29-588 (2) 76 WOODS RD BP-2018-1392
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map: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)
Cateeorv,Deck BUILDING PERMIT
Permit BP-2018-1392
Project# JS-2018-002474
Est.Cost, $10000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sp. ft.l: 29795.04 Owner: JONES JEFFREY W&MARY E PALISI-SCHUELKE
Zoning- Applicant: JONES JEFFREY W & MARY E_ PALISI-SCHUELKE
AT: 76 WOODS RD
Applicant Address: Phone: Insurance:
76 WOODS RD
FLORENCEMA01062 ISSUED ON.7/Z2018 0:00:00
TO PERFORM THE FOLLOWING WORK EXTEND DECK, SCREEN IN EXISTING 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: ak 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 7/2/20180:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2018-1392
APPLICANT/CONTACT PERSON JONES JEFFREY W&MARY E PALISI-SCHUELKE QCC—
ADDRESS/PHONE 76 WOODS RD FLORENCE
PROPERTY LOCATION 76 WOODS RD
MAP 29 PARCEL 588 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FI
Fee Paid A . _
Building Permit Ft
Fee Paid
TTypeofConstructi= EXTEND DECK SCREEN IN EXISTING DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included,
Owner/Statement or License
3 sets of Plans/Plot Plan
THEYOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON Z
!NYORMATION PRESENTED:
_Approved_Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project Sita 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
-Demolition Delany
�(n✓ k/t 6 29 1B
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 Office of
Planning&Development for more information.
n1EEDs r ° mUd j Bffo(LE Is_' INSPEczld
Department dee only
City of Northampton Status ofpem�' )�
Building Department t r ,*ItilrArl10 wi Permit
�( +. 212 Main Street Jim
( Room 100 RECEI
Northampton, MAO 060 Of gOteplanffi..
phone 413-587-1240 Fax 4 72
3- 7-172
272 Z G 5 city .•
APPLICATION TO CONSTRUCT,ALTER, REP IR, NOVATE OR DEMOUSJ A O E OR TWO FAMILY DWELLING
DEPT.OF BUILDING INSPECII
No TA, TIN
SECTION / -SITE INFORMATION
1.1 Property Atltlress: // This section to be completed by office
w W000/1 Map -g_ Lot ✓ Oa Unit
lila/'[h/4 MP�QO) Zone overlay District
Q/Q 6 ;1- Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
/ (U o�w 76 CfJa��/S �dAo�
Name(Print 1 Cupen 61 king Adosre-2
Telephone
Signal e
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 bermit applicant
1. Building /j Ll y (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) M I tj Y'C/o
5. Fire Protection
6. Total=(1 +2+3+4+5) 1 1 Check Number
This Section For Official Use ON
Building Permit Number. IIsssued:
Signature
Building Commissionerllnspector of Buildings Date
@ eoM eAs� a et
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
GmaL-URGENT:Call the Mass,Legislators Today to Defend Tirne and a Half! 8111118,624 AM
Y
httgsdlmallPage 3of3
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
Int Size G7. _ e67
Frontage
Setbacks Front
Side L:_R:_ L:_..._R:— ..
Rear ... _.
Building Height ---
Bldg.Square Footage ?Iqo % oZ1�10
Open Space Footage %
d.at arca minus bWg&pm-eJ
rkin )
#of Parking Spaces
File
(vol,meis Locai nnl
A. Has a Spe 'al Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wettands? NO VDON7KNOW 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 6
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 V
IF YES, describe size, type and location:
E. Will the construction activity disturb(cl anng,grading,excp4afion,or filling)over 1 acre or is it pad of a common plan
that will disturb over 1 acre? YEE NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement WfndAlteration
(s)Altera (s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding M) Other[q
Brief Description of Prgposed
Work�_ ?Nd ,fY rem l/£LlC J 4e -,em
Alteration of existing bedroom_Yes_3,fNo Adding new bedroom Yes �- No
Attached Narrative Renovating unfinished basement _Yes _ No
Plans Attached Roll -Sheet
sa. If New house and or addition to ex]ating housing complete the following
a. Use of building: One Family- r Two Family Other
b. Number of rooms in each family unit: /O Number of Bathrooms S
c. Is there a garage attached? pS
d. Proposed Square footage of new construction. Ice Dimensions
e. Number of stories?
f Method of heating? 19l/ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction LCLK
i. Is construction within 100 ft.of wetlands?_Yes _�' No. Is construction within 100 yr. floodplain_Yes_�Jo
I. 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, 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 ' 1 Date
I, V v/ W �a4'eS ,as Owner/Authorized
Agent hereby d -eclare that the s Cemen,ts 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.
J.e r LU , J D.10
Pnot Name 7
Signal o n 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.Realalered Home Improvemard Contractor. 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....... Ld" N.-.... ❑
✓ Massachusetts
s
(. DEPARTMENT OF BUILDING INSPECTIONS im
212 Main Btmet • Municipal Building Vp CD
Nortks pton, as 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modemizatios, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units or to structures which am ad/acent to such msidence 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: Deck -e / Est.Cost: /0 00 0, 0
Address of Work:% a OOQ�s'
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.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
1 hereby apply for a building permit 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 o v r the above prop
_Z
4 -/R
8
Date Owner Name and Signature
t[ Massachusetts
L PHETDrENT OF BUILDING INSPECTIONS
212 Main Street .Municipal Building JA �:
North 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:
7� rUoa�'s RDA a1
(Please print house number and street name)
Is to be disposed of at: A '/ `/ T
��v'� dA�� KdAcC /`l dleGe 9�J 1 e�c��cf M 171'61 )
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company
�Name and Address)
e Permit AyPicant 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 of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www roass.gorldia
w
1Forkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /� Please Print Le ibl
�
Name(Business/Orguniza[iom'Individuul): n . Vq�W�
Address: CU 0 v S tK r if / (.(/,/ ,4-41.9 ref phi) AIA OC`/a 6 Z
City/State/Zip: Phone if: q12 30'- q`1 f T
Are you an employer?Check the appropriate box: Type of project(required):
I.c3lamaemployer with employee,ballsocior part-time)." 7. ❑New construction
2❑I am a sole proprietor or partnership and have no employees working for me in 8. HRemodeling
any capacity_Mo workers'comp.insurance pacro ed1 r4u•1
3❑lama homcowner doing all work myself INo workers'comp.Insurance required] 1 Demolition
a_ am ra homeowner and will be hirin contractors to conduct all work on m IU❑ Building addition
g Y property. I will
unsure that all contractors tither have workers compensation insurance or arc sole 11.0 Electrical repairs or additions
Popper...with no employces12.❑Plumbing repairs or additions
5 am a general conuactor and I have hired the sub-contractors listed on the attached sheet.
❑1 g 13.❑Roof repairs
rors
These sub-contrachave employees and have workers mmp.insurance.) '
6.❑We are n corporation unit its officers have exercised their right of exemption per MGL c_ 14.�ther ]YJ
152 41(4),and we have no employees.[No workers'comp.insurance required.I
'Any applicant hat checks box 41 must also fill out the section below showing their workers compensation policy information.
I Ih m owners who submit this affidavit indicating they are doing all work and then hire ournme contractors must submit a new affidavit indicating such.
[Contactors that cheek this box must attached an additional sheet showing the name of the sub-commeans and stale whether or not those entities have
employees. If the sub-contmaors 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 4 or Self-ins.Lic. 4: 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, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify u e pains and pen tes of perjury that the information provided above is true and correct
atu
Signre: GW Date:
Pha e# 4'/� 397- D"N
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#: