12C-023 (3) 22 BURNCOLT RD BP-2016-1547
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-023 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRAC.I ING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit# BP-2016-1547
Project# JS-2016-002641
Est.Cost: $28000.00
Fee: $182,00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NICHOLAS RILEY_
Lot Size(sci. R.): 13285.80 Owner: MASLOWSKI JANET K
Zoning: RI(100)/URA(100)/WSP(10Qy Applicant: NICHOLAS RILEY
AT: 22 BURNCOLT RD
Applicant Address: Phone: Insurance:
77 MASSACHUSETTS AVE#2 (413) 531-4370
C H I C O P E E MAO 1013 ISSUED O.N:71512016 0:00:00
TO PERFORM THE FOLLOWING WORK SIDING, WINDOW REPLACEMENT & DECK
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:
FeeTvpe: Date Paid: Amount:
Building 7/5/2016 0:00:00 $182.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1547 `gy (
APPLICANT/CONTACT PERSON NICHOLAS RILEY rib"
ib"
ADDRESS/PHONE 77 MASSACHUSETTS AVE#2 CHICOPEE (413)531-4370
PROPERTY LOCATION 22 BURNCOLT RD
MAP 12CPARCEL 023 001 ZONE R1(19O)/URA(100)/WSPQ00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TvpeofQpgstruction: SIDING WINDOW REPLACEMENT&DECK
,,,,,._
New Construction
Non Structural interior renovations
Addition to ExistVtg
Accessory Struc ire
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:
V 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
Demoiit• Delay
Oririr
J
Sig adding 0 'cml 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.
RFCE '_El I use«dy
City of Northampton Status of Permit:
Building Department Curb CWdiveway Permit
212 Main Street Seve/SepucAvai y
Room 100 WatedWeiAvailability
Northampton, MA 01060 Two Sete of Structural Plan
phone 413-587-1240 Fax 413-587-1272 PIot/Site Plans
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
2?. )3v240C.0C-.t P014„t7 Map Lot Unit
r002C"/1CCI: r P'7A0l06 Z- Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
=SA f-)c i /nq ewcALC,K. t 22 ,t),.N(r)4r aoAt:, Fze'z r,l-u:.
Name(Print) Current Mailing Address: > c,
St- coir r/AC`s Telephone / S 58'j .3 {z p ..
Signature
2.2 Authorized Anent:
A)ICHOu`kS wiz-c-7- 77 MhSSs ANIC ClitCoPc ,MAoc/3
Name(Print) Current Mailing Address:
L
29±117-e- ' ilir, z/y3 S3o2$99
Signature Telephone
SEC RON 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2. Electrical ...... (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee /070Q
4. Mechanical(I1VAC)
5.Fire Protection /'
6. Total=(1 +2+3+4 +5) •�, QaCJ Check Number qqs / 10j,..)
This Section For Official Use Only
Building Permit Number Date
SSaed:
Signature:
Building Canmissionernrupector of O Mims Date
Section 4, ZONING Mt Information Must Be Completed.Permit Can Be Denied Due To incomplete Information
Existing Proposed Required by Zoning
This column to be fitted in by
Building Department
Lot Size )3/ftV $4Fr ,3, yeta
Frontage / J cO
Setbacks Front
$ide L: 3v R: Z-c3 1.: L[it' It: Z-t=
Rear
Building Height Vit, Ib"
Bldg.Square Footage lo`}B .0
Open Space Footage , 'f,
(Lot arca minus bisig&paved ti,U 11 62,4
parking)
N of Parking Spaces
Pill: /Illti
(volume&Location) /
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO DONT KNOW YES O
IF YES, date issued:
IF YES: Was
'�the permit recorded at the Registry'� of Deeds?
NO 0 DONT KNOW 0 YES 0
IF VES: enter Book Page and/or Document it
B. Does the site contain a brook, body of water or wetlands? NO �4. DONT KNOW C) YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , DateaIssued:
C. Do any signs exist on the property? YES O NO 0,
IF YES, describe size, type and location: YY''
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
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 I acre? YES C> NO {�+1
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION S-DESCRIPTION OF PROPOSED WORK(check all aonfca)de)
New House ❑ Addition ❑ ReplacementtWndows Alhxation[s) 0 Roofing El
or Doors 7
Accessory Bldg. ❑ Demolition ❑ New Signs [Di Decks Ico Siding[A Other[o]
Brief Description of Proposed _
Work: Si.bt.-'C //,i4ti_bo,- •pcP'Lf{(C(YICfLi\ b&Ct-
Alteration of existing bedroom Yes % No Adding new bedroom /Yes 7 No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
sa.If New house and or addition to existing houshm,comfiete the following:
a. Use of building:One Family )4 Two Family Other
b. Number of rooms in each family unit:_,- 6 Number of Bathrooms i ._
e Is there a garage attached? ht-3
d. Proposed Square footage of new construction._ Fa/(24 Dimensions_
E Number of stories? 1 _
f. Method of heating? 1-4CT U)ATC-1.- Fireplaces or Woodstoves 73 Number of each O
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction RES
i. Is construction within 100 ft.of wetlands? Yes jQ No. Is construction within 100 yr. floodplain __ Yes A No
. j. Depth of basement or cellar floor below finished grade 7 '
k. Will building conform to the Building and Zoning regulations? )1 Yes No.
I. Septic Tank_ City Sewer„ / Private well City water Supply )G
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. WO Sc (O/"'iei .�..... as Owner of the subject
Property .—...
hereby authorize t -BOt iS ;Zttr"
tii
to act on my behalf,in ail matters relative to work authorized by this building permit application.
Signature of Owner n Date
11111.111.11111.1111.111.1111.111.1111.111.1
I Ot C I-1 ottq s 7 %1,6,-z/ —.... ,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.
0tG#4oMS Xitt
Print Name ,¢J )) / � /
'fi' 8➢ •Z`l�i L
Signature o r/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
n Not Applicable El
Name of License Molder: L>"t5 2 (1t _ 0970 77
License Number
77 fl,4SS ,'we Ciltccet My? ofoo 9 - z9 - J6
Soarers 4,2(y .. 93' Expiration Date
Signature Telep
9.Registered Herne Impravament Coplractetc Not Applicable 0
N < IL-et CO/USTraLc 7On) 15b6q
Company Name Registration Number
77 rnetss /tut, (4-( [caeca „r g_ _ 7- iz -C7
Address �-7 Expiration Date
Telephone 1/1353 !�il/ t *
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§25C(S))
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 ❑
il. — Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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,Chin 750, 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
stmctures.A person who ceastructs more than sue home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Oficial,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 bt 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 1 oral Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature 1.4?
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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.
Address of the work: Z7 /Ln) CCLT �D
The debris will be transported by: Ru- WASE fe7rio JAL
The debris will be received by: MctvA MR4A TO_RiuSiceiC
Building permit number:
Name of Permit Applicant 0I r-t(U[_RS
(, Zy - l4, gmr
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
• . itai Department of Industrial Accidents
;.
G 'ma �
Office of4nvestigadons
1 Congress Street,Suite 100
sa �
t- .� Boston,MA 02114-2017
.y www.mass.gov/die
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organizatiorindividual): i3, F-1 LA.:. DIOS-7
Address: 77 mAss AVL-.
City/State/Zir. _Sr°Or-% A ptot3Phonea: /3 5-_t 2 370
Are you an employer?Check the appropriate box: Type of project(required):
1.71 I am a employer with 3 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9
[No workers' comp. insurance comp. insurance. ❑ Building addition
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
r c. 152, 1 4 12.0 Roof repairs
and we have no } ,iG f
insurance required.] ), 13_5hther i tb+ 4,41-t'''I `-
employees. [No workers' - — -
comp. insurance required.]
'Any applicant that checks box VI must also fill out the sects below showing their workers'compensation policy infomrntion.
Homeowners who submit his 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-contractos and state whether or not those entities have
employees. lithe sub-contractors have employees,they must provide their workers'comp.policy number.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. `` s� ``n�rr
Insurance Company Name: t�Gl/1TC-U_. '✓jrwquCU
Policy#or Self--ins. Lie. #: 13311-G-oo 8'3 7(,o 1 Jo IS Expiration Date: L ' '" 17
Job Site Address: ZZ- /_COLT /Zb' ,._...-City/State/Zip: thee CC:: Ind
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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify a der:h.pat and penalties o perjury that the information provided above is true and correct
Signature: d < - �. „/�°'"'.'. Date: b741-
Phone th
41-Phone#: '-t1$ C3( 73.7D
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):
I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector
6.Other
Contact Person: Phone#:
111IVAL Riley
Construction/General Contractor Page 2 of 2
Acceptance of proposal:The listed prices,specifications and conditions are satisfactory and are hereby accepted. N.Riley Construction,Inc.
is authorized to do the work as specified. Payments will be made as outlined above. This updated contract supersedes any and all others.
Please remit payment and signed contract to N.Riley Construction, Inc. 77 Mass Avenue Chicopee, MA 01013 prior to the scheduled start
date.
Authorized Signature:
JANET Dale of i///t///10
Job Name: MASLOWSKI Axeptance: 7 -/ -y"'��y�
22 BURNCOLT y '�'yiil4�r-
Job Location: ROAD Signature: �q,
FLORENCE,MA rJ
Phone: Signature:
2//3 , 33S . 3L'9O s
\ * 1C/e‘-(9 S 1, cel 7-5—/
g-at --r-�u ! , cam,-11 `5., X7 r
00,
+' City of Northampton I� a
,\ d Building Department
Plan Review
------ - _ 212 Main Street 1
Z ii. __ Northampton MA01060
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