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07-005 (3) 480 NORTH FARMS RD BP-2017-1312 GIS el: COMMONWEALTH OF MASSACHUSETTS Map:Block: 07-005 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-2017-1312 Project JS-2017-002177 Est.Cost:$4000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq.ft.): 25221.24 Owner: ATKINS SUZANNE E Zoning: RR(100)/WSP(l00)/WP(16)1 Applicant: DONALD PELLETIER AT: 480 NORTH FARMS RD Applicant Address: Phone: Insurance: P O BOX 5020 (413) 538-6002 WC H O LY O K E M A 010 41 ISSUED ON:5/12/2 01 7 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATION EXT ALUM WALLS 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: OI: 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 5/12/2017 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-1312 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE P O BOX 5020 HOLYOKE (413)538-6002 PROPERTY LOCATION 480 NORTH FARMS RD MAP 07 PARCEL 005 001 ZONE RR(1001/WSP(1001/WP(16)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvpeof Construction: INSULATION EXT ALUM WALLS 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 INFO3MATION 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 Demolition Delay Si_- f Buil gO ficial 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. Building Department ICS CuvDriveway Permit r'212 Main Street l Sewer/Septic Availability Room 100 1 Waterlwe;l Availability I Northampton. MA 01060 IT.vo Sets of Structural Plans phone 413-587-1240 Fax 413-567-1272 IPlousrte Pians I Other Sceafy APPLICATION TO CONSTRUCT.ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION I 1.1 PnQroce��llAAdddress. This section to be compile Y/Jad by office LASO`x ` .QCST\S Map Oil Lot 00 Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT - 2,1 Owner of Record: SOZOLrxmQ. F*kvn Cit n 'taccnS RA - - vvCurrent Mailing?Adri,p 3 D \ t S Ky\�U6 Teleph one 1 S:E-r..e 22 Authorized Agent: • �nkNi l0�\M, ec 1107 (N14om Current Mailing Address t Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Items I Estimated Cost(Dollars)to be Ofioal Use On:y completed by permit applicant I Bui dnc I (a)Building Permit Fee 2 Eecr2 ( (b)Estimated Total Cost of c � 1 Constmdionfrom 16) 700- li 3 P.r-o-_ Building Permit Fee 4. Mer^ to : .Ar .^. reE 2 g #0V/J a Tea - "_ e 1NS.f r6-lam prrj OA Check Number 6706 j This S_ tdc ion For Official Use Only Date Bu:idtc Per"- 'vz-c_ ____ I Issued Signatcre Bundmo Commissiooerllnslxxuor of ECQt r s Date F— - . MAV SECTION 8-CONSTRUCTION SERVICES ' 8.1 Licensed Construction Supervisor: \�\'(� Not Ap livable ❑ { Name of License Helder: y )(� },1C.V t. t C,.�ij1CT(ty-t€ r License Number • k . . . Y ... IRO 1r) _ ry4r 'Ick- r6- /g -... _ ExpirationDate C3FADon.... Telephone 9. Registered Home Imdrovetment,Co 1ntr(accttoo-r?' Not Applicable 0 ( Companvigarne Registration Num r aC/- tom ,;; ':ss Ate, SI nTelephon¢ J � t--} Expiration Date _ 1 ✓`lam t ]J ,l� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152, §25C(6)) N Workers Compensation Insurance affidavit mu e completed and submitted with this application. Failure to provide this affidavit will result in!ice demai of The issuance of the building mit. Signed Affidavit Attached Yes No O 11. - Home Owner Exemption The current exemption for"homeowners'was extended to include Owner-occupied Dwellinzs of one(I) or bw(2) families and to allow such homeowner to en_aec an individual for hire who does not possess a license,provided that the owner acts as supervisor. (:MR 788. Sink Edition Section 108.341. Definition of Homeowner: Person tsl 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 geriod 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 alt such work performed under the building permit. As acting Construction Supen'isor s our presence on the job site will be required from time to time,during and upon completion of the wrork for which this permit is issued. n iso be advised that with reference to Chapter 1521 Workers' Compensation) and Chapter 153(Liability of Employers uy Employees for injuries pot resunine in Deaths of the Massachusetts General Laws Annotated,you mow be liable Tor person e to perform work tor)ou under this permit. The undersigned'hommwner certifies and assumes responsibility for compliance with the State Building Code.City of \orthampmn Ordinances.State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-.DESCRIPTION OF PROPQSEO WORN check all applicable) New House ah Addition ) Replacement Windows i Alterationisj L I I Roofing {'"-' Or Doors Accessory Bldg in % Demolitio ❑ I New Signs (0) Decks ni Siding ILi Other r i Des !on c.`Pro sec w '•. ...... . erotic^C'ex!stino bedroom Yes No Addino new bedroom Yes No 'e_hed Na'fa'_ive Renovating unfinished basement Yes No P ars Aranned Roil -Sheet 6a. If New housea d •r add' -.n oexistin• ousin• om•lete tilt followi e. a Use of binding-. One Family Two Family Other : ri_mee cd rooms m eacfi family hob Hunner of Bathrooms ... here a garage attached9___ 'socsed 8ovare footage of new construction._„ Dimensions__ — Nanoer or stones^ Method of heating" Fireman-es or WnOdstOVes Numberr of each ? Energy Conservation Comphance MasscheCa Energy Compliance form attached? Type of construction !s antsmi con wino `h it of wet train Merv` No is construction anion 100 yr floodplain Yes Benin 01 r aleaZai pf Malar floor bolo?finished made - .. ,Cotttoor ;ft tne o mdin t and whiny regulatchsh Yes No Seciiic TtInc..__ CI, Sewer Pr. a:e 4iEii _..._ CO, water Supply ._ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN I OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Suz tnr\q FvnS ,_ as Gamer o!tnesub.ci act(...,. "I\` OZ.\AQj t-C? c C' c-3�' ! (r‘ tens relat,y to work euthorixed by this building permit agplicaboa fate 6 SC w r'Sk_\ -Rkie - s:e that the statements and infcrmabon on the foregoing abdication are toe aec atobtrate rn^-e hes-- ?nabob '. --- e car, a o oenanes , perlu asp 05/04/2016 11:40 14135871272 NIGH BLD DEPT PAGE 01/01 ,,l,,,, City of Northampton - Massachusetts t C '` i SI �1 i y �} DEPARTMENT SOF PDT LIMN INSPECTIONS V $. ,,,p y5 212 main meet a municipal Building \�J rc�� Northampton, M 01(06�D�.f ° :. Property Address: "I a-0 f C Q«S `` ' Contractor Name: )(--- 33e. 1 o v aAd �A ,(--- X 1l�C Address: Ak �� ( 0.L0 � City, State: l-k k G . 61 Phone: si ( 3 l h WO �--- r Property Owner n `may 1� Name: [ `-1 ))?_Y1YT1�` QkK c 'b Address: 1',TI�CX )� \-- cO(r&S S4 . /' City, Slate: '�l 1T K)(f''V `--`{i I'-t � I d l00� I, 75' GA-4 i,\LU i 2( (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 he insulated and that I have provided the property owner with a copy of this affidavit contractor signature t5 r� ,. ! eta 4 W Dale 4^ (r) mad sal—so 't- -- ammo Gyp so !an se ithis inn...s1 rnJ 110 1 -we , 77 LII _� � las p op aid•mg Si hai I'Islr all014101 pies VAI-.10P1 11130111 00104.u.HY1010O 100 WV110O1U 01011101111111W all 01 SE/COY HAVII 1001OO Ufl%LCIPEIAOI Sq MOH WWY31 &V 1f[L 4 1013V1113403 ainramosTipin A 0W41IY903 1015 W NNO 1®a 01AT1fU CIGDIAIO n semi/Tmo1 uallaora °moi 5c17 pd101►a 1W b,uc sonsa*I awl 14 PIMP Wm— :Okra sgr•11111 AI 11•40•1 Wm SM!I•H 1•111 41ano/awl I C -b s messily IMaUoalma api SOK) ac - r'_apoe+fin'+f—spas gr'Ise pair Sal sr M alio .. seme=gam YU 1'311)^ VIA --1sagswaso1..en..olai�e asp 101DK14 nd ocampity!mad lepo of +" 'i AFI nJIpaincy CERTIFICATE OF UABILIT)( INSURANCE ;,�. WS 'ME CBORIGATE■SEM AS A W%TTflt OF IN OS110M ORLY AMo ECISERI_NO MOM IRON TIE ISa'wCATE OOIIU.flEE TatIMPICATE 00111 NOT ARAA7NST OR REMTIYRT Ana EOM OR ALTS THE WY®IA6E TNF MSWNO�— IER Mine TN EOM% AIMTHMI E Ot FROO�MARCIM M CEO H000NSITION 4CONINCT BETWEENJ I PORTAMT: VIM.swa.abolds barn Se.. aMasWasO R7IEROOATHIHHININES, ssilletinsanned usehasatetniaist, po4isssr+eView wisimwr. A_____enM%awake.dam Ma Cara wM%%r11b.a ya Slag M W at aaawYrwRIIESI.opoopoosom eearu-. UNE HUB INTERNATIONAL NEW is wqa - . .._ rc aw ESHAKER MAO EAST LOM EADOW.MA OWN saaaaa nowanc OINasot� waoY OMAN w:ACE w.ear.Y.aa r aa0~1r IMMO ..__�_. arae*: PELEUER WORLD OBA HIXINLLTEN TSA01010 i:;! /N:ILYTJITE,aM OtOsO ( NumT: — ••,an.'. ' THIS IS TO%FRTFY THAT THE MUMS OF INSURANCE USVED BELL*HAVE BEM ISSUED TO THE MIRED NAMED ABOVE FOS THE POLICY PER/00 NCAOLITB3 NO'/YNTl6TMONB AM'RECAME EMT, TEM OR Ctl%O%HOn OF ANY COMPACT OR MIER OCKONE HT WM RESPECT TO YRSCHI THIS C9ITENCATE MAY SE MEMO OR MAY PEtTAN 1 .€ INSURANCE REFORM() BY THE POLICES OEICRMED HERM B TRs.EcT TO ALL THE MINS. EXCLUSIONS AND CONE/MONS OF sun POLICES-I.IYES MOM MAY HAVE BEM REDUCES BY PNC IAAS®. YTe��a nsaar srry rasamaw" rat.Ne "— —...._.. __ SwYsaYTNISM clA%%tli %Ia a¢{IB1D[Y mr.aeaa.aaaeM.[Malty WYYY-AYrtgallrallIMI % oco as mPn2wPaoJ assawaawwa % Tart 0101301PO iEwRMIT PIM PDM wKR Vaf .coat maPOLICY ✓i � Ft Altlassa Asir WM 110 YY SSV/Ansi 45.1.0111•61E0 — RU 8!$J . .y-a-vp. o 11414420/1100 SEMEM".N5_ HAIN Nom *wog aae1A1M.� nom I �iO'0a'0i "nasome fCLIMOSIVAOFwOP % Mir!-Mnwva _.., s am- NOIMPLOYROUaSHT AMY N Tow LaTIE! o mrorn+ .Jw MIMS Nati flail aor%E 77!lIO.� —.• moomorMa. I MINO 111100/ rrMB NH Yalta way EJ..aw1N-♦ouNta r MOTO rE TM WORKERS COMPEASATIONMEM OCES WIT PROPER COWMEN EWESocRMLO CRIMMATE NO1D91 AAWE OF TME AROSE nescameo POUI.'ES BE DOWD NST07 HMRIASYT��MLE CMOS/ED D SSW TME .MPfM TMS1�F. L OE ® NI ACCORDANCE MN TM ,axyaEMA 01010 NOTICE __ SE IYB P'OUCT1IKERMO IR Ae1R11anegRIM1aT11a ze uaricAmisoftt ----I—--ban coesloin NAM.triad PCOM El OnESER The AWN)Awa sed Imp as r.SSNeY mots of The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations t;- 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name lBusinessiOrganixatmnnndividuat): )Q\\et( eC1 cr GJ`0.'1v e' c Address:!._... vLl Soccb 11.0k �j \ ^.....�N 9� ^� City/State/Zip: 0k L { w S3 6 bb . -, a Phone#: ( Are you so employer?Cheek appropriate box: Type of project(required): I.bib am a em 1 er with_ 4. 0 I am a general contractor and 1 P 6. ❑New construction employees(fill and/or part-time).' have hired the sub-contractors 2,0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g. 0 Demolition workingfor me in anycapacity. employees and have workers' P R 0 Building addition (No workers comp.insurance comp,insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions ( ffi officers have exercised ❑Plumbing their 11. repairs(] l am a homeowner doing all wort: or additions myself. [No workers comp. right of exemption per MOL I'D 12.grpairs insurance required.]' c. 152.§1(4),and we have no employees.(No workers' 1' _. . —__... comp_insurance required.) •An}applicant that checks but a I must also till out the notion below showing their workers'contamination policy information. •ilumeownen who submit the affidavit indicating they arc doing all work and then hire outside twnuacvrts MUST submit a new aatlavu Skating such. -CtminMnsthat check this ben must attached an additional sheet showing rhe name of the sub-stratraciort and Veit whether or bol thou entities have employees. If the subccontlaclora have empkoyees,they must provide their workers comp policy monitor. I am an employer that Is providing workers'commentating insumncefor my employees. Below Is the policy and job site information. /� �/� Insurance Company Name:_.. IR C t: f�f'tfft€ACS{a,C Policy#or Self-ins.Lie. : 1ov W � yu U f qc{l3gq r 9/ Expiration Date: r/-7�/ d O i 7 Job Site Address: Sie Ls C44 - tonic Pc Citv/State/Zip:_ /-i- d-e? 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 MGI..e. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 eerrufy under eekeepains /anti penalties of pedwy that the information provided above is trite and cornet Signature! 'S-/1 Cfl(CSK)�iC11f�.6 Y�18}.�s.1�-!\ pate: J��....1 7 Rippe#.(_9 43 > S S�/O6Cte) Official use only. Do not write in this area,to be completed by city or town o ciat _ _ City or Town: _ Permit/Licensea Issuing Authority: Building Department Contact Person: I Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration _— ReplSalbn: 150319 Not krasiabta •j.- Emi'appn: 32412018 Ira Slam DONALD PELLETIER + DONALD PELLETIER M = -- I - -- 1107 MAIN ST `•Z HOLYOKE, MA 01040 W A=1 Update Maras sad'Sr.rad Mark roma ter cbage n Addresss..d❑ Rp ..w.,..ai 0 Lw1 Card SCA i a Mail' Massachusetts Department of Public Safety Board of Building Regulations and Standards License: CBBL-101/176 ConstructionnSpecialty Specialty DOMKD W PELLETIER 110 MAN STREET HOLYOKE MA „ase N,nn l/L— Expiration: Cdnmissioner taM0A1a • en • Permit Authorization 'rN� MASS saw: Form emegaNMIN S6d•v6nlmq� Sy- a.,.ac,sn Site ID: 502259846 Customer: Suzanne Atkins Suzanne Atkins ,owner of the property located at: (Owner's Name.prMtedl 480 N Farms Rd Fllorence (PropertyStreetAddress) (City) hereby authorize the Mat 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. • Owner's Signature: Date: M'///a /./b FFF FOR CLEAResult OFFICE USE ONLY CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: • Participating Contractor Date • 123'D CIFAResult • SO Washington Street,Suite 3000 • Westborough,MA 01581 • 1800.480-702 D For pace UseOnly Rev.102015