07-003 (4) IPARnCI)PATING
ass save COUTRACTOR
PERMIT AUTHORIZATION FORM
I, Paige Nangle ,owner of the property located at:
(Owner's Name,printed)
534 N Farms Rd. Florence
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
X /yL
Owner's Signature
lAt
Date
FOR CSG OFFICE USE ONLY
Conservations Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
0$r0
For Office-use only
Rev.12132011
A F-ADAVTT
Horne [mprovement Contractor Law
Supplement to Permit Applimtiori
Suggested Affidavit for Home Improvement Contractor Permit Application
For ice Use Only Name of City I Town
Permit No:
Date:
Note_ 242 A, requires that the" reconstruction,alteration, renovation,repair, modernization,conversion
improvement, removal,or demolition, or the construction of an addition to any pre-existing owner occupied
building containing at least one but not more than four dwelling unit(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^�j )�� " -- Est`/Cost ,
Address of NVork: S j' n— Eq r Cy
Owner's Name: p_
Date of Permit i Application:
I hereby certify that:
Registration is not r:,uired for the following reason(s):
Work is excluded be lax
Job under S 1000.00
Building not oauer-occupied
Owner pulling OVM permit �.
—_X__—Other (Spe6ffi-): 0.2 -- _C�:�1�✓ 1�&D
Notice is hereby given that:
O«'tirERS PULLING THEIR OWN PER.WT OR DEALING WITH UNREGISTERED
CONTR4CTORS FOR APPLICABLE HOME MPROVE- ENT WORK DO NOT HAVE ACCESS
TO THE ARBITRATION PROGRk'vl OR GUARANTY FUND UNDER
MGL C. 142 A.
Signed under the penalites of perjury:
I hereby apply for a rcm-tit as the agent of the owners:
?a
Date: r � l `1 Contractor: ! Rcgistrahoi
OR
Not withstanding the above notice, I hereby apps; for a permit as the o«ner of the above property:
Date: Owner:
City of Northampton
Massachusetts
DIEPutaewr OF BUUMM INSPsscsUxics
212 Main Street a Municipal Building
Northampton, 2M 01060 Ave
Property Address: 5'7 �� '( u
Contractor 1 \
Name:
Address: 1 1 61 112A
City, State:
Phone:
Property Owner
Name: �.
Address: YvA-
City, State: 2�L�
(contractor) attest and affirm that the building 1 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
The Commonwealth of Massachusetts
ND Deparfinent of industrial Acddents
O ce of Investigations
600 Washington Street
17 Boston,MA 02111
www.mmgou/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/'lumbers
AyOcvat Information _ Please dint LeObly
n 1
Name(Busincs&AoWnizatioanndividual):
Address: t i U`7 1A1 j7 .
City/State/zip: UK "ct-'55 Phone.#:
r3E] you an employer?Check the appropriate box: Type of project(required)_
I am a employer with 4 4. ❑ I am a general contractor and I emm ployees(full and/or part-timne).* have hired the sub-contractors b. ❑New canshvction
I am a sole pm oprmietor or partnerlisted on dse attached shell 7. [)Rcmnotleling
ship and have no emmloyees These sub-contractors have g- ❑Lh-,Mlition
working for rite in any capacity. employees and have workers'
[No workers'comp-insurance comp.insuranee.t 9. ❑Building addition
re uired 5. ❑ We arse a corporation aril its 10.❑Electrical repairs or additions
4 I officers have exercised their i 1_I am a homeowner doing all work ❑Plumbing repairs or additions
myself [No vvorkers'comp. right of exemption per MGL 12,0 Roof repairs
irsurance regth-ed)t c. 152,§1(4),and we have no �,7 tv°ti I s,. +c•J
employ=.[No work Cs' l�•rjl Other J
comp.insurance required./
'Any appi{eant dot chwim box#1 awes oleo fill om the section below showing Ov it w*i ara`ems mwico policy irfonratiat>_
t Hooe mmem who subvit dw affidavit indwatiag dicy are doing all wart aW dim hire otra*cawacta rs nust rAn it a new affidavit indko iag such.
tComw-tm dot c,.k this bm rout-u=% d an*&Htioaw ow*&wins**name of the and sate whedw or sot&'Me cNitles have
arVtoyem tr ate Mb-cmunchns have envaWiar,d,ey,nisi pMKk their work=V ctffy-veer ntattber.
I ain an employer that is providing-workers'co-pensetivn inn"W"ce for ety employees- $etvty is fhe policy and Job site
information.
Insurance Company Name: t' �'i;:: , ►?S it CIV�1. l_ G //
Policy#or Self-tots. Lid #- ���----�0(%-3 0-7 T Expiration I?a�
/.)5Gt�
Job Site Address:—. �5_T i �� � City/Statct4-S b 1 \
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratiol date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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. Be advised that a copy of this statement may be forwarded to the Office of
Investi scions ofthe DU for tots cave Ugg veriksmia
f do hereby cert�under the pains and penalties of peryury that the information provided above u true and correct
Si natur : fir / Date:
'hone#_ If 1,3 oc --
flc/rr/use only. loo not write Iry is vier, to be comp by city or town offciaL
City or Town: Permit/License#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
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 ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ® YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
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.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: e� . �� ! p 6
License Number
A
Expiration Date
rMr�_O_
g �
Signature Telephone
9.Registered Home Improvement Contractor Not Applicable O
nRio`\ q o. � � t\k t� C IS`,,`' C ��
Company Name u Registration Number
1 � 1() -� La � -- 16
Ad ess � Expiration Date
��
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must q9,completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building pe
jwmlt
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 buildine 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,Citv of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows I Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Si ns [p] ks Siding[O] Other jt'x
Brief Description of Proposed
Work:
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 existina 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 stories?
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PER
1,_ rk 1 �' � �•
property
as Owner of the subject
�
hereby authorize r '-� �� L._1. V '_Wc' k \
to ac n my behalf, in all matters rel to work a onzed by this budding permit application.
Signature of Owner Date
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. �^
.G R
Print Nam
of
Signature of Owner/Agent Date
ele use«�!y
[D7-
City of Northampton ��Perrrltt:Wing Department t b�r P 12 Main Street
:,r; t. Room 140' ampton, MA 41060 Tvwrr�; aft �- 13- 7-1240 Fax413-587-1272 coons
O 1Y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Milan: This section to be completed by ofirke
SS -/ � 1—�(_'�'^1S ���. � Lot Unit
Zone Overlay District
Elm SL Disbict CB Disbict
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print ,.( c Current Mailing Address:
t -F lG e( �l i(� 7 Ted
Sic}r►ature
2.2 Authorized Anent:
tJame(Print) ' current Mailing Address:
Signature Telephone
SFGTION 3-ESTtMAMID% 4,TR,tCTl C^ T s
Item Estimated Cost(Dollars)to be Official Use Only
completed by it 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 ��� ()�� a IT
6. Total=(1 +2+3+4+5) � Check Number
This Section For OffWal Use Only
Building Permit Number: Date
Issued:
Signature:
Building C of Buildings
Date
File#BP-2015-0016
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413)538-6002
PROPERTY LOCATION 534 NORTH FARMS RD
MAP 07 PARCEL 003 001 ZONE RR(100)/WSP(100)/WP(65)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildine Permit Filled out
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
INFOR TION 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
Demolitio Delay
Si OofBuilding 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.
534 NORTH FARMS RD BP-2015-0016
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 07-003 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-2015-0016
Project# JS-2015-000023
Est. Cost: $2600.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(` . ft.): 105023.16 Owner: NANGLE N PAIGE
Zoning_RRS100)/WSP(100)/WP(65)/ A1�1�licant: DONALD PELLETIER
AT. 534 NORTH FARMS RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538-6002 WC
HOLYOKEMA01040 ISSUED ON.71312014 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 7/3/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner