36-103 (10) BP-2023-0702
947 BURTS PIT RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
36-103-001 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-2023-0702 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
GOLD STAR INSULATION &
Est. Cost: 4000 CONSTRUCTION LLC 065992
Const.Class: Exp.Date: 03/16/2025
Use Group: Owner: TRUSTEE RACE,JOHN T.
Lot Size (sq.ft.)
Zoning: URA Applicant: GOLD STAR INSULATION & CONSTRUCTION LLC
Applicant Address Phone: Insurance:
1 CONGER RD (774)329-4664 65620B5N23815620
WORCESTER, MA 01602
ISSUED ON: 05/30/2023
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATION
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 VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
1 2 .
'Pi •
I Ii
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissi ner
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Buildinar4 rt
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212 Main str irvvG/Zi•-.. i INSULATION 1
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Room 100
Ik`lrfillPr**, Northampton. MA 01060 '... 7.9,6o
phone 413-587-1240 Fax 413-587-127i— / ONL
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APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
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SECTION 1.SITE INFORMATION INSULATION PERMIT
This section to be completed by office
1.1 Property Address
2.ti ---1
,
L.) f 4'S V fk— Map
Zone Lot Unit
Overlay District
/
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,1 Owner of Record: cl(-1 —L 60 c A-.-. Q
Name(Pr :21= Curlers.Mailing Address
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Telephone r, .... „,.. .
•Signature
2.2 Authorized Agent: :
I *f..11<„,,,-
Name(Prtrlt) Current Mailing Corkitess
. -7—) (1. .,. 0-5
Signature 'L-leohorte
SECTION 3.ESTIMATED CONSTRUCTION COSTS
heir Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
I. Building CC° (a)Building Permit Fee .
2. Electrical (b)Estimated Total Cost of
6 Construction from(6)
3. Plumbing
6 Building Permit Fee
L.)4
4 Mechanical(HVAC)
5.Fire Protection
6. Total=(1+2.3*4+5) Li.al.C} Check Number Coat --
1 This Section For Official Use Only
6 -)i3- 70- 1 Date
Building Permit Number. I Issued
Signature
f,r-va CammtssionerlInspecicr of Building: Date
1
EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR)
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SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Sypervisor Not Applicable 0
. .
Name of License Holder' lc---&vi yi (34, A il€4/1
License Number • .
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Address Expiration ate
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Signature Telephone
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• 9.Registered Home Improvement Contractor Not Applicable a
0U L:„4-c---r --. I\ 0
Comftfiv Name Registration Number
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) C C--AA,3 CX- 1U.J Cr Ce.,,S-I,tr WI- p 1 A 2
Address Expiration ate
ud
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SECTION 5-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 buidpg permit.
"&oned Affidavit Attached Yes. ... 'Me No. 0
Brief Description of Proposed Work NOTE: INSULATION ONLY I
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Cy 6.) ee_ri c it ul c6 ..
1
1 .:\ - P's\( (--- 2 _ ,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 peryalties of penury.,
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Print Name
.S/3ola 3
Signature of Owner/Agent Date
' 6 )-\I, L r . RG-6-e-- ,as Owner c4
property
hereby authorize ,7 J211 0 —z—C—.e—f----
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to act on my behalf, all matt relative to work authorized by this building permit appli hon.
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Signature or Owner Date
City of Northampton
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City of Northampton
Massachusetts
. DEPARTMENT Or BUILDING INSPECT TONG
Ma n Stramt •manacIpel aulleling
Northampton, HP. 01069
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40. 554, 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:
C .1)‘ C? •C't
(Please print house number and street name)
Is to be disposed of at:
—1 +-Cr
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name 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 Commontreahh of Ma‘vachu‘etts
Department of IndstAtriul tecUlent%
1'4 1 Congresw Street,Suite 100
•-•-•-,° Roston..11.4 0211.1-201 7
\kup.
44R.EFP www.mass.gov/dia
Vt orkers'Compensation Insurance Affidavit:Builders/Contractors/F:lectriciansiPlumbers,
TO RE FILED WITh THE PERMITTING AUTHORITY.
Applicant Information Please Print 1,c2itils
Name(lA us'nes Organ mu on v tdual Ill :5
Address: C.4-11 S-Car
CityState'Zir: ‘,..)OCCE./5 (YVIA--- Phone#: 7 3
Art sou an employer?Check the appropriate hos.;
Type of project(required)
t<iiployet with ). ctiiptoymi thin and or pan-titnei• 7. 0 New construction
:El I am a sole(sliprictof or partnership and have no employees working for mc in 8. Ei Remodeling
any eapacity IN()wookers'comp insurance required I
3 I:31 am a homeowner doing all work my5elf IND workers'comp insurance required j• 0 Demolition
E]Building addition
4 I am a homissw no and will he titrmg coninketors to conduct all work on my property, t will
ensure that all contractors either have N'Oebteet.compcnsatum insurance is are sole IIEI Electrical repairs or additions
propnetors with no auployers
12. Plumbing repairs or additions
T3I am a general cow-actor and I have lured the tab' tractors mtmt am the attached sheet
Iti :
o;t,sub-contractors have employ131:Roof repairs
and have workers'comp insurance I
h c art a corporation and tts officers has(eseicUrd then ngh«if exemption per hitit, e
14.pye :411
I i2.4104i.and we have no employees (NO workers'comp in:mance required I
•Ans applicant that checks bas el must also till out the section below show ing their workers.compensation policy information
/Homeowners who iashmo this affiilasn tridicaunn they arc doing all work and then hire outside contractors must submit a new strida*it indicating*uch
:Contractor,dud check this Ime must attached an additional sheet showing the name of the suh•contractors and able whether or not those entities hai c
employees If the soh-contractors have CraprioYee),thr:.must provide then workers'comp polio iminher
lam an employer that is providing workers compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: k.) 1\. _Yr1-
Policy or Self-ins.Lie.4: 6-73 Expiration Date: d3
Job Site Address: Li -1 IOU Re) City/State/Zip: f
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MG1.,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 to 5250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance
cox erage verification.
I do hereby certify under the pain and petraltie perjury that the info,'nation provided above is true and correct.
Signature: -,e,:211,71.011'2-2.40--- Date: ,_<) of
Phone
Official use only. Do not write in this area.to he 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
6.Other
Contact Person: Phone#:
City of Northampton
Has sachusetts
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