29-077 (5) I ..
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DEPARTMENT 01' BUILDING INSPECTIONS , -
212 Main Street Municipal Building
Northampton, Mass. 01060 r'
WORKER'S COi>Q'ENSA "i LON MSURANCr AFFIT MVIT
I, All Star Insul,ajion & Siding Co., Inc.
4, (liccnsc Jpermittec)
v.rith a principal place of business/residence at:
56 Franklin Street- Easthampton, MA 01027 (phonc)413 -527 -0044
(sari- t /city /suix!ri p )
do hereby certify, under the pains and penalties of perjury, i_hzt
(x) I am an employer providing the following orker's compensation coverage for my
employees working on this job
- , CC 1�� � h. - r � _ I V;\
(Las n Conner ) (Policy Nu r) (Expiration Dale)
( ) I am a sole proprietor, general contractor or homeowner (cicie one) and have hired
the copsactors listed below who have the Following worker's compensation policies:
( iam of Con mcio") (In uranc;c Company/Po NuII1hC:) (Epirduon Date)
•
(Name of (lnsusaocc CompauyPo!ie; Numc- r) ( —D ion Dale)
(Name or Coaracto,) Qasurancw Company(Policy N:tsbcf) (Expiration Date)
(Namc of Contractor) (Insurance Compzay/Policy Numbs) (E -piration Dais)
r± t oo .--. - to c,cv -dr iafo(nv._ioo pcteiains to di oacc -Gn:a)
( ) I a-- a sole proprietor and have no one working for we
( ) I am.a home owner performing all the work myst°lf
NOTE: plea be emrc th *..+'1:Jc bcmocrAncra v.bo aaplcry p�oci _ work, on of
mot wort th, n L oa era in which ttx bonwowoc rt do or cc the pmincb z -ulcn_-1 (been'- -c w! t-r= JJy crcd-rod to he
employes „ v - the , .+ukds a -••'ca Aai (G(2152.= l (5)).:-pplia.000 by • bovloom-tcr fci n liege « pc-mit ray c•-rd-or- the
I r®l runsr of ea rcalorer under the Wo4Fo Comp.ecr _io, /.et
I tin c -tt.nd &e > copy of thin rn r.-.,,....r ouy be for-A.ard.eA tn tte pcpartms or /.cddCnb' Ofrioe of Irv.. - to For the
covctgc nnf caioa anal th l f1)tae w ururc'coverage tery: soetion 25 A of MOL 1 52 cm Ind to the j ad:diw of eimica! pco- +hies
coast: ng of a On of up to S 1300.00 .nd!co- ion:Fr or up to uric yczr cad in the form of o Stop Wort; Ordc aor
rein of S100.00 . dhy apuaa me
For cnly
Pu wit Nwnbcr
Lot . ".
sijiat • of Liczn_scclPcrrniucc
•
SECTION .8 - CONttRUCTION SERVICES ,+
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License liolde_r : Edwin Losacano CS SL 99739
License N mber •
128 Glendale Road - Southairpton, MA 01073 l I (
Address 7 Expiration Date
t
� - . - -_ (413) 527 -0044
Signature Telephone
°-�:, .m.,a tr�cs� - +�u +s���3+'�.'"�` t c� k �� s �°.�.� �....y -er=a. k ^fir °-
. rRegrteredr 'orr► prover i nit id%it'i r ORWM y R -, , Tt l`,'i 4 t.st'r�; �: Not Applicable ❑
All Star Insulation & Siding Co., Inc. \ L
Company Name Registration Number
56 Franklin Street
Address Expiration Date
Easthalrpton, MA 01027 Telephone 413 - 527 -0044
SECTION 10- WORKERS COMPENSATION INSURANCE AF FIDAVIT (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 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
r
o
SECTION 5 DESCRIPTION °OF PROPOSED WORK (check:: alt applicable)
New House n Addition ( 1; Replacement Windows Alteration(s) [ I Roofing
Or Doors El
Accessory Bldg. n Demolition 1 1 New Signs [tom] , Decks [C] Siding [O] Other [O]
Brief Description .f Pr•po .` r` n ! f
Work: Ai A \ .\ C .. ' � _ ) , J 41..--r2 •
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea refart arms it add o .��v a Illi q.�EiOUsklirarlibig gth oltovuii q:
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
i
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 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 7a= OWNER AUTHORIZATION TOB COMPLETED WHEN
OWNERS AGENT OFf FOR,BUILDING PERMIT
1, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, All Star Insulation & Siding Co., Inc. , 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.
Ed Losacano IA- ' - 'e -.
Print Name
.; �i:% G _.1 —` _. _ 1 D - ( -c) 7 —
Signature of Owner /Agent Date
City of Northampton S t o R < "� 7 „424416. y- -r
�, �• �
Building Department to a 1 a s r q' �� a� 1-'
212 Main Street
ewers - o ”" ..�- � .
Room 100 re v : o
Northampton; MA 01060 Se s B � rp ura ��., _ ; �. �.
� .
phone 413 -587 -1240 Fax 413-587-1272 R• a n- �' f��
0the kre ti tl K44? �I j ` 19
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 : SITE_INFORMATION
r ' tYltn Thls sectlo tdkbe completed by bffce
1.1 Property Address: " 't # y i} , r8 ✓ n €
(r �` ' 1 , t x t g a31 g + ? ty amt" •OS ti 4�i 1 y
t s
Y12, r "Zone �.; r Y' ;�- OverlaDist�rrct h t 51 dryar )'"t u t
\aciAc. C� err n� E"i - ...,ndAttaitY r i t .�r�'� m + n xa w
tt€ _Elm-5t District .. m r! n -.CS D►sfr et i .a e r,.. �
. .
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address
Telephone
Signature
2.2 Authorized Agent:
AU Star Insulation & Siding Co., Inc. 56 Franklin Street - Easthampton, MA 01027
Name (Prr'tpt) Current Mailing Address:
413 -527 -0044
Signature Telephone
•
.
SECTION 3 = ESTIMATED CONSTRUCTION.::COSTS
Item - Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building "_.. (a) Building Perrnit Fee
J;
2. Electrical (b) Estimated'Total Cost of
Construction frorm (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection r '
6. Total = (1 + 2 + 3 + 4 + 5) Check Number J/
J.
this `Sectpoii F.Or Official' Use.Only
Building Permit Number.. Date'
Issued:
Signature: r
Building Commissioner/Inspector of Buildings Date
70 ACREBROOK DR BP- 2010 -0389
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 077 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0389
Project # JS- 2010 - 000515
Est. Cost: $5983.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALL STAR INSULATION & SIDING CO INC 99739
Lot Size(sq. ft.): 20603.88 Owner: O'BRIEN WILLIAM & JUDIANNE
Zoning: URA(100) / /WSP Applicant: ALL STAR INSULATION & SIDING CO INC
AT: 70 ACREBROOK DR
Applicant Address: Phone: Insurance:
56 Franklin Street (413) 527 -0044 Workers
Compensation
EASTHAM PTON MA01027 ISSUED ON:10/9/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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: Q K to - id-1
THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu • anc l..eira.r� • si_ nature:
FeeType: Date Paid: Amount:
Building 10/9/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo