24A-185 (3) 55 JACKSON ST BP-2019-0140
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 24A- 185 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catetorv: KITCHEN&BATH RENO BUILDING PERMIT
Permit# BP-2019-0140
Proiect# JS-2019-000225
Est.Cost: $75000.00
Fee: $487.50 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor_
Lot Size(sp.ft.): 5009.40 Owner: PALERMO LISA J&KRISTIN L WOODWORTH
zonine:URB(96)/ Applicant.- PALERMO LISA J & KRISTIN L WOODWORTH
AT. 55 JACKSON ST
ApplicantAddress: Phone: Insurance:
55 JACKSON ST
NORTHAMPTONMA01060 ISSUED ON:812/2078 0:00.00
TO PERFORM THE FOLLOWING WORK:kitchen and bath reno
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 Occuoancv Signature:
FeeTvpe: Date Paid: Amount:
Building 8/2/2018 0:00:00 $487.50
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
Building Department >c m permit
212 Main Street '6
Room 100 70 I Availability I
Northampton, MA 01060 >N Two Sispophod,plans
phone 413-587-1240 Fax 413-587
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RE OVATE OR DEMOLIS A ONE OR TWO FAMILY DWELLING
I ] - cto
SECTION I-SITE INFORMATION &19-, tqi
1.1 PropertyAddress: This section to be completed by office
TC45 Oil Map Lot 165-
a UnitZone Owirlay District
Elm St District CIS District
SECTION 2-PROPERTY OWNERSHIPIAUTHORUE wzENT
2.1 Owner of Record:
Name(Pdnt)
�,,
�
La Telephone rY
07 Signature
2.2 gprized�Aen�
, a
Name(Pnm) Actme..
OYZI14 L47
Signature Talapli.na
SECTION 3.ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by pemit applicant
1. Building (a) Building Pennit Fee 1-10 7
2. Electrical (b) ad Total
ot from Cost Of
=tartutbam m (6)
3. PlumbingBuilding Permit Fee
2-,
4. Mechanical(HVAC)
5, Fire Protection
6. Total=(1 -2-3-4-5) ZS� 000 I Check Number
This Section For Official Use Only
Building Permit Number Date
Issued:
Sign ure:
Bull mg Co I jonedinspectorofBuildings Date
I 4(�AW811-0
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
Section 4. ZONING All Information Must Be Cismpleted. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Buddo,Department
Lot Size
Frontage _ .._._.
Setbacks Front
Side L - R: - L ._ R
Rear
Building Height
Bldg.Square Footage % --
Open Space Footage % _...
(L.area minus bid&&Paved
m in
#of Parkin Spaces --
.olume.
Loeationl --- .._._...._
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW O 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 O DON'T KNOW O YES 0
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 O
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 O
IF YES, describe size, type and location:
E. Will the cwnslruchon 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 O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
/
SECTION&DESCRIPTION OF PROPOSED WORK Icheck all applicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[01 Other[Q
Brief Description of Proposed
1I6 Work: LITW �# oor \ /
Alteration of existing bedroom_Yes No Adding new bedroom Yes No JX\
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Be.If New house and or addidon to exhitGln housing, complete the followhw:
a. Use of building One Family Two Family Other
b. Number of rooms in each family unit. Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new censtmction. Dimensions
e. Number of stories?
f. Method of healing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
1. 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 regulators? Yes No.
I. Septic Tank_ CitySewer_ Private well_ City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
XL4 Ierm" as Owner of Ne subject
property
hereby authorize C,
to act on my behalf, in all matters relative authorized by this Qrnit application.
CJ
Signature of Ovmer Date
I, Z-/sa. S' Pa le-rryz-o 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.
isa pa /err✓
Print NNapame� � �
c l Y!/� rGf li(/GiD !e4
Signature of OwnerlAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Noma of License Holder
License Number
Address Expiration Date
Signature Telephone
B.ReeisLexW'.Hdms tmprovement COMrabfor. . Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.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 Afficavit Attached Yes....... ❑ No...... ❑
r
City of Northampton
Massachusetts
x
DEPMTMEIiT OF HOZLDZNG INSPECTIONS p
212 Hain Street a Municipal Building =�y� T•;`
Northampton, I 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
perforating 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 preexisting ownerbccupied 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
t1 contracted with a corporation or LLC,that entity mustberegistered
Type of Work: i�p. V'I�d Ce. If `75 Est.Cost�: /,?.5'�0�/0�/U.0o
Address of Work: �� `J(, L �� �^^�� 7��nn Ao(ff� �4 "I Z)7 11 r " ' C/() 60
Date of Permit Application: )C,
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
_Sob under$1,000.00
Owner obtaining awn peraut(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 perjury:
I hereby apply for a building permit as the agent of the owner:
I d „✓�(-��— trt I I I
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
salll i z_jsa T. Pel/erng-6 a .
Date Owner Name and Signature
City of Northampton
1 . s
Massachusetts
I �
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DEFARTHENT OF BUILDING ZNSP£CTIONS
212 Main Stueet • Municipal Building
NorGa ten, M 01060
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 farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section I I O 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.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Official, on a foam 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.
City of Northampton
Massachusetts
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i
212 nin S OF BNZZDZNi ZNS Building NS 2
232 Mein Street •[p,niapel Building
NaxtM1empton, 6P 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:
:; TCIC�c�DT� S31 �Cf, /Y�/Yf/ /!7 /J7 Y/ 1l O/DloU
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address) q
yu
Signature of Permit 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 of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 0II14-20/7
nwimmass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED 14TTH THE PERMITTING AUTHORITY.
Applicant Information Picture Print Le ibl
Name(Business/Orgmizatiomindividual):,/ Z-1-Ta y r7—- P,q >°rrkz-r
Address: �iS ,J �,e-�(]7 2fij'irfff
/�// �
City/State/Zip: r Yl7 Phone#:` C1k9E�20O(e
Are you an employer check the appropriate box: Type of project(required):
LLJ l am a employer with employees(full rather peri-man),* 7. ❑New construction
2.❑lant a.tole lanpriemr or leadership and have no employees working for me in g. ❑Remodeling
any,opacity.[No workers'comp.returnee required]
yr l am f.
a homeowner doing all work mysel [No wormos'comp.announce required]' 9. ❑Demolition
�
Im�
Pleasure
homeowner and will he br ing conavema to conduct all work anmy property. [will 10❑Building addition
awt all conaaedrs either have workerscompensation inverence or are sole 1L❑Electrical repairs or additions
propmedrs with no employees_ 12.❑Plumbing repairs or additions
51 am a general concessions and 1 have hued the sub-conaaodrs listed on the mmchcd sheet, 13 Roof repairs
Theo sub-conuacmrs have employees and have workers'comp.uuumme.
6❑We an a continuum and its officers have exercised their right of exemption per MGL c t4.E]Other
152,ssI(4),and we have no employees.[No workers'comp,insurance de,n I
'My applicwt that checks box 41 must also fill out the section below showing Mew workers'compensation policy inPonnation.
t Homeowners who submit N
is affidavit indicating they am doing all work and Nen hire outside conhadrs omus[submit a new affidavit indicating—la,
tComnactors that check this box most aural ed an additional sheet showing the time ofdae sub contactors and state whether or not those entities have
employees. If the sub-contactors have emplovices,they must provide Neu workers'rompw(icy mambo.
I oro 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.Lia#: 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.
Ido hereby certify under thepains andpeennalNes of perjury that the information provided above is true and correct
Signature: C AA/ � ' �� Date: W///o
Phone#: 016202QJ-7 2- O&
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 J.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Ph...#:
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 aloin 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 o£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 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 permidlicense 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 proofthat 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-NMSSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
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
ofthe 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 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 ofthis 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 your insurance company's name, address and phone number along with a certificate 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. Had 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 continuation 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 ifyou 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 pennitdicense 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). 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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
TeL # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
F—Revised 02-21-15
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