),and we ha 70.❑ Manufacturing
no employees. [No workers'comp. insurance req "
4.F] We are a non-profit organization,staffed by vol tors, 11.[] Health Care
with no employees. [No workers'comp.insur ce req.] 12.❑ Other
"Myapplirantthatcheelobox4lmust also fill owns,section cosshowingtheirworkeo, compessuiciawlicyinf,man—
'9fd,e cotpomtco[ficers have exempted Memselves,bw lhcc nonnaeo,heremployce ,awerkem'cmpensanon policy is required and snehan
organceelon should cheekIs.HIL
I am an employer that is providing workers'c mpensation insurance for my employees Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy 4 or Self ins.tic.4 _ Expiration Dace:
Attach a copy of the workers'co pensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as re ired 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 ear imprisonment,as well as nvil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day agains the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA to insurance coverage verificatic n.
I do hereby certify,undo thepains and penalties of perjury that the information provided above is true and correct
Si nature: Date:
Phone#:
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/Tiwn Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
ww�- vov/aio
The Commonwealth of Massachusetts
Department of[ndustrialAccidents
I Congress Street,Suite 100
Boston, MA 02114-20177
roymmass.gov/dia
R others' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED N'ITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name fBusivexx/OreanizatioNlndividaall: ,J //�� J or) ig5
Address: rJ [� t/� Dof XBitC/
City/State/Zip: D F" taFra ( Phone#: Z7113
Are you an employer?Check the appropriate box.
Type of project(required):
Il am a employer with employees(full and/or gain tral.' 7. ❑New construction
2❑l am a sole proponent or partnership and have no employees working for mein 8. Remodeling
any capacity,for systems compinsurance required.]
3,[]l am a hfw
omeowner doing all work mysel [No orkers'comp-insurance required]' 9. ❑Dem01i[ion
4.2 r1m a bmnrowner and will he hiring comraao ,to conduct all work on my proper,. I will 10❑ Building addition
ensure mat all contractors cine have w oden'compensation insurance or are sole IL❑Electrical repairs or additions
pmprimoa ,In no cmvioyccs. 12_F1 Plumbing repairs or additions
5.E]I am a genial tonna ror and I have nixed the sub-contractor,listed on the coshed sneer 13.�oc f repairs
These sub contractors have employees and have workerscompinsure
6F we are a corporation andis officer,have exexcised th5r,right ofleemption pv MGL r 14.❑Other
159,k 1(41,and we hme no employees.[No waders comp_insurance required.]
'Any applreennnat checks box 41 must also fill out the section below showing their workers'compensation policy information_
'Homcowncrs who submit this affidavit indicating they are donne all work and then hire outside contractors must submit a new affidavit indicating such
:Contractors that check this box must attached an additional shoe showing the name ofthe sub contractors and suite whether or not those entities have
employees. tribe subcontractors have employees.they must provide their works'comppolicy number_
I am an employer that is providing workers'compensation insurance for rap employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lir.#: 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 MGL c. 152, sy25A 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 farm of a STOP WORK ORDER and a fine of up to 5250.00 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.
da Xereby certify u�r e pains and p allies of perjury that the information provided above is true and correct.
Signature. � �� Date' s —/1
phone# S / Q/9�
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#:
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 ajoint 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 stare 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)stales-NeiH.er fl a 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 numbers)along with their cetifrcare(s)of
insurance. Limited Liability Companies(LLC)or Lin ited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workerscompensation insurance. If an LLC or LLP docs have
employees,a policy is required. Be advised that this a Tide vit may be submitted to the Department of Industrial
Aceidents for confirmation of insurance coverage. Also he 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 Offic:of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pertnit/livense number which will be used as a reference number. In addition,an applicant
that most 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"alt locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner err citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston. MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax h 617-727-7749
Revised02-23-15WW i.mass.gov/ilia