42-163 Property Address: �1 1, �'� yd
Contractor
Name: `fib �l (.j \'- � -�-\ C
Address: \ `) '�`�1G r <-t
City, State: K`Q V\-(O-,, CU c"�y V
Phone:
Property Owner r
Name:
Address: h�yR
City, State:
(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
Apr- 24, 2013 11 . 28AM Center for Eco lechno� logy No. 1494 P. 27
P 6
►umcir�nMa
mass save �roA
+nVi•!JI 1lOY!�1 On.1�y P I1K%aK)•
PERMIT AUTHORIZATION FORM
Bo L,.)r1c� , owner of the property located at:
(Owner's Name, printed)
I
�' �Gb�Ll�l� fall r° pa cl N o�'�1a -J-ON I MOt
(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's Signature
� 3
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
--
Participating Contractor Date
Rev. 12132011
AFFAD A VIT
Horne Improvement Contractor Law
Supplement to Permit Application
Suggested AIIida,,it for Home fmprovemeat Contractor Permit A.pplic..ition
For Office Use Only Name of City 1 Towu
Permit No:
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-e.cisting 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. 0
Type of Work: t^� t)tC3. `�"'y ..°•-, Est Cost 6�
Address of Work_ ( �. e, �`
Owner's Name: c
Date of Permit i Application: 3
I hereby certifv that:
Registration is not r°cuired for the foilo%ing reason(s):
Work is excluded by law
Job under$1000.00
Building not owner-occupied
OwTier pulling own permit { V
Other (Specify): __ ,
Notice is hereby given that.-
OWINTERS PULLIN(,THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CON7RACT0R.S FOR APPLICABLE HOME LviPROVENlENT WORK DO NOT HAVE ACCESS
TO THE ARBITRATION PROGRA-M OR GUARA-N-1Y FUND UNDER
MGL C. 1.12 A.
Signed under the penalites of perjury:
I hereby apply for a,ermit as the agent of the owners:
Date: -- ContractV�� i s7tatioi { .
OR
Not withstanding the above notice, I hereby apple for a permit as the owner of the above property:
Date: Owner:
Department of Industrial Accidents
Office of Investigations
�V_ _J 600 Washington Sheet
kv Boston, MA 02111
»nvw.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Nance(Business/Organization/individual.): lbo (
Address:
City/State/Zip:_ Phone #:
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.❑ I am a sole proprietor or partner- listed on the attached sheet. t 2. ❑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 10. Electrical re
required_] officers have exercised their ❑ pairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees.[No workers' 13. er ►//� C J� '1 ,('
comp. insurance required.)
`Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infomtation.
I 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 prov'id'ing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name: 1 C'_-C� `l���C7 � � "�.� � CC) .
Policy#or Self-ins. Lie. #:�i ,� L ' � i G jL� Expiration Date:
Job Site Address:
City/State/Zip: IF O(e (�
Attach a copy of the workers'compensation policy decitration 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 imp;isonment,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.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
iivnature Date: y` /
'hone C -41 )
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Pertnit/License# _
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.Cit_v/f own Clerk 4. Electrical Inspector 5. Plumbing,Inspector
6.Other
Contact Person: Phone#:
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
"Ibis 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&L.ocation
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 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 ® , 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 0 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 ® NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSE WORK(check all aoalicable)
New House ❑ Addition ❑ Replacement Windows Alberation(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [ol Decks [M Siding[p] Other
Brief Description of PrpoQQ0sed A ,
Work— iA-M10 i tLx&
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.#f New house and or addition to existina housina 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 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 BUILDING PERMIT
(, CC0.SS kd l Jjz�t >,1 l 1/` as Owner of the subject
property ,I�
hereby authorize1f
to act on my behalf, in all matters relative to work authorized by this building permit application.
0--) s �-- 5 n ed -Y-q- 13
Signature of Owner Date
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 perju
JA C
Print Name
A c C L ;)-S- j
Signature of Owner/Agent Date
0eparonant tase onfy
City of Northampton StwA of Pon
171, ._.;E — J Building Department curb C ff lyPomlt
212 Main Street Sewedseoc Av l_,
Room 100 Water/Well A"NOOKy
Northampton, MA 01060 TVM Sett of Structural tom_'
Dt�
OF g�I�pING
INSPECT' 413-587-1240 Fax 413-587-1272 Pk�t/fiite P
NORTHAMPTON,MA 01
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
s section to be completed by office
` Map Lot Unit
( �e ' �
1 Zone overlay District
Elgin St District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: (11
Name(Print) _ , rgnt�laili !k-,%2
v�(1Q� au-_ CitAboC92Q+)0 �� ylidnull
Signature
2.2 Authorized Agent:
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) Tv-S0 iCA-
5. Fire Protection
6. Total=(1 +2+3+4+5) 1 aQ . Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/lnspector of Buildings Date
File#BP-2013-1039
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413)538-6002
PROPERTY LOCATION 997 WESTHAMPTON RD
MAP 42 PARCEL 163 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
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 FOL WING 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 Perniit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
n Delay
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.
997 WESTHAMPTON RD BP-2013-1039
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42- 163 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2013-1039
Project# JS-2013-001717
Est.Cost: $1900.00
Fee:$55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq.ft.): 158166.36 Owner: BOWMAN CASSIDY
Zoning: Applicant: DONALD PELLETIER
AT. 997 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538-6002 WC
HOLYOKEMA01040 ISSUED ON:51212013 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 Si nature:
FeeType• Date Paid: Amount:
Building 5/2/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner