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05-049 (9) 3� a ' PARTICIPATINQ mass save ©ONTRACWH SiirlrP tttr0U0 @MW Y -11...- PERMIT AUTHORIZATION FORM I, Brian Eastwood ,owner of the property located at: (Owner's Name,printed) 623 Kennedy Rd Leeds (Property Street Address) (aty) 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 Owner's Signature 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 01 �°• For Office use only Rev. 12132011 City of Northampton Massachusettsr r.; r BAR or 1 MZJ)ZM nFSPSCrZoWS 212 !lain Street • Municipal Building � .D Northampton, WA 01060 Property Address: 6z>)S /-�P n Yi E? cl Contractor ,, L Name: C4 Address: City, State: �� � - Phone: o C) Property Owner Name: j \ T�' Address: City, State: to j Y-Y -t' `3 I, ����d C.a., U I e'� e.0 (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 71 1*IC.-,,­,, ftilprovement Conu-actor Lav• S,;pp,Lcm.crit to Pcm t Application Affidnvit tur Home. fmtprovemew Co-ri" -,or Permt AprIjc--3t;0II N 1.ine of Cir, P rl-,r t o Note: 142 A, requires that the reconsi"(.,ior, ah�znation,renovation,repa-ir, modernizatjCF4 jmprmmtnent,mawN-A or demolition,or be construction of an addition to M pre-e-.Ndstingg owner oc",pied building conLairting at least one but not more than four dwelling unit(s).or to structures which are adjacent to such residence or bnildi-ng* be done by registered cona-daors,with certain exceptions,along with other —I"--\ requirements. - J� ,e I -_ Est Cost - —e of W14,.0 2) Address of Work- C� Ov met s'.',larnC.- 3 Date of Permit i AppiicJU0n I hereby certiA. that- Razistvation is ncr T-qjired Cot the fbtlo%ing mason(s) Work is e.Kcluded by 131V joh. under S IN-Y),00 L'tri din rot ovner-occupied C'n'%-ler pulling mva pe"111j, Chhcr 011,10 �;e 0 (Spccl�): Notic-, is hereby'given that'. ow NERS PULM-G,-FrUR OWN, PaNUT OR DEALM w1l'i'l uNREc[sTERF-F) CONTRACTORS FOR APPLICABLE HOME DAPpC)VEMPS—t WORK DO NOT HAVE ACCESS TO­PiT AR P ITR A-1710N PROD MA M O?-GU ARA N-FY FUNro UM)EP, MU C, 14 2 A. I �;igncd ender the penali(CS Of PIdur, I hereb-, apply for a ,:rynit as the agent of the oNvncrs: OR' the aix)N c notice, i 10V;jy frj- emit at the owner of uie abcm C prnperty Date %nor The Commonwealth ofMassaehusetts .Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MM 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: BaiIders/Contractors/Electricians/Plumbers Ap pficant Information L Please Print awe ribl ' Name(BusinesdOrpnization/Individual): QT%f, 4,O A) Address:_ 11�� ¢}. 1`0 City/State/Zip: �-Wq 4 k e- pct 010q0 Phone_4: i 3' 5 3$- 1poo D. Are you an employer?Check the appropriate box: Type of project(required): 1.19 I am a employer with 4 4. [) I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a soli:proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have $_ [:]Demolition working for me in any capacity. employees and have workers' 9 n Building addition [No workers'comp.insurance comp•insurance•# required] 5. ❑ We are a corporation and its 10•❑Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their t I F1 Plumbing repairs or additions myself o co right of exemption per MGL y [N workers'comp- 12.❑Roof repairs , insurance required.)t c. 152,§1(4),and we have no �N S ' o employees.[No workers' 13.0 Other comp.insurance required.) *Any applicant that clucks box ill 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 m asubmit a new affidavit indicating stick. tCon tractors that check this box must adachcd an additional shat showing the name of the sub-contractors and state whether or not those entities have employem if the sub-contractors have employees,they must provide their workers'corgi.policy ntmber. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 0 Q s c o TPJ1 V U VL-1,.2_ Policy#or Self ins. Lic.#: c��JO� b "t Expiration Daft~ 7/o75 /Qw Job Site Address: (::�D > >—t f d City/State/ * 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 penall es of 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. Be advised that a copy of this statement may be forwar=ded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ynder thepains and naUies ofperjury that the information provided above is true and correct Signature: 0 I Date: ��- Phone#; - Official use only. Do not write in this area,to be completed Fy city or town official, City or Town; PermitUcense# Issuing Authority(circle one): 1_Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: I"SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑/ Name of License Holder License Number AddrM xpiration Date Signature Telephone 9.Reaistered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date .� Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152,§25C(6)) Workers Compensation Insurance affidavit st be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi permit. Signed Affidavit Attached Yes....... No...... ❑ 11. - Dome 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check allIcablel New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 171 Accessory Bldg. ❑ Demolition ❑ New Signs [Cn Decks [Q Siding[p] Other Brief Description of Proposed ' ` ? / f J Work: •n t � "Z r! �iJi �C'_, D 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 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. 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 as Owner of the subject Property ^� hereby authorize to act on my behalf, in all matters relativgto work authorized by this building 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. ,)—,) �L�C� Print Na Signature of Owner/Agent Date 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 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES V 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 o 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 © 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 0 NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. rty of Northampton at p �J ilding Department 1 8 2015 !, 212 Main Street film Room 100 No ampton, MA 01060 VOW Electric, Plumbing ,! Ins ecgigns 7-1240 Fax 413-5$7-1272 Northampton, 4l APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I -SITE INFORMATION 1.1 Property Address: This n to be completed by office 6 c3 J ��� �� j Map Lot Unit Zone Overlay District ent It Dilt6rlet C8 0"ict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Madi Address: A 12 Telephone signature 2.2 Autltorized Agent: � Name(Print) Current Mating Address: Signature Telephone SECTION 3-ESTW4TED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only coo eted by it applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimate!Total Cost of Construction to: 6 �C 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For OftW Use Only Building Permit Number. Date Issued: Signature: BukWV Cor w*nionerflnspector of Buildings Date File#BP-2015-0872 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002 PROPERTY LOCATION 623 KENNEDY RD MAP 05 PARCEL 049 001 ZONE RR(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC/KNEEWALL INSULATION New Construction Non Structural interior renovations Addition to Existing Accesses 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 INFOPMATION PRESENTED: Approved 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 D n Delay 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. 623 KENNEDY RD BP-2015-0872 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 05 -049 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-2015-0872 Project# JS-2015-001693 Est.Cost: $3000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin DONALD PELLETIER 101876 Lot Size(sq. ft.): 78843.60 Owner: EASTWOOD BRIAN&LIS MANGIAMELE Zoning: RR(100 /W�SP((l00)/ Applicant: DONALD PELLETIER AT. 623 KENNEDY RD Applicant Address: Phone: Insurance: P O BOX 5020 (413) 538-6002 WC HOLYOKEMA01041 ISSUED ON:312412015 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC/KNEEWALL 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 3/24/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner