36-304 Property Address: ,p,� ic : ; c r
Contractor
Name:
Address:
City, State: //G. ( h i
Phone: ` L.te l 3S
Property Owner
Name: -
Address: 0 4
City, State:... =cam.. ; ,1
fi r' �L� F.' ,/ (contractor) attest and affirm that the building I intend
to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavit.
Contractor signature
Date
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The Commonwealth ofMassachusetts
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1 = 600 Washington Street
- - Boston, M4 02111 "
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- - - -- Workers' Compensation Insurance Affidavit BaildcrslContracto ici hamben
'Walkout _ --
Information r �} Pigase Print- Levibly
Name ): , } OA) P ig a) , f �i t) 11 .212.
4 "
Address 1 t 0 7 f A t 1J S'++
City /state/Zip: 1 l -o lu t7 I' e C� 010 � f o Phone #: Lt 13 5 3S _ h 00D.
Are you an employer? Cheek the awe box: " Type of Project ( ):
10 I am a employer with 4. 0 I am a general cofactor and I 6_ ❑New
employees (� and/or p�'�e) s have hilted the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
slip and have no employees These ads have 8.:J Detnoli& n
for me in any cavity. cvsPlaYees and have warble 9. 0 Building addftion
- [No workers' comp. insurance camp: eve.$ -
5.0 We are a aorporafion and its _ 10 -0 Electrical TeRirs `oradditions
require,' d.1
3.0 I an a homeowner doing all work . officers have exercised their 11 -0 Pl unb* repairs or addifiens
right of exeaiptkon per MGL
myself [No warps comp. right Roof repairs
insurance .l t c: 152, §1(4), and we have no
employees. [No workers' 13.0 Other
i - comp. insurance required.]
•Any applicant dud chocks beat di mast also MI out the section below showing' their wodoas' compensation policy man.
t His who submit this affidavit indicafing 1bcy&e doing all work and then him cubicle co nowt sahiert affidavit Iona; ing mob:
tContracires that chock this box most an additionalsbeet showing the name of the sub-oonnactwsand state whether or not those ratifies have
e m p l o y e e s . If d u e s a n c t nshave employees. t h e y most provide their wodo xs'comp. policY noneet -
I am an employe; ttbmtIs >aorkrrs' efts my employees. Below it the policy and.* site
Insurance 'Name: te C41 / O 1011 0
Policy If o r S e l f - i n s . Lie. #: 1 IV t� q 0 1 - QS' Expiration Date: 1 x J
Job Site : S A . C , City/StateJZip :11 D le'_,l CL'- Net ,
Attach a copy of the workers' compensatiol ply declaration page (showing the policy number and ezpantion date).
Faihire to secure coverage as required under Simon 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 bnceisonment, as well as civil penalties is the form ofa STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a-c opy °oftlns statement may forvtarded to the Office of •
Investigations of the DIA for insurance coverage verification. -
I de hey catfy tinder litepadns dadpataltdrs ((perjury that the Information provided above is true end apnea
- tn. P..ch s' �� Dame: , ----) – � - i ( .
Phone if:
Official use only. Do not write in area, m be completed _by y or town owl — — –
City or Town Pie # -
A D
{ - Contact Person: ` Phone # (413) 4994440
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r
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / _ { ` Not Applicable ❑
Name of License Holder : JU t& L C o (�J l o f i e C g 6
License Number
O i &t,r'\ , i'43ZpJkf iicei Ci %3/0 4it/ 3v
Ad ss Q ', > ( Exp iration Date
Signature Telep
9. Registered Home Improvement Contractor. Not Applicable ❑
Company Name - Registration Numb r
1 \ - ) e.t • Not Yom 0-
Address Expiration Date
Telephone
— L C ) , 0-4
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 ❑ No ❑
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) 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. CMR 780, Sixth Edition Section 108.3.5.1.
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
structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, 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 be 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 Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
e
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other id
Brief Description of Proposed L C e !, v to pc-)pcie
Work: o yi_v.. 14 \ Z 14 d EL ) I 5P 4'/ v-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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 construction. Dimensions
e. Number of stones?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. 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 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
t i1 'u 0 C H W to___ , as Owner of the subject
property ( �
hereby authorize " t11di (k) , \ e ^ ` -
k 9 C
to �ct o �} my behalf, in all m rs r ative to work authorized by this building permit applica ' n.
V
Signature of Owner Date
I, r lAa lCt W , � kk� - k, , 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. –
` - CvA.eti \c (,j , eV\ f__,,k)%„Q_ r
Print ame
......my ignature of Owner /Agent Date
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 1
Existing Proposed Required by Zoning
This column to be filled in by s
Building Department
Lot Size ».
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW ® YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained o Obtained ® , Date Issued:
C. Do any signs exist on the property? YES I NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO
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 1 acre? YES ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t • Department use only
RECEIVEIYity o orthampton Status of Permit:
Idin Department Curb Cut/Driveway Permit
2 9 2 ' 12 ain Street Sewer /Septic Availability
• om 100 Water/Well Availability
No a pton, MA 01060 Two Sets of Structural Plans
I�nMh1'b ; s^'. 87- 240 Fax 413- 587 -1272 Plot/Site Plans
C 1060
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
Tekcei r Map Lot Unit
f j o r . i1- C--t Zone Overlay District
Elm St. District CB District
,rte SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
(Y 1 2.1 Owner of Record:
v 1 N t i= 1,J '7 U k-t r•> r i2 Z Z T� v2 tiq 12 . Fi o R F � ' )` 01 6 - Z
Na a (Pr" t) , - # - Current Mailing Address: �/, / 2 ) 6-2_
' - » -- �. e ----- Telephone / k�
Signature
2.2 Authorized Agent:
r- O•so/koL Lt.) t tD tr\4CAI VE .0. Hal yokx tic .310Clo
Name (Print) Current Mailing Address:
, e ,
Signature Telephone
SECTION 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
4. Mechanical (HVAC)
5. Fire Protection
�,)j 6. Total = (1 + 2 + 3 + 4 + 5) a \ .� Lt Check Number U l/P
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings 1 Date
File # BP- 2012 -0119
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS /PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION 22 TARA CIR
MAP 29 PARCEL 517 001 ZONE URA(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out .)� /� J���
Fee Paid
Typeof Construction:_INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 101876
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION PRESENTED:
pproved 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
dfr
7-/- !�
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.
294 CARDINAL WAY BP- 2012 -0120
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 304 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0120
Project # JS- 2012 - 000178
Est. Cost: $1638.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 147232.80 Owner: MIRANDA THOMAS A & MELISSA WYANT
Zoning: SR(100);,:WP/WSP II Applicant: DONALD PELLETIER
AT: 294 CARDINAL WAY
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON:8/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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:
FeeType: Date Paid: Amount:
Building 8/2/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner