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43-101 • Property Address: 9j - Pair 1 H:11 Roaa(, FlaNei'tce. MA OYoG Z Contractor Name: L 4evI IA. ems y , L 1... C Address: 33 ti)jscoH.s; u. /kV,- City, State: Moo W I c % , GT cg.36.6 Phone: F f 7 - 37 g- 3C9nl Property Owner Name: #� ic44.v► 1 Sicc. Address: 7 2, Eva.w voi City, State: /.44-1A a,Gut.. pfi014 M A 1, 2 :c.c,.a.v►e-i 4 61 (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 ���.. Date V2 2O!! "owr Now The Commonwealth of Massachusetts Department of Industrial Accidents -M Office of Investigations { 600 Washington Street .� j Boston, MA 02111 "'" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Ln,,Atev.vt 'k,kp, (A 5Y ) L LC Address: 33 W ;sc. o IA f., i I4 0..Je City /State /Zip: . G o • , • Phone #: $ ?7 g ?g - 3066 Are you an employer? Check the appropriate box: Type of project (required): 1. r l I am a employer with 30 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. El New construction 2. ❑ I 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. E] Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 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 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no ^.. employees. [No workers' 13.® Other .71.7 comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are 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 entities 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: 1.4 am. t}ovj t iot K. G t Fi v'e =k5• Policy # or Self -ins. Lic. #: 31 W ECvT F5 /SO Expiration Date: /z/ 31/ 2,0 if Job Site Address: 95 Paud < 14 i II Il o o cl City /State /Zip: Flovcttice MA 0/06•Z 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 certi& under the pains and penalties of perjury that the information provided above is true and correct: Signature: i4AL £ J Date: 4/2.,//9...0 t / Phone #: '(oO — 366 — '7 z 73" 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 6. Other Contact Person: Phone #: **ow lour Notw 9 'L rid , e e 4'fI. > ' 'I Office of Consumer Affairs and usiness Regulation �" AIIW X. { r 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169979 Type: DBA Expiration: 8/25/2013 Tr# 216225 LANTERN ENERGY PETER CALLAN 33 AVE. NORWICH, CT 06360 Update Address and return card. Mark reason for change. rl Address j Renewal I _ Employment ❑ Lost Card DPS -CAI (b 50M- 04/04-G101216 elite 6o rum ,uoea`ai Ic' ` i iatida �' to License o r registration valid for individul use only Q— Office of Consumer Affairs & B mess Regulation g y HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: I ` = -� y j" k , Registration: 169979 Type: Office of Consumer Affairs and Business Regulation 1, ; � Expiration: 8/25/2013 DBA 10 Park Plaza - Suite 5170 j Boston, MA 02116 LA1ERN ENERGY PETER CALLAN , -- ° 1200 MILLBURY ST 9D ' / a WORCESTER, MA 01607 Undersecretary N ali without signature • elik '�rrr SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction 7 Supervisor: Not Applicable ❑ Name of License Holder : I(t Gk• j 4 6ts 74 License Number 132 ? t v o nec+ stu.ee+ S/2.a I Address it tion ate t •tileueeroi 0/6 Coo – 3O( - `72 7s Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ / ) LLC /(9979' Company Name Registration Number 33 U.);SGAlnStitt a.ue V2.412At Address Ex it tion Date 4/0V L , GT 0(e3(t Telephone 877- R 78-3co ( 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 )2( No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) 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 period 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 all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature AkflW 10.11W 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 Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage I Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW *) YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW © YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. NNW 1 400 0 441111111e SECTION 5- DESCRIPTION OF PROPOSE WORK (check all soofcable) e New House [] Addldon ❑ Replacement ndo�we ANNa ions) ❑ Roofing El Or Doves Accessory Bldg. ❑ Oemolibton ❑ New Signs [D] Decks [D Siding [A1 Other 410 Brief Description of Proposed Work: Art k. Tus u.Int ;out 4 M eet( SR 64s j P pa r..i •u * l'dr 4 , i/err{ ball. 41. to ,_ : "enly 400 *t on kiwtc4 . Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Rod - Sheet fa N New house illd 1X adiltloft t aldstlfia houski t. domoP* t he follOr11it1A• a. Use of building : One Family Two Family Other b. Number of rooms in each family unit Number of Bathrooms a Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of constructor' e L Is oonstrucdon within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will budding conform to the Building and Zoning regulations? Yes No - I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOIE BULGING PERMIT 1 , ' , , , , . d P 7r j c , as Owner of the subject hereby authorize at. 4 ^ . s to act on my . ,, , in ad ra -�:' ' ,"�- :T, • rived by this budding permit application. / . - - %� A �/� 9 21/201 j .- - Dais I Z; .el MA'S as ownedAuthorized Agent hereby dedare 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 penalties of perjury. gn K: r ".1..41. A 6+r elik Print Nuns °,( •„6,,,c,i 'l z'/ i i SloneaMe of OwneriAoent Date ------ *Ile 1 Oa a.) 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File # BP- 2012 -0290 APPLICANT /CONTACT PERSON RICHARD ABTS ADDRESS/PHONE 132 PROSPECT ST EAST LONGMEADOW (860) 306 -7275 PROPERTY LOCATION 95 PARK HILL RD MAP 43 PARCEL 101 001 ZONE SR(100) //WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out v r Fee Paid p( f5 Typeof Construction: INSTALL ATTIC INSULATION & BATH FAN VENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 74666 3 sets of Plans / Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 �r /912 /✓ Signature of Building 0 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. , 95 PARK HILL RD BP- 2012 -0290 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 43 - 101 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- 2012 -0290 Project # JS- 2012- 000467 Est. Cost: $2298.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RICHARD ABTS 74666 Lot Size(sq. ft.): 43342.20 Owner: SIAS JANET E Zoning: SR(100) //WSP II Applicant: RICHARD ABTS AT: 95 PARK HILL RD Applicant Address: Phone: Insurance: 132 PROSPECT ST (860) 306 - 7275 WC EAST LONGMEADOWMA01028 ISSUED ON:9/26/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION & BATH FAN VENT 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: Oil: 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 9/26/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck— Building Commissioner