29-517 A •
Property Address: y /` < �' , r,
Contractor
Name: i , .��,�( 1(
Address: / /C."? ��'I= 7
City, State: /
Phone:
Property Owner
Name:I�1
Address: ) Cr -- , eL
4
City, State:
I, !. ; ���, t ` + c [( f. k `; (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
\IC)\ #1111( =r11C13"ailliliQ 311a
:Wady) sajpeadmign
"Tad lrenwtmannamawavaintrytemocausaxtvantiav
HEIL-0i T Iii IMIXIMV /Vli
t 3 •
" - Q\(V pp ' t o --- - - -
dmo d 0 -
_ - OWNSs ger _ -
• � " - -
0 i -
4
cam.- L, � :
C - • �WAvY0D 0 *min smairw
- - L Y '1,2. I - NV \ =pomp edify
vomatempbazianolgailkaaresuoodocanwupwamatrseopannooptuarifftelqauppaqsamentpossuippar /.
romanam
ilegwiripsamegmaamosigmposils
•
Ain .11,0111M03 inumaidinq agog -
- -
9tAJtA� - - - - - - - - -
- - _ The CC omvedidfe of Massach
- Deparnent elndastrhd A •
1, ' =s '�� �e ofin� .
1 - . .,7:-.4t 1 ,-_r_. - -F m+ 600 Wad Street
= - Boston, MA. 02111
_ : .; - '• ww mumvps dia .
Workers' Compenssatiion Insurance Afdavi B iau s/C ' a bra = - -_
An licant Information - Please Print- Lemlily
Name ): Oft) A- je 0; P 14. ti -e12
- Address: 1101 Im rA t O Sf; .
City /State/Zi : p -o k4 p i' Q.. - )4 c► O i o q0 Phone #: q I3 - 3 ?- & oo . -
Are you an empIoyer? Cheek the appropriate box ' -Type of Project (re iemtd):
I ,g 4. Iama a I am a wilt g' ndI 6-- D New Cen a
employees (full and/or part-time).* have hired subs tracts
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub,cont rectors -have - g D -
workmg fix me m ally capacity _ anPinYeas and have wa hers 9. 0 Building addition
- [No workers' =up. insurance cognlx luserance.t. - -
5. 0 .We are a Corporation and its 100 Electrical ical repairs-ora
3.0 I am a homeowner doing all work • officers have exercised their - 11 43 Piumbing repairs or additions
rift of exemption per MGL
myself_ �t comp. - c. 152, §1(4}, and we have no 12-0 Roof insurance - . employees. [No workers' - 13.0 Other
comp. woe wed.] - - - -
•Any appliMmt that checks box#1 mast also fill workers' ll oatthe section below showing their woers' compensation policy iethzmpion.
Homeowners who submit d s affidrarit initialing they ins doing an wc,k and then hire outside oorttaednzs must submit anew affidavit Winkling suck
s that chock this boa mast attached an additional sheet ahovang the name oftbe sob- oomtzactoss and state whether or not thosa entities have
e m p l o y e e s . Ifthe mss have enpioyee , they mmtprovidetheir washers' comp - policy
ransom employer that it providbsg workers' compensation jet my Ottigoyees. Below iT the pr ty iadj.,site -
` Instaance Company Name: 2 0 • , _ .A1 4 0
Policy # or Self -ins. Lic. #: ( 3 a ? • 'J 0 S - - Expiation Date: ' // �-
Job Site Address: ` - CO ec h n a 1 Cit - /O�' ► e - o ,
Attach a cop of the workers' _ poky d�6 p (stream the pe; y- naie®ber and a ithatieh date).
Failure to secure coverage as required underSectica 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa -
fne up to S1,500.00 and/or one -year imprisonment, as well as civil penalties in the fay of a STOP. WORK ORDER and a fine
of up to $250.00 a day aganat the violator. Be advised that a copy :ofthis statement may forwarded to Office of - - '
- Investigations of the DIA:for insurance coverage verification.
Ito hereby cm* ander the pains mod perra s rfpcy the information provkled above singe and correct. .
t -
SignatureAnAzA.M U - R.Di Q Q 1. Date: . -
- Photte #: • •
_- __ it - _.... .. -.. -.. -
Feral use only De not write m this Wm, w be completed by city oilmen official
■
I C ity or Terri: Pere #
I A Department -
1
I -
- ContactPersoo: ' - .Pheae#: (413) 499-9440 -
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: k Not Applicable ❑
Name of License Holder : ki.0,‘ C'l 1 e 1 tN ( I D ` 2
License Number
a 1 Nta - c Nok ok.s_ NA v 10 /D' g''c ' 1 3 —
Address r Expiration Date
( 3 &`
Signature ® Telephone
LP ,�Y( c) P., J2,1,1&
9. Registered Home Improvement Contractor Not Applicable ❑
MC VL4X. k CL) le e � (S O 31
Company Name , Registration Numb
1 l
3"'" v`-'`t` v c3 iaV O �- �--`� ' 36).
-
Address Expiration Date
� - Telephone
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 - �J" 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 perfprmed 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other
Brief Description of Proposed 1‘ 14 -
Work: Orpe3 C ttw Add I0 etiIt l ko c35 Cu Se 11ti0-
Alteration of existing bedroom „e" Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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 stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Massched( 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 - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR : ILDING PERMIT
I, I iCi i`ii _ , as Owner of the subject
property �,�
hereby authorize C )OVIS V 6. ) , I 1 \ '�
to act on m ehalf, in all matters relative to work au rized by this buil ing pe 't appli
/ 61 1 - i'y1.6oR Q z.,7" 20/(
Signature of Owner D
I, ve- ,. \ , UL) . / �e.�,�t - k 1. •Q. C , 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.
.`Fe ll @ @
r- bi Wa ( ) %. e.._C
Print
ri, rth tap rt /2 4i4.-;
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 column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage °A)
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 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained V Obtained O , Date issued:
C. Do any signs exist on the property? YES 0 NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O
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 O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• Department use only
ICC/Ven • of Northampton Status of Permit:
Buil• ng Department Curb Cut/Driveway Permit
2 2 Main Street Sewer /Septic Availability
jt1N 2 2011 Room 100 Water/Well Availability
ort ampton, MA 01060 Two Sets of Structural Plans
o8 u' r 3- :7 -1240 Fax 413 - 587 -1272 Plot/Site Plans
��HAM
• a ONS Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
OZ / y 6-doted- Map Lot Unit
�Q Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /I/ £ L / 554 la 6 /U 7
o,i4 , - (14 tOM 0 4 w �'6y
Name (Print) Current Mailing Address
c
Telephone /r � J /f)
p
Signature
2.2 Authorized Aaent:
Name (Print) q Current Mailing Address:
/ �/
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total = (1 + 2 + 3 + 4 + 5) �� , L 1 Check Number 97 °
17
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0120'
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS /PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION BURTS PIT RD
MAP 36 PARCEL 304 001 ZONE SR(100) //WP /WSP II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out P i e y 5V
Fee Paid �J
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 F ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
RMATION 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
. t . elay
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.
22 TARA CIR BP- 2012 -0119
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 517 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 -0119
Project # JS- 2012- 000177
Est. Cost: $2178.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft): 6882.48 Owner: OCHNER VINCENT R & JANET
Zoning: URA(100) / /WSP Applicant: DONALD PELLETIER
AT: 22 TARA CIR
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON:8/2/2011 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: Ilouse # 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 8/2/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner