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17A-285 • Property Address: G`-1 Kts -f-c k Q 5 - Contractor Name: ..ACi 7 -emei le 7 Address: A 1CJL 1 City, State: o._ 0(--10 Phone: \ 6 C ) 2 -- Property Owner Name: 7.- Ocrl'e\r"• \ CS"N Address: 64-i- 6 • City, State: \ t (e ��' O e 0 \T 6 - I, rimer\&k ?tk le+r 1? c (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 Q 1 � Date 26 SI L �.v,w,u / r, IwI4 Vi 4I1NJ.1Nt.fJ HAGUUJ Y• Department of Industrial Accidents • Office of Investigations 600 Washington Street Boston, MA 02111 L wnm.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians / Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): }.O r \ - L \ ‘e C Address: 1 \©''T �l c* • V ic` City/State/Zip: Nd \- yc) e . YYVX Phone i,3) 5 3 Are you an employer? Check the appropriate box: Type of project (required): L 0 I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub - contractors 2. ❑ I am a sole proprietor 7 orpartnet- _ - - listed on the attached sheet. t ID Remodelin g ship and have no employees These sub - contractors have 8. ❑ Demolition - working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 14.0 Electrical repairs or additions required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 110 Other comp insurance required.] *Arty applicant that checks box RI must also fill out the section below showing their %e acts' compensation policy infonnatioa. t Homeowners who submit this affidavit indenting they are doing all work and then hire outside contractors must submit a new affidavit indicating such tConactors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees Below is the poluy and job site information. Insurance Company Name: t C'_ C 1. `-No V7 Q U V \ S CO ° ^y am Policy # or Self -ins. Lie. #:��) C saq6yt7� Expiration Date: a✓I ) lob Site Address: 7 675' J- t) (f.;= - City/State/Zip: Fio `e eL-- 0-10 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a : ne _up.2o S imprisonment, aswell ascwikpenalties-in# he-form of-a STOP WORK ORDER-and -a fine — - - - )f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of .nvestigations of the DIA for insurance coverage verification. r do hereby certify under the pains and penalties of perjury that the information provided a bove is true and correct signature: V ∎p er Date: J 1 S t 'hone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (cirde one): 1. Board of Health 2. Building Department 3. City / toown Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other r' °- - gip, Liiii I 1 , - . =. . M MN l 1 N 0 M M N, N M .0 M N 1. * IR / r at: 010 .li il 1 1 n h!iJ i i l , . a r 1 1 .. hi II I s . ' . ' blir . 4 , s - .' ' , $, S"."' I 1 , ' , 1 . 1 ' 1111 � • : (Ill ill , 1 ' ti i I i : ' ::*1". ;41 . r 11'111 1` .Y� 'N, . '����i I � zWM ess: 1 , . r i d , ' : I il I • AFFADAVIT Home Improvement Contractor Law Supplement to Permit Application Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only Name of City / Town Permit No: O (f' Date: Note: 142 A, requires that the " reconstruction, alteration, renovation, repair, modernization, conversion improvement, removal, or demolition, or the construction of an addition to any p owner occupied building containing at least one but not more than four dwelling anit(s), or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exceptions, along with other requirements. Type of Work t )1Q t6N, Est Cost Address of Work: b X�' Owner's Name: roY`- e V" ten 22 Date of Permit / Application: 3 13-1'D-- I hereby certify that Registration is not ret;uired for the following reason(s): Work is excluded by law Job under S1000.00 Building not owner- occupied Owner palling own permit l X Other (Specify): _ _. Q_ Notice is hereby given that: • - OWNERS PULIMI•Ci THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL C. 142 A Signed under the penalites of perjury: I hereby apply for a p ermit as the agent of the owners: ContracAjoliikft 41 trgstratim iSbS OR: Not withstanding the above notice, I hereby apply for a permit as the owner of the above property Date: Owner: 4h. sA0 3 Mae PP1101 31 4 Mul.P annbS Palmer *ado P mask awn Jo GAL =Pod /0130P30-304020i4 wash Xamfajo adia, sq. • 6111001 aqusattl 0111001 Pati 0 AmPllitt saaldasgP =Patti 1 0003 100010 r_, ( laptg asaig 01 " 0 4 30 P t 1 ` 08001220 9 0 1 30 0 eg - bap= ;nog ploy o, Vsulyild 0 1 1 P 0 K 99 10 1 04 1 00 NW& ONEWIRENISIZETa pumas aq ass *swan aaspuadag aapaussuaclap am vapausagai 11315111MANIME a pain aq tan madam Nll a _ jr aumai aapadta; ago - yp; - Tow imam pug 411111111a Jo =oe uopazgqme %saws Gan NE ma tueigard (3/B) aloaxer0 3011001A00kR 0100 0 ! 1 1010 1 1 0 101 Po) loom= pawpaws mason apuatuao sem Vaa amasawsp; ap latanaggaq sumo aqauswao try - 1 :SKIM ”..-,:::;sitZ:=4::-• • Owes *PAM) mold 0 .1 108 14 0 4 10 41 0 1i ;AMMO Asa ---E I ---‘_ CO p\w-cg, 110 Ple aPelm 4 01 11 0 1 WAD= Pus =I 2 ! 00 11 03 sidd 0 0 P11 1 41 00 ! 1 0 00 Implaglajat aqt.10 Fps asp Amfadjo =Nand pas aqui =papa sane Alum riaaraq awn La Zapaan • • Nouvarroa maw/ etentosiaitlio mum° (=mew aweiptialauntoymac• mi. I — -00 20 1 MAG4P 1 4 101 11 110 4 2 A4Rai 210 UrAiliaq 4011 410 • Y AQ Wg Au* `131alkad pakat aqua xamo se g; MGM etaarielli.01 SIMAVIICILIVILIAX1110 UMW 111411111NACK NZBACCILL7IOIVO3 280114010211Mtitifirith1MO Gal $ 11 P I 11 P9 '4 010 d 10 5 1 0 01 1 01 117 30000010 f 01 11.1 0 Pr al Von ILIA 11 0 14 001 d 0 1 =Lod -110 11 00 4kb IOW& P Tow Paytdo° Vane 4 =RA ROM • • asa0aRL JIZ -0QW:S t>et c - 01-.A c 0 8 4,1 111 POW Q ;MS POR %.).■N. LQs aan4iamaiftatt 3111. 01011 1 3 3IH mealwatt!tha JapnitosiguggOks am - A..a-Nitt6 pvo\Acq 101 Sr ?-S I (3m)-3 Suagammulmil mon P rs a slow pas suandan I J 2:518Z5 9- samanddvallantapma mos as 311 841 Iftska Amen Pi sliZ r inictusio awastairmeamplespisam (11 va Wit aidaslignafOloPtesalutl 11 . ' A41 0 ACDA■1/2 - .`z adte. Poe 1 401 - 0 N N z 0 08 Isco -mos isaio goati ova =mum aqiimmantafirt 6 \er,1( - Y) AU-KILL I k 9-UAC)t emo)ansn assiazados ampasaaao rs - . _ MIMI= 610113111LISNO3 *MOLD= • • . . - . • I The Commonwealth of Massachusetts Board of Bantling Regtdations and Standards 11111 ' • •-• Massachusetts State Band% Code, 780 CMR. Revised Sept 2011 -"--= Building Permit Application To Contract, Repair, Renovate Or Demolish a • _ . , ' , In; , , . -, O 7 7 .... 7 Building. 1 ' A „„bed:. „ :_. . ..,._„.... - ,-...- . .... -,:..----sgcno. 1: 871811 ';•-.:-i - -' -- - ..- :C::A3:;:- - ., , ' 1.1 Property Addrear _ 61- 6.6' L—e4 '-e c-cts ---,,,,, ...--, `,--- ---'-' ' • •-•*=‘‘`-‘ =1' ... --. ..-.1.„ • - -c- --- ,% . - v.rs:...,:, ms. --, -' 1.1a Is this an accepted sheet? - no 1 -:-- :--‘, 4-4,- P`• :N.. a "....t ' --1,.. 4 ,-.-- 1--:-. -, - -..... ;•, - — --E -. ' - = , &- ----- - -- -- - •r'.. -- ?- - - w 4.-.4,--- - -z- N 1-1 "/ .- - . :1.--.- - -----4- . v t ,, " - -;-, i-.,.- - - -- ----,-,----..-_-...„ ----_,...,:-L...„-----z--- --,,.- 2--,---_ ,, , - f.,„_ rr- • -&- , , „L . ,_/..,..,..L.... ›,-:`,',.- - 4,, 4. ••.'1 ' --- ,•:-•• .-,..-- V.:._■-. ZI. .:::*--' .,,,,- ' - _ ' ., ' •%-.'‘ '' ‘i - W- "' -"'" ''• ' - ■ '-,---, ■!=-) --•":.'''••••A''''Z - ' -, 3 1.5 Staling Setbacks (ft) c i Front Yard rule Yak* Rear Yea Remind Provided Reqtdred Provided Required 'Provided i . _ 14 Water Supply: (SLO.L e. 40, §54) 1.7 Flood Zane Information: 1.11 Sewage Disposal System: . I Public CI Private 0 Zone: — Outdde Flood Zone? municipal 0 on sue capon, 0 I system Li I Check ifyesC1 2.1 Owner' ofRecerth i I '... \CPA. V-■ - 22_ Npi ‘ P ‘ re. \P--C 4 t? Y 1/4-10 \,_ Name (Print) Cray, State, ZIP 6- AY La /if -ii- '. No. and Street . Telephone Email Address • . %. :!-:•-:=151CCTION5:, ) i t ' I i , „pit PROPROCD WORK Acheekaillbst oppb1 :::1_1----.:,:i . New Constractime 0 Existing Banding , Owner-Occupied CI 1 Repairs(s) CI 1 AlumadOn(s) 0 I Ade:Edon Cl . . Demolition Cl Accessory Bldg. 0 Number ofUnitti (Other Cl Specify: BriefDescription of Proposed Work ,-) y e Ip 01/4.i 4 k ( ' -..... Str k 8' ` . -I's k Ko : z gfamijigis eptignivariopitoirrg j_ Edimated Costs: - '--'; - z ;_z., Item ; . - s ' - : - . ' '--‘--. 4/facial Use.Ooly.!- (Labor and Mttaials) -- * --. -- - ' • - -.: . - - -,...:::::::: ---..-:- -.7 - - ---- - --. -.=. • - 1. Bullfrog ' $ 1 - -EllarmlitP40ni lindicate 14Pig fe0 ill delamit)0d:._: - --- - ---- -- * - - - --- -- '- -------;:=.----..;: i_ - _ - _ - :, 0 Mandatd (7 APO . .-_-=_:, 1 - - .:-;,-'-- - i •:;"::; -_-. ' -: -..--..- --- 2. Electrical - S T „.... ._ • CI otal rroject Cost 6) x nudtiplier - - x - - 3. Plumbing S s ' ' ' - - - ' :" k " .":: - .:1. :. : ••, :: ::::: ........i Y77= •:: - , : : , , ,,. 1- ... 2. _Othcattclx S ''-- ••- -:-.„, . --I. - -...„-: t , _-.._,„ ..,_, , .-.-_-_-,- 1_ :_,-;_-; -..:;,-, .- -_-..1,::::-_ :-- 4 ., Mechanical (HVAC) -S L iSl j -_,-_,,,, ..-,:_-_-:. - --.;-_,;-::-..-----%.--- -- - -.--:--- -- - - ---:: ‘----- - :--., -_ z -- - ----= -., ..... 5. Mechanical (Fins S epossion) Total All Fem $ S a . -- Check No. - - Check ABISUBL - Cask Amount - - 6. Total Project Coot S 1 )OZ::3 ., CI Paid in Pall z ' - CI Outwearing Balance Da= - - • 64 LAKE ST BP- 2012 -0791 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 285 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 -0791 Project # JS- 2012- 001383 Est. Cost: $2200.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq. ft.): 13372.92 Owner: RIZZA DOMENICA Zoning: URB Applicant: DONALD PELLETIER AT: 64 LAKE ST Applicant Address: Phone: Insurance: 1107 MAIN ST (413) 538 -6002 WC HOLYOKEMA01040 ISSUED ON:3/13/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: I NSU LATE ATTIC 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 3/13/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner