17A-306 (7) i
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PERMIT AUTHORIZATION FORM
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I, Andrew Kesin , owner of the property located at:
(Owner's Name,printed)
77 Hillcrest Dr. Florence
(Property Street Address) (City)
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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.
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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
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For Office Use Only
Rev.12132011
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City of Northampton
X15 a„ 3'iC
Massachusetts
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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