17A-142 (12) 201 CHESTNUT ST BP-2018-1313
GIs#: COMMONWEALTH OF MASSACHUSETTS
MU.B1ock: 17A- 142 CITY OF NORTHAMPTON
Lot,-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv, INSULATION BUILDING PERMIT
Permit# BP-2018-1313
Project# JS-2018-002336
Est.Cost:$4000.00
Fee $65.0 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: POTENTIAL ENERGY LLC 106184
Lot Size(sa. It.): 25482.60 Owner., HOLLENDER FAYE
Zoning: URA(100)/ Applicant. POTENTIAL ENERGY LLC
AT. 201 CHESTNUT ST
ApplicantAddress: Phone: Insurance:
4 D QUEEN TER (860) 506-4266 0 WC
SOUTH I NGTONCT06489 ISSUED ON.6/12/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 10" CELLULOSE IN ATTIC, INSTALL VENT
CHUTES & DAMMING, AIR SEALING
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: O�1• 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 Occuoancv Signature:
FeeTvoe: Date Paid: Amount:
Building 6/12/20180:00:00 565.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
f RECEIVED ynsLkif(kq— -.
Department uss only
o No ampton stow of POM*
JUN 1 iltti g artment Curb CULVtKWvay Plarelt
212 Mai Street SawarAWPlcAVUOOM ly
\' F BUILDING INSPEC Rom 100 WolshWaH Awl
"HAMPTON, MA01060 Two.sets ofsbuoWrel Plans
phone 413-567-1240 Fax 413-587-1272 PIoYSNs Piens -
OSMrspsdfy
APPLICATION TO CONSTRUCT,ALTER,REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ATION
SECTION 1 -SITE INFORM )b0 I "�}p_' .3 / S
1.1 ProgerN Address: This section to be completteed by office
20) /1
eixkuv Map Lot 1 +4 Unit
f (.fA- ,
W, IIA- zone Overlay District
tZ.dp �•�
Else St.Dhdr CB Disbid
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�i �+
r /�oLLP.J/ K 2-01 egarAlur snel:tr, i L09QJe 1q olcy0
Name(Pnnp Cunent Mailing Atltlress:
,t ,_ 4/� SB40848
-5�/M wh}Ai7h1 &RK- Telephone
Signature
2.2 Authorized Agent:
/g�uFaasMearnxz/Fbrewn4_i5lin q (o( EAs—MmAfrST"erf &Fr«.,Cr obdto
Name(Pnnt� Cumenl Mailing Address:
5��5-79B-o2r73
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be ofidal Use Only
completed bv permita licant
1. Building VI/Lao_ (a)Building Permit Fee
2. Electrical N (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Parrott Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3 Check Number
This Section For 011 ial Use Only
Date
Building Permit Nu Issued:
Signatu
Building nmissionedlnspe for of Buildings Data
/, L @�o ,lnM lekGYUs.COPA
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
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 De arm o,
Lot Size
Frontage
Setbacks From
Side L:- R: L R;
-
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot arca minus bldg&pave
#of Pari Spaces
Fill:
(volume&Laca'an
A. Has a Sp%Dcriadb
ce/ riding ev been is ed for/on the site?
NOOW YE Q
IF YES, date i
IF YES: Wd at the egistry o Deeds?
NOKNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavation,or filling)over 1 acre or is it pan of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storrs Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK!check all applicable!
New House ❑ Addid. ❑ Replacement Windows I Alterations) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ Now Signs [Oi Decks [p Siding[O] Other
SU
Brief Dgscrip�On yfpeup,°uawu?d&M, MsrML ✓r 170"m tul6 4 OftrM 411 SCAUA
Work: am C
Alteration of existing bedroom Yes--y—No Adding new bedroom Yes --A No
Attached Narrative Renovating unfinished basement Yes _,XNo
Plans Attached Roll -Sheet
sa.If New house and or addition to existing housing,wtnolete the followlna:
a. Use of building:One Farl Two Family Other
b. Number of rooms in each family unit: Number f Bathrooms
c. Is there a garage attached?
J. Proposed Square footage of new cWtion. sions
e. Number of stories?
f. Method of heating? dstoves Number of each_g. Energy Conservagon Compliance. gy Compliance form attached?
h. Type of construction
i. Is construction within 100fi.ofwefltion within 100 yr. floodplain_Ves 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 Ta-OWNER AUTHORVATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Li »
I, V.- IINC as Owner of the subject
property
hereby antnodze �rCNOLAS �SrIe 1Q1`Wnl 6
to act on my behalf,in all matters relative to work authorize by this building permit application.
-to Aymeat-wncs) 41u t
Signature of Owner Date
I, Vlewa i4 /'/CSri<rQ as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application am true and accurate,to the beat of my knowledge
and belief.
Signed under the pains and penalties of perjury.
�tcr,<ocks Mn,srcR
Print Name
Signature Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SummisorNot Applicable ❑
Nameef LcensHOW., MCAOLhS Misi t5k `sF -jLXj0
License Number
4D Qun� Tawe i2alAomfJ l Cr X89 4129119
Address Evimtion Date
�BcoIVYoU433
Signature Telephone
9 Reolstered Home Improvement Contractor. Not Applicable ❑
l'144o1
Company Name Registration Number
,41Cq nal6letsTa /Pomwri m. EwA,, 7�ZS�18
Address Expiration Date
1/0 SAI AW WQL0nl (T-06469 Telephonepr w162O-4433
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C.152,§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....... TA No...... ❑
City of Northampton
±' Massachusetts r'ss sr'
r
j DIPAR1aaINT OF BUILDING INSPNCTIONS _
212 Min Succi • M,ntcipal Building
N.rtbampton, M. 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC').
M.G.L.Chapter 142A requires that the"reconstruction,alteration,renovetion,repair, modernization,conversion,
improvement, removal, demolition,or construction o/an addition to any pre-existing owner-occupied building containing
at least one but not more than Pour dwelling units ...or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work:I[S_J(JED211 „('+ Est.Cost:
Address of Work:-2-0k 1.♦ s 1Ur JTf
Date of Permit Application:_
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):____
Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
bhqcA1iaa #1622- n 179401
Date
Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
Massachusetts 3 ��
4 � nsennaaffirr OF sozaozlrc zssescmroas
\ 212 win Street eaenici"l auild q
QQ aorthampton, M 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
ZIoI &",I(X�uM."
(Please print house number and street name)
Is to be disposed of at:
I�Q 60Pvm - "tanoi Ci
(Please pant name and location ot facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If,for any reason,the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ogee of Investigations
600 Washington Street
Boston, MA 02111
_4NW www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ./ Please Print Legibly
Name(Business/Orgmimtionhndividml):P
TQnZ:pnAI ru/ L�.0//y/GNOL/1S 1'1�15'ft'(Z
Address: 4'/ Que nl FFR illez
City/State/Zip:" C Phone #: O- 6'tf2(oC:,
A11rres�e you an employer?Check the appropriate box: Type of project(required):
1.ICi I am a employer with 7 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).'s have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp. insurance comp.insurance.*
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.[] Plumbing repairs or additions
myself [No workers'comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] f c. 152,§1(4),and we have no
employees. [No workers' 13.0 0thcJ4,rU4nAD0PJ
comp. insurance required.]
'Any applicant Nat checks W.#1 must also fill out rhe section below showing their workers'compensation they information.
I Homeowners who submit this affidavit indicating they not doing all work and then hire outside co muctors most submit a new affidavit indicating such,
lContmetors that check this has must attached an additional sheet showing the name of the sub-wntmeturs and state whether ar not those entities have
employees. Ifthe subcontmmors have employees,they must provide their workers'comppolicy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. ��//
Insurance Company Name:§MA DEORD �rJCURt1l�CF C'�g�P
Policy#or Self-ins. Lie.#: 62\,(ECCR0,?g5 Expiration Date: C86hole
Job Site Address: 201 Chestnut Street City/State/Zip: Florence,MA 01062
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 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
Investigations of the DIA for insurance coverage verification.
I do hereby cerfify ug r the pains and penalties of perjury that the information provided above is true and correct
Sienature ' Date: 5/24/18
Phone 9bo•5o` •42(.6
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
Owner Authorization Form
I, Faye Hollender ,
(Owners Nome)
Owner of the property located at:
201 r:hAstnut Street
(Property Address)
Florence MA 01062
(Property Address)
hereby authorize Potential Enerev. LLC , a certified Mass Save Home
Performance Contractor, to act on my behalf to obtain a building permit and to
perform work on my property.
Gayer �e
(Owners Signature)
(/,/,8'
(Date)