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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 7 a.z; _ t f _ 3 - - 'Apadtutsql 41 miuniaisals_liasilwilmaqggittaimisgagri AM ‘ \ : # ikqr :=0... _d_wyjnrOtulimr) ,_ t / _ -c _. 4 :Ma ' - HELM P'II!lV QIrI MMIM1Od Willuml klieg 1 .1 40 9 0 ).1 � Q \ .\� ` pp •" - _ - _ - vuodurollagabouiso _ 1 z r _____r._. - _ - - .. WOOS$ zoimn get _ : _ - - - - milt AllatibPla VIA 1 - --A L . :intimadiVIIPIuMPasva - ingstoun Immune gapipausacoaw aqt wig Bawl= - N ZPI mei SI34ri +*ai .�I1i - . , staitaallt The Commonwealth ofMassachusetts ,, �.- „""` �1 11ep ofIndwarialAc ` 1/4 44,.._ " _ Wee ofhivesiigatwns . 1 = 600 Washington Street - - Boston, M4 02111 " -- www mass gov✓die - - - -- 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 s — 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 w 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