44-112 BP-2023-0608
1170 FLORENCE RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
44-112-001 CITY OF NORTHAMPTON
Permit: Swimming Pool
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2023-0608 PERMISSION IS HEREBY GRANTED TO:
Project# INGROUND POOL Contractor: License:
Est. Cost: 49950 ALEXIS POOLS
Const.Class: Exp.Date:
Use Group: Owner: M SCHAEFER PETRA
Lot Size (sq.ft.)
Zoning: SR Applicant: ALEXIS POOLS
Applicant Address Phone: Insurance:
37 THAYER RD
MONSON, MA 01057
ISSUED ON: 05/16/2023
TO PERFORM THE FOLLOWING WORK:
10X52 INGROUND POOL
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORI'HAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
I t Cr►
I
Fees Paid: $75.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissioner
2- U 4
File #BP-2023-0608
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APPLICANT/CONTACT PERSON:ALEXIS POOLS N=-�D� �� v 12������,
37 THAYER RD MONSON, MA 01057
PROPERTY LOCATION 1 170 FLORENCE RD
MAP:LOT 44-112-001 ZONE
THIS SECTION FOR OFFICIAL USE ON> Y:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Building Permit Filled out
Fee Paid $75.00
Type of Construction: 10X52 INGROUND POOL
New Construction
Non Structural Renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans/Plot Plan
Driveway Grade%
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN 6RMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR S ecia'1 Permit With Site Plan
P
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 1 Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit froii CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
/1/43Z 5- i1. zo2.3
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden¶o 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.
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The Commonwealth of Massachusetts 4.4qy FOR
Board of Building Regulations and Standards �9 UNICIPALITY
_ Massachusetts State Building Code, 780 CMR � 3 USE
Building Permit Application To Construct,Repair, Renovate Of l ,ish a Revised Mar 2011
One-or Two-Family Dwelling , ,,,;,
This Section For Official Use Only , "'0sr�0'S
Buildin Permit Number: &A 3 — LIt 01 Date Applied:
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Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Prope Address: 1.2 Assessors Map&Parcel Numbers
► O HO VeinCL Kd-
1.1 a Is this an accepted street?yes k no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
c3y' �71 a%
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
PC±CA ►M . S C kdi e1e-x JUO Aiktivielb / ifl A
Name(Print) City,State,ZIP
I170 -FIo►v,,,_e Rd Gy9-607-03a
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction71 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work': 165c 5 2' Jvv.v-c�v''t P incs 1.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
Pc,0 $ 17 -{ c 1. Building Permit Fee: $ Indicate how fee is determined:
( ❑Standard City/Town Application Fee
2.Electrical $ • f)oo
0 Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees
Check No. Check Amo . Cash Amount:
6.Total Project Cost: $ CC) ❑Paid in ull ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R ltestricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 RegFistered Home Imp vement contractor ( 8166 8 •
41 e)c'I 5 1'��5 '- ("1!bC V HIC Registration Number xpiration Date
HIC ompany Name or HIC Rekyjnt Name
31
46
Noland O t40� 11 A- 07
-7 Email ad s G i I
City/Town,State,LIP Telephone
SECTION 6: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 No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PER
MIT
I,as Owner of the subject property,hereby authorize tkC.e'X 15 ? -•3
to act on my behalf,in all matters relative to work authorized by is building permit application.
kut-61,04.1iFe S/9 72. 2-5
Print Owner's Name(Electronic Signature) I Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
c.-q- zo
Print Owner's or Authorized A nt's Name( lectronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) A 1Q (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) ILJ(� Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of ialf/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost" /j 4-
City of Northampton
;
r " Massachusetts
•
4• DEPARTMENT OF BUILDING INSPECTIONS y x
fi 212 Main Street • Municipal Building
Northampton, MA 01060 ems!-4 p‘A'`
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: t-'' i--- ete) v� ' ( pYJ
5 �
The debris will be transported by:
Name of Hauler: � S coals
Signature of Applicant: Date: SIT �2�
The Commonwealth of Massachusetts
—7. _ /, Department of Industrial Accidents
t. _`;,�►_= 1 Congress Street,Suite 100
rd Boston,MA 02114-2017
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�� www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
LID I am a employer with_ employees(MI and/or part-time).' 7. 0 New construction
2. 1 am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3 ElI am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 Q Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.0 We area corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this 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-contractors and state whether or not those entities have
employees. If the sub-contractors 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#or Self-ins.Lic.#: 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 under the pains and penalties of perjury that the information provided above/ is true andt
� correct.
Signature: Date: .��-'T -Z /
Phone#: - l( 3 gg- C) 7 6
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#:
SHEET 1 OF I SHEET
PETRA M.SCHAEFER a(
1170 FLORENCE ROAD IV
NORTHAMPTON,MA 01062 I
44-112-001 '
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SITE PLAN FOR PROPERTY IN
THE CITY OF NORTHAMPTON, MASSACHUSETTS
SURVEYED FOR
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PETRA M. SCHAEFER
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