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32A-209 BP 022-1550 16 BUTLER PL COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-209-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2022-1550 PERMISSION IS HEREBY GRANT D TO: Project# INSULATION Contractor: License: Est. Cost: 4500 SDL HOME IMPROVEMENT 103635 Const.Class: Exp.Date: 05/20/2023 Use Group: Owner: RUTH MAHONEY, KELLYANNE Lot Size (sq.ft.) Zoning: URC Applicant: SDL HOME IMPROVEMENT Applicant Address Phone: Insurance: 24 CHESTNUT ST (413)247-5739 WC9024456 HATFIELD, MA 01038 ISSUED ON: 12/05/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATI ON 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 97-) tI Fees Paid: $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner RECEIVED ity of Northampton RE zr:p I krii-:, ri 1 , ilding Department 212 Main Street IC*1 DEr N , Room 100 INISPEC'TIONSNo hampton, MA 01060 NPR-riii- ' ' .'; ,--,' - ' DEPT OF UM rAN:r lt,' PCTICPq`3. L. t iN•Mtfritre 4.13, 87-1240 Fax 413-587,1272 ,,,, ' . APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT . .. This section to be completed by office 1.1 Property Address • Map /4 Lot Rog ,i, . Zone Overlay District — Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Rectl: Ki0</Zy i4--/-i cl-L, rqa-h Ortf hi /Go Qact/1. ' )04 eA Name(Print) -- Current tytalLingikret, c:L;J-71-z-z-c-ke---`1' Telephone Signature 2.2 Authorized Ad,,nt: 4_,,,, cS i-u-k(--i ,t---k Name Current ya117rerk ,5.-I- .74,24/7_L C-217/ a-e-I ature Telephone SECTION 3 .ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building <_.• (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3 Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection -,. 6, Total=(1 +2+3+4+5) 1/ s.)--- _.)0 Check Number ti 5 This Section For Official Use Only Budding Permit Number 6a- AA-156-0 , Date issued. Signature, /.-- _ /2- '- ZZ Building Commissioner/inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION-4-CONSINUCTM 8,1 LICArnied il,Kfr: Not Applicable 0 4/ 0Jji i'C t- - 1 to p .- license Nu ber Andres' CA/cr-#u1J` } )Lc ((If �4 qq o 6? Expirati Date ,� Aiorv.,....04„........... 1/13- 1./9- 573, , i�natur Telephone Not Applicable 0 C•it..;..n ., Lip .. ,, - I'Y"�„a--. egistration Number r7S e .S4-miet- & _.. Z_e? /0?' Address Expiration ate V—Vet k-gC.._l thNfzt 010 S' Teiepnond4 l3- )4'7 s739 SECTION 6-FRS'CENOPEISSATICSIIINABRAME AFFIDAVIT(M A L c.152,3 6)) Workers Compensation Insurance affda * must be completed and submitted with this application.Failure to provide this affidavit will result in the denial of the issuance of the bui permit. Signed Affidavit Attached Yes No a Brief Description of Proposed Work NOTE: INSULATION ONL Y is/4/k/ 6 9 tfi' ?'I �-, (�4 c�. Cie l 10 n 2y c v�+�( l l�- lc-ND 2 c,I__.-t .A.A.1_0. . f_, Fi ci. , 1-11_,,, a " (7_ t.5 , ci louq,czi (-g-g,,,,_ __.) (, 5_1 6 .rh lc(' 10,101,_ ie _ Loy 71-ii-)c- ---pc. _)g_, of--,--- lo, I, Pil It I ""' '\ '"' . as OwnerlAuthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best o`my knowledge and belief. Signed under the pains and penalties of perjury. 1 _ Rid 3c .k_" a'` � Y -.m�., , `" .,0„,( cCb,s, . ...., Print Name --- Signaturg—Ovegent Date I, Kp,\LeJ Alq ri-L (1 Cit.k,02—'-/ , as Owner of the subject property hereby authorize S is l— to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date -„: City of Northampton Massachusetts 4>�' .w. ' ` `` DEPARTMENT OF BUILDING INSPECTIONS ;-y 212 Main street •Municipal Suilthng Northampton, MA 01060 1� `yh...e�, 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: IlQ C��tl� r (Please print house number and street name) Is to be disposed of at: e n ' �-- 1,�. g. t� - 4- k- A (Please print n me and loca'n of facility) Or will be disposed of in a dumps r onsite rented or leased frArm LX f\ � (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. City of Northampton � Massachusetts Affi. , DEPARTMENT OF BUILDING INSPECTIONS 212 Ma,n Street • Municipal 8uiiding Northampton, MA 01060 t. "4,. 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, renovation. repair, modernization, conversion, improvement. removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four 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 LLt;, that entity must be registered Type of Work: 04-1 t—VA Est. Cost: 2 � Address of Work: / LQ 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.G.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 ,ierebv apply for a building pettmit as the gent,of the owner: 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: Data Owner Name and Signature 4„T� . City. of Northampton :x , '� s>= Massachusetts h/ 46. :g 'frr. 212 Main Straat a Municipal Suildinq Northampton, MA O10V 4 MANDATORY FOR HOUSES BUlL r BEFORE 1945 Property Address: I LC t-L c. 01 oc c1 Contractor Name: * 1Q-.= �. () -"' ''c- Address: rs9 Li ( 11.G h...L..k- �` City, State: ?..)e --\---\--etA VL. � `� 1 �' � i Phone: )4 t 3 (4-1 " .,``) 1. 1 Property Owner 1 ^ _,,_ i Name. ''l--I 1 L(-At\ru� si- rnckf--k m,h v n.--,e. Address: ) Co ee1 U-FL-K. Pi City, State: 11‘ n-+cc.rn p A -, pc)' pi a I, tt f rv\ d"t- (contractor) attest and affirm that the building I intend to insulatedoes 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. 1 Contractor signature jziet ________ iy- Date Permit Authorization ris SaVet Form Site ID: 4285489 Customer: KELLYANNE MAHONEY Kellyanne Mahoney , owner of the property located at: (Owner's Name,printed) 16 Butler PI Northampton, MA 01060 (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor fitted below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: Kellyatafe Hahiozcey Date: 11 / 06 / 2022 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 For Office f_ ., Document Ref:A37EU-AOR3M-XZMCN-QKGE9 Page 7 of 17 The Commonwealth of Massachusetts t r:--1(A Department of Industrial Accidents .1 Congress Street, Suite 100 = ti Boston, MA 02114-2017 s�.'<,; www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/individual):SDL Home Improvement Contractors, Inc Address:24 Chestnust Street City/State/Zip:Hatfield, MA 01038 Phone#:413-247-5739 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 7 employees(full andfor part-time).* 7. ❑New construction 2,0 I am a sole proprietor or partnership and have no employees working forme in $. ❑ Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑ Demolition 3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10❑ Building additio 4.0 i am a homeowner and will be hiring contractors to conduct all work on my property. i will ensure that all contractors either have workers'compensation insurance or arc sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 3.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 14.0 Other Insulation 6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'camp.insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those enti ics have employees. if the sub-contractors have employees.they must provide their workers'comp.policy 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:Selective Insurance Company Policy#or Self-ins.Lic.#:WC9024456 Expiration Date:02/23/2023 Job Site Address: /( c L LQ r Pi Q Liz_ City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expi ion date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 o$250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA fo insurance coverage verification. s I do hereby certify.unde the ains and penalties of perjug that the information provided above is true and correct. Signatures Date: //- d 0 rc71- Phone#:413-247- 739 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: