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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 � x 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 � c 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 , a � , � _� �.,, _� �� �, �� � � Q ��� 1S4 - � � -► n-�C� � ,� � � 1' p ��,,�� ��� � � �, U �,�a3� � � � � ! � � t X �_-_-- �11 +, } + / 7 r3 144 d 0 Jt- w �t1 o+Do 1.) , dam �pcC1����ks e� Z Q � 0 in Iz Q � v � Q � I It's ZZ Iz L'Q d w,ndoy W ex e�.