37-015 Property Address: Cek9 f 1 O4'e-! -=67
Contractor / l
Name: t�;,u4(cC , ikfi-e C Pel F.rr 175 q4:
Address: /`{S -GU •
City, State: /1._ I
Phone: t 5 (c a
Property Owner
Name: t.<2 � :aM 70 ( 0,.t.)
Address: (o(aq eNtc
City, State: Flo be
I, U ),v,4.0 6(F (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 fi / /
Date
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AFFIDAVIT
Home Improvement Contractor Law
Supplement to Peanit Applicalio n
SonegetAthdnellarliosualapalemesteaduciarPasitAppfsation
Name Town
For Office Use Only
F 1 v\ct. Y-
Pw* No.:
Da*
Note 142 A, requir' es that the Areconstmction, alteration, renovation, repair, modernization, , •
,, - removal or demolition or the consbucliond uf an edition to any pre-asisting owner '
containing at least one butno mon dam four dwdling =it, or to sfructunts which ere adjacent to such
residenceorbuilfinge bedozobyregisteredoonuactors,mbhcertainezeeptions, along-with otherniquimments.
-
Type °Mork: o Est Cost a Lk) S C -
Address. ofWodc 66q v`A
-
Own= Nam= ( t c1/4_ N" - "Ti)
Date ofFemdt / Applicatimc 63O)
• I hereby certify that
llogieration is not required for the following (s): -
-
Work eaduded by law
Job tmder 500.00 —
- -
Building not owner omapied'
Owner pulling own permit -
_ - Other (specify) C$Sid C
' -
-
Notice is hereby given that
OWNERS PULLING 'MIR OWN PERM /T ORDEALING wrm UNREGISTERED CONTRACTORS
FOR APPLICABLEHOMEIMPROVEMEN'T WORLD° /4MT HAVE ACCESS TO TEE
ARBITRATIM PROGRAM OR GUARANTY FUND UNDERMGL C 142A.
Signed unler penalties ofperjury:
' hereby apply for a pennit as the awn oflhe cownec
- Jr-7r
Date: (o /j-) ecetmcgoc ..if Reg.
OR:
- Not withstands& the above notice, Thereby appkr for apt as the owner of thaproperty.
Date: Omen
SECTION8 * CONSTROCIKON SERvISES
8.1 Licensed Construction j Not Applicable 0
Name of License Holder: +' r� V (' `�� Q e . c 10 \ e. 6
License Number
\ C NOX S1 � t yo & - � - 2) )
Address y
Expiration Date
019 eq1A tiv P, .44 s vsC c)
Signature Telephone
r . ti k; Applicable ❑
- ` YL�,ACI (J. ) e U .._ Not A
Company Name 1 Registration Number
c
Addiess Expiration Date
17� rs (4) P,c)J-kftie Telephone SS 6 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 ❑ No ❑
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
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. El Demolition ❑ New Signs [O] Decks [p Siding [0] Other,
Brief Description of Proposed i .
work: I S C.6 Iv 77Q- +c) 1 ,�5r, 1 C pe vt 4 N . `
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stones?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction 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 building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 4 AMORI TION 1O COMP WHEN
CONNERS NIESTOIUMPORACCOR
�- APPLIESfOREMILERIE PERMIT
•
W , // / /oJ , as Owner of the subject
property
hereby authorize L} k Ac' l (X k r r I I 'e fl e fL
to act o my • half, inal[matters relative t• • •. - • ' ed by this building permit application.
Signature of Owner Date
Nr UL) , � `'� i• -� � 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 penalties of perjury.
Print Name
uJe7d W
Signature of Owner /Agent Date
. .
Section 4. ZONING All information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning •
This colunm to be filled in by
Building Department
• Lot Size
Frontage
11
Setbacks Front 1 E-7I 1----
_ .
Side L[F--.-- R4----1 L:r ThE
Rear = 1 j =
Building Height
Bldg. Square Footage = 11' I % E=
Open Space Footage %
(Lot area minus bldg & paved ET1 1 I E. 7 1,1 r 1
parking)
[-__J- r i
I
# of Parking Spaces 1 1 - ___
Fill: r ....._ ...... _........._,_ ..............._ ....._ __ —
(volume & Location)
A. Has a Special Permit/Variance/Findin r been issued for/on the site?
NO 0 DONT KNOW YES 0
r— ---1
IF YES, date issued: t
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 ' Pager i and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , Date issued:
C. Do any signs exist on the property? YES 0 NO 0
r ----;
IF YES, describe size, type and location: i
€..
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: I
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
N
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1
RECEIVED City of Northampton
Building d De
1 9 artment p
6
2 Main Street
Room 100
Northampton, MA 01060
o euiwwo it "
. •.. 413-587-1240 _
1!IORTH�
13-587 -1240 Fax 413 -587 1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOUSH A ONE OR TWO FAMILY DWELLING
SE. Tit 1 -� CRMATI ,; , I
1.1 P 1,6 rooertvv Address:
1-,..4,,,,,,,.%,,),,,,,I,,-,,,,-;,,,,,,,„ .y, y a < . k 'M x k ° t r ,
1 I o e n {( e - eT 'S`- 4 $ 2: +" 4 da is' . `' ,-
r b fe,fr7 c.)4_____ a . �YS. a sus - . +. ;. t ., +>
•• - , i - �R
2.1 • ner of Record:
Name (Print) Current Mailing Address:
.s a - 2* 3
`' V �I2" -�.,� Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
Item Estimated Cost (Dollars) to be mat "tom" ft)' .
completed by permit applicant
1. Building
fa) Bia s Pefrnd t"e
2. Electrical lb) . t; Tot t 'Covet
, .
3. Plumbing
4. Mechanical (HVAC) -.SW.�j) `tom- 1 'IN ,f-- --
5. Fire Protection
6. Total =(1 +2 +3 +4 +5) . . r4 C Nt m"�
Th , : • for "a .a , "title' a its
t Irg I�* knelt Num
t
�., . of s ,
File # BP- 2011 -1102 '
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION 669 FLORENCE RD
MAP 37 PARCEL 015 001 ZONE SR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out //
Fee Paid 02bY S
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing,
Accessory Structure
Building Plans Included:
Owner/ Statement or License 101876
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
1/ 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
6/ZetiL/
Signature of Building Official 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.
669 FLORENCE RD BP- 2011 -1102
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 37 - 015 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- 2011 -1102
Project # JS- 2011- 001770
Est. Cost: $2406.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 40859.28 Owner: TOBIN INGRID F & WILLIAM FX
Zoning: SR(100)/ Applicant: DONALD PELLETIER
AT: 669 FLORENCE RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON:6/30/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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 6/30/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner