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29-332 (3)
300 i mass save SavkK» tlrwgb *new etl,den[y PERMIT AUTHORIZATION FORM 1, �U; / � ` , owner of the property located at: (Owner's Name, printed) A rv%r r:- T7 Draft (Property Street Address) (City/Town) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and /or weatherization work on my property. Owner' signature " i ") /7/6 Date FOR CSC OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Horne Energy Services Participating Contractor to the above referenced project: c_ E � It� 1 Participating Contractor Date Rev. 12132011 AFFAD AVIT Home Improvement Contractor Law Supplement to Permit Application - Suggested Affidavit for Home Improvement Contractor Permit Application For Office Use Only Name of City / Town Permit No: t- l o re N\(?"9 MCA Date: Note: 142 A, requires that the " reconstruction, alteration, renovation, repair, modernization, conversion improvement, removal, or demolition, or the construction of an addition to any pre - existing owner occupied building containing at least one but not more than four dwelling unit(s). or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exceptions, along with other requirements. Itr4 Type of Work: j [ )10A t6' Est Cost Address of Work: D( Owner's Narne: [ k C sec t t7 r Date of Permit i Application: 1^ I hereby certify that: Registration is not required for the following reason(s): Work is excluded by lair Job under S 1 000.00 Building not owner- occupied Owner pulling own permit � `." }( Other (Specify): C.K.Q k3SQ Notice is hereby given that: OWNERS PULLING THEIR OWN PERMJT OR DEALDIG WITH UNREGISTERED - CO?'TRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL C. 142 A. Signed under the penalites of perjury: • I hereby apply for a r ermit as the agent of the owners: Date: ` 'h Va Contract Rtittit siratioi (Z i OR Not withstanding the above notice, I hereby apply for a permit as the owner of the above property: Date: Owner: t� a Department of Industrial Accidents Office of Investigations _; 600 Washington Street _'. Boston, MA 02111 • ' awl" »nw . mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business/ Organization /individual): \ C Address: 1 VS . 1 `CC" ks-ic 'pk o \ 6 City /State/Zip: `r- des. -t Phone #:J ! 3) 5 3 6a_ Are yo employer? Check the appropriate box: Type of project (required): 1. am a employer with 4_ ❑ I am a general contractor and I 6. ❑ New construction employees (full and /or part - time).* have hired the sub - contractors 2.0 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. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.E1 Electrical repairs or additions required.] o 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13. er 11 Cl 1tCst es °,J` 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. tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information. 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 E- ‘"*", `r'<- VD ' 'C S CD Policy # or Self -ins. Lic. jc t 4-4D Expiration Date: — D5— 1 Job Site Address: r ` 6 c cc .b(O rOc , City/State/Zip: n ©f e V _ Q 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 $1,5 - 00.00 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. t do hereby cert j under the pains and penalties of perjury that the information provided above is true and correct. 5_gnature: t,t• Date: 'hone #: ('•4 1 'n S Official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/ own Clerk 4. Electrical Inspector S. Plumping Inspector 6. Othcr Contact Person.; ... �... .,,,...,.,., ,... Phone #: i MeV. IrorLV LI �� Mp> City of Northampton Massachusetts '` { f 1 I t , i # f' 2 x ' ^%,' ' :',' ,,,, DEPARTMENT OF BUILDING INSPECTIONS 4 1 ' 212 Main Northampton, Municipal Building �c ti 40.0' Property Address: a6 C 6 a.c cc_ b C ,O,O iC Contractor � • �� , Name: � _� 1 ! r Address: \ \O) XC1C* \ 4 City, State: 1--1b M '- o\cs,10 Phone: 1 ' 1 S q COO.? Property Owner �, Name: l.�? t \"V � 1'� e_ v r Address: i 6 D a.c -r °e b ((DO iL, .. City, State: \----N to r 't v` -c-'_ rrvx 1, eic k VI i 4 .e.M. \! ( (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 1 have provided the property owner with a copy of this affidavit. Contractor signature ZCIX 'Q4LUI-N-5--- Date , , k()\- 1 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: - Not Applcable ❑ Name of License Holder : �1C � � C� � , e ( 1D 1, License Number V\ c Nt rl A Address Expiration Date r ,. \ ( % C Six C; o Signature Telephone 9, R H sne nDroveff eM Contractor: Not Applicable ❑ S 11 Company Name , Registration Number \a ry"'N■ k . W O \\4 & 0-tek dress ,, Expiration Date (} (L Lt \ L.) k�t.�.9.. Telephone C 32 G 6 6 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 Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dweilines 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 1083.5.1. 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 SECTION 5- DECRIPT1ON OF PROPOSED WORK (check ail applicable) New House [] Addition ❑ Replacement Dooms Windows Alteration(s) [ Roofing El Or Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [a] Other Brief Work: Descxiption of Proposed O Q 0 . V cf �b� V� <* .` ` cf I l l.' •� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet Sa. 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. 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 Budding and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT GU I, � Wfed ? ()( , as Owner of the subject property � . hereby authorize C ,/ A to act on my behalf, in all matters relative to work authorized by this building permit application. v (1 SC, SCE v -Ft r Signature of Owner Date ,,,, Nd 1 1L) d , 1 , e 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. Print Name 6 S Jam, t Signature of OwnedAgent Date Section 4. ZONING Alt 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 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 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use onty City of Northampton Strew of Permit t3Dilpting Department Curb Cut/Driveway Pernik, 2,12 Main Street SevmdSoptio 'A t> ft DEC 2 6 201 ' Room 100 atertWeit ty . Z Northampton, MA 01060 Two Sets of Strurtrr PI phone 413 -587 -1240 Fax 413 -587 -1272 PI Site Perms Otter Spar APPLICATION TO COCT, 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 Map Lot Unit cetiro )k ` ( Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: (&.j< c e d a(54. acr th-oc Name (Print) c^ Current Mailing Address: \1`nC -S> CC1. v2 fc rrA '‘. & Telephone Signature 2.2 Authorized Acient: Name (Print) 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) ell k. 0 Check Number � k This Section For Official Use Only Building Permit Number: Date Issued: _Ad% Signature: _____ 1 . � Building Commissioner /Inspector of Buildings Date 268 ACREBROOK DR BP- 2013 -0669 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 332 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit # BP- 2013 -0669 Project # JS- 2013- 000608 Est. Cost: $1800.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq. ft.): 10497.96 Owner: REYOR WILFRED J & BONNIE A Zoning: Applicant: DONALD PELLETIER AT: 268 ACREBROOK DR Applicant Address: Phone: Insurance: 1107 MAIN ST (413) 538 -6002 WC HOLYOKEMA01040 ISSUED ON:12/27/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:ATTIC FLOOR 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 12/27/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner