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17A-160 (11) BP-2024-0051 35 FOX FARMS RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 17A-160-001 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-2024-0051 PERMISSION IS HEREBY GRANTED TO: Project# insulation 2024 Contractor: License: GOLD STAR INSULATION & Est. Cost: 1200 CONSTRUCTION LLC 065992 Const.Class: Exp.Date: 03/16/2025 Use Group: Owner: HIRSH,JOHN DANIEL &HIRSH,MARISA Lot Size(sq.ft.) Zoning: URA Applicant: GOLD STAR INSULATION &CONSTRUCTION LLC Applicant Address Phone: Insurance: 1 CONGER RD (774)329-4664 6rs7139623 WORCESTER, MA 01602 ISSUED ON: 01/17/2024 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERI ZATI 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 VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I l +, • .5.2 51.-*1 Ii Fees Paid: $75.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner ,.., •5 ...,_ . . 8 E t------ i r...._,_____C ..-trt 1 r. .,z,,f,7---4_, i 1 City of Northampt,n Den im gli. r il- ------- -6-4-1 lir ie Building Departm nt jilt,/ , 212 Maid Sire t " 1 7 - Root i 100 24 NtILATI . . i , Noilhamptop, MA phone 413-S87-124i ,rax4/6 Igft2.;ilvsp cr i NLY ,...,_ APPLICATION FOR INSULATION FOR A ONE OR llir‘f0 FAMILY DWELLING ONLY t SECTION 1 •SITE INFORMATION INSULATION PERMIT This section to be completed by office 1.1 PropertyAddress. —C--IN 4 _(' in gC_,Vd Map Lot Unit Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,So IA iiN A's, cSi Name(Print) Current ALtIclie?:osttc. Telephone . I Signature < < 2.2 Authorized Aelem: ! (-11CIA ref ttiC 11 Name(Print) . Current Mssindress: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed bypermit applicant I Building 00 (a)Building Permit Fee 2 Electrical n (b)Estimated Total Cost of Construction from(6) 3, Plumbing 0 Building Permit Fee 4. Mechanical(HVAC) 6 ' ' 1 5 Fire Protection 6, Total.(1 +2+3+4+5) 1 aco Check Number This Section For Official Use Only 1 Building Permit Nuint. s dr 14..6 Date Issued Issued Signature .,, /- /7-zoz LI c.,.......rnnspecto,Qf Buildings Dale , EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) r 11111111111111111111 IMMINNOMMINNININNIMMINIMENNA ilv SECTION 4-CONSTRUCTION SERVICES — ... ' — 8,1 Licensed Construction Supervisor: Not Applicable p— Al, eik . ,0,_, ),.. License DAG‘.\ {\ 54- Address Expiratio Date - kN. '—?-1 Li 3)-.9 Li (._-cy ,rature Telephone S.Registered Home Imerovement Contractor, Not Applicable 0 Como in, Name , Registration Number I C (5-9 — P--01 1 a/3 D Li Address Expiratio Dat 0(-(, eL-i-ck-- M'NR- Telephone —) )it lacwrzat 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 buildin ermit. Signed Affidavit Attached Yes No 0 Brief Description of Proposed Work NOTE: INSULATION ONLY , , f11 \1(\e) i\ L__1o‘ k " ._.-• c \ d\fy,O .cd/ L...) i i Ai .as Owner/Authorized AgenhrtiebytEr\declare that t}st nts and information on the foregoing application are true and accurate,to the best of my knowledge i 1 and belief. 1 Signed under the pains a5penalties of pefjury. 1 ( C;/ 1--k) C'i Port l / . , Signato•E of OwneriAeht W\C LSK as owneif of thei suet property i I hereby authonze LA,6---) per1/4.4...eti. to act on npy behalf in at rs i rel tive to work authorized by this building permit p lication.cf)-\ . 4.. ..... . .. „ . 1 ii , L . . Signaluto of Owner Die City of Northampton AveMbh. City of Northampton 1 L$; -' , Massachusattn DEBARMENT OF BUILDING ZNGPRCTIONG1/4its) 212 Main Str••t 'Municipal Building Northampton, NA Q1060 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 • r \(„ (Please print house number and street name) Is to be disposed of at: (Please print name and location of tGi(y) Or will be disposed of in a dumpster onsite rented or leased from: 6Cit SLAPA— C4f\ (Company Name and Address) Signature o r?It 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. 1110111.10111.11.11, The Cnrttrrton svraltlr of Mossnehusefts Department of Industrial Accidents I Congress Street,.Suite 100 Boston, ', 011I4-20I • � ` >t t eatrraF goy/dla Workers'Compensation Insurance Affidavit:Builders/Ct ntractorsll leetrieianclPluhnhers. TO BE FILED WITH THE PERMITTING AUTHORITY. A )leant Information lease Print Le ibl Name HinsinessiOrgtanization/Individual): Address: ai'k, City!Sta1eIZip: (Jfee -- Phone#: , 1 ) ( "1 ... Are you an employer?Cheek the appropriate hot: Type of project(required): I• a employer with „employees(full and/or pan-time).* 7. 0 New construction 20 I inn a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp,insurance required.) 9. 0la am a homeowner doing all work myself.[No workers'comp.insurance required) Demolition 4.❑1 am a homeowner and will he hiring contractors to conduct all work an my property. 1 will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions I proprietors with no employees. 12.[D Plumbing repairs or additions 50 I am a general contractor and i have hired the sub-contractors listed on the attached sheet. I3.nR00 repairs These sub-contractors have employees and have workers'comp.insurance? we arc a corporation and its officers have exercised their nght of exemption per MGL c. 14. Other 152,i t(4),and we have no employees.[No workers'camp_insurance required.) *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy mfonnatian ±homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indreatin s iJ ;Contractors that check this box must attached an additional sheet showing the name of the sub•contraetors and state whether or not those ctrritnc^s hate employees, If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the police'and job.site information. Insurance Company Name: VI,-6 Policy H or Self-ins.Lie.#: 63 1.3 qct,33 Expiration Date: �Job Site Address: 3 4r rn City/State/Zip:T. a re -,.._._... Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,{25A is a criminal violation punishable by 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 5250:00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of peduty that the information provided above is true and correct. Date; Signature: Phone#: Official use only. I)o not rewrite in this urea,to be completed by city or wan City or Town: l'erntit/Licensa� Issuing Authority(circle one): 1.Board of Health 2.Building Department 3,C'ity!fowu Clerk 4.1E;lectrical Inspector 5.Plumbing inspector 6.Other Contact Perron: ��� �� City of Northampton 07.101:34 se HetSSAChtISOttS rePARTMENT Or 1311LEING INSPECTIONS O =i - 212 Main Strata a Municipal building', MOrtAAMpt0A, MA 01060 " g MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address 0 /1 1, ..._. Contractor Address: 1 07 TrYI \ AA ,_S 1 City, State: V\ O'll,-S4e-- Phone: Property Owner •N 1 Name: jdiAll \-\ \ 'Sk- Address: 'IS City, State: I i --torl-)6- IA A- K..c, , th A. 0 i &ir) (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 A. Date tl ItiCi'l q 1