Loading...
17A-306 (7) i I t*orgy S i f PAFiTICATO mass save R . II CNTAC TgR I i PERMIT AUTHORIZATION FORM { I, Andrew Kesin , owner of the property located at: (Owner's Name,printed) 77 Hillcrest Dr. Florence (Property Street Address) (City) l t 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. i t X Owne s S nature 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: I Participating Contractor Date i i i For Office Use Only Rev.12132011 i i s City of Northampton X15 a„ 3'iC Massachusetts X{ 3 DWARnMr OF MTZLDZIFGV ZA9PRCTZCKS * 4�v 212 loin StIVet a b6mici.pal Building NorthwWtaa, 1K 01060 Property Address: Contractor Name: Address: City, State: hHo k�-Q)Z� _. c) V-4�q Phone: Property Owner Name: Address: 1 C r City, State: 1_� P (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 �� A 11c,"re [MPr0vCIxn1 Conu-xior Uvv S"pp1crnrnt to Permit Application S!M A fri(J-1,j[ for flom-, inIPMCnient Contractor Perrait Appiimt1oll NIllne 01 Cit-. j T()Wl, Note. 142 A, requires that the reconstruc-iori,ahcration,rtnm3tion,mpaii, modernhaticci, ,:C,:n improvement, "wxyvA or deza)ljfir,,or the construction of au addition to any pre-emstfag owner occupied NWding waLuxiin-a at least one but not more than four dwelling unit(s)_or to structures which am adjacent to such residence or building' be done by _gincred conwacwm with certain e=qvtions,along with 0tIbEr requirements. Trpe of Work: E-SIL Cost .4ddrc&s of Wr)rk: � (_ t V`. �Q s f'S � � - — _ __. 0,%Mer's Narne. Date of Prumit AppliC06nil, I herebq ccrtif-,. that - ReglstGitiotr is net r,!-,sired for the following reasor(i) Work is e.\cluded by 13%V Job tm&-r S I(X)00 _Building cot owner-oLcupied O'Amer pulling 0"'.11 permit )C Other (Sped! ) al-I Notice is her-,bv Bien that: OW\IIRS PULLL\�C,JaIR Oti ; pE&MR OR I)EALLNG Wj,FH uNREGISTERFD CON�? ACTOPLS FOR APPLICAPLIF 140ME NPROVEMENI-7 W%K DO NOT HAVEAC(TSS TO-PT- ARPlTPATl(W PROGII-Am Op,(x1APAN­TY Ft ML - Ut,;DEP NIGL (7 1-1? A Signed under the penalite5 of ptjur i herein apply For a ti: m t as the agent of the ouncrs, OR t:au withqtanding the aM*,t notice., hr to, -C 'T' rr-ii ai� the o-omer of dw abo,, PTOP X, kY Date (hs nor The Commonwealth of Massachusetts Department of Industrial Accidents . Of xe Of Ln Vadff4d0fts 600 Washington Street Boston,MA 02111 www.mass.govldia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): Z+,en- 64,O Address:_ I t 61 6 tJ Y, City/State/Zip: �-6 1!4 0 K e- pe, 010go Phone#: qt 3- 5 3$- 1,0o D_ Are you an employer?Check the appropriate bor: Type of project(required): 1.0 I am a employer with. -1 4. [] I am a general contractor and 1 b. Q New construction employees(full and/or part time).' have hired the sub-contractors 2.Q I am a sole proprietor or partner- listed on the attached sheet. 7- Q Remodeling ship and have no eniployees These sub-contracts have 8. Q Demolition working for me in any capacity. emloyees and have workers' y Q Building addition [No workers'comp.insurance cone.insurances required.] 5. Q We are a corporation and its 10•Q Electrical repairs or additions 3.Q I am a homeowner doing all work officers have exercised their t I n Plumbing repairs or additions myself o workers'co right of exemption per MGL [N comp. 12.Q Roof repairs insurance required-)t c. 152,§1(4),and we have no S U p�:m employees.[No workers' 13.[!t Other c3 comp.insurance required.] •Any applicant that checks box#1 must also fill out the section below showing their workers'conq ansatim policy infanmtion- t Homeowners who subrnit this affidavit indicating they are dit all work and dlen hire outside cwtlractors mtut subnit a new affidavit indicating such. 10mtmctors that check this box raem Attached an additional sheet showing die narne or the mb-coaractors and side whctber or not close entities have employees. If the sub-canaxtots have mVloyces,they must provide their workers'cane.policy nunr6w. I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site information. �" Insurance Company Name: K!Q S 0 V ` -NS U UL4tt -- Policy#or Self-ins- Lic.#: W W C 306-15 03`7 Expiration DRS � /Jots Job Site Address: ' I C S r City/State/Zip: 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 fine up to$1,500.00 and/or one-year imprisonrnent,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 _ Investigations of the DIA for insurance coverage verification I do hereby certify ynder the pains and allies of perjury tkat the information provided above is true and correct Si nature: Date: Phone#: Ll 13 a- Official use only. Do not write in this area, to be completed y city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed ConstructionnSSugpeniso\r: Not Applicable ❑ Name of License Holder: License Number Add Expiration Date /r4n Signature Telephone 9 Reralstemd Hone ImR2L90 ant Contractor Not Applicable ❑ Company Name Registration Number Address t ] Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,S 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....... OJ 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 he 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 all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [Q Siding[p] Other[ Brief Description of Proposed -�c> u �' l I C ry V t,1 5e - Work: C_�P e,� l� �1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. 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 r hereby authorize `...)ZS ra d to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date �� � �'}tt;✓ 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. - Print 7��cj(nc) •- (/'-J Signature of Owner/Agent Date oftwtftv 17� M r� City of Northampton E Building Department 212 Main street MIR 015 Room 100 W A N rthampton, MA 01060 587-1240 Fax 413-'587-1272 A 01060 .r �a APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Prouerfir Ate: This wedon to be completed by office ` Map lot Unit zone Overlay DisMct Ehn SI.obbk:t Ce DktrkA SECTION 2-PROPERTY OWNERSMPIAUTHORIZED AGENT 2.1 Owner of Record: - Name(Print) Current Madi Address: Signature 2.2 Authorized Agient: Name(Print) Current Mailing Address: '1aje 1/'( J U (a wc�� Signature 7 SECTION 3-L' TED CONSTRU9jM COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by it apoicant 1. Building (a)Building Permit Fee 2. Electdcal (b)Estimated Total Cost of Con"ion iraet 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) C 'a S Check Number This Section For Official Use Building Permit Number: Date Issued: Signature: Binding Cwrwksiorrerfinspeclor of BtWdings Date File#BP-2015-1007 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002 PROPERTY LOCATION 77 HILLCREST DR MAP 17A PARCEL 306 001 ZONE URA000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out A42444 41 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 ATION 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 in ' 'o lay 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. 77 HILLCREST DR BP-2015-1007 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-306 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-2015-1007 Project# JS-2015-001928 Est. Cost: $11000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sy. ft.): 21823.56 Owner: KESIN HOLLY B&ANDREW M zonin4: URA(100)/ Applicant: DONALD PELLETIER AT. 77 HILLCREST DR Applicant Address: Phone: Insurance: P O BOX 5020 (413) 538-6002 WC HOLYOKEMA01041 ISSUED ON.412312015 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 4/23/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner