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35-227 r,......... 4 . ti wwnaruINe mass save Swigs tYrotrgh oncrgy eMlcitncY PERMIT AUTHORIZATION FORM 1 AP--"/ ato6coni , owner of the property located at: (Owner's Name, printed) C?) �� rfP Lki PLOP-EWE r rut A (Property Street A dress) (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 3141 "(2Z f3 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: ti d9w)(312-94(_&60: 7-A_,e/) '- (--a-O L Participating Contractor Date Rev. 12132011 • Property Address: SZ Lad l i 0 p, i 1- K- r Contractor Name: `- �,1ci C, ) 7�, 1�%�- e Address: 1 I, 3Th \ '\(--"' c-sk-° ■ City, State: -% r" . C K cc-) 6 Phone: - S 6 W . 1--- Property Owner Name: ``C`n O\ c3 v----- Address: s, �-- `_ i ,Q ( .1-- City, State: . -kcCe"NC-C ' Yin . 1,--1, ar0,-kd RU. ,.-t C (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. 0 Contractor signature y e /QAT ) Date q' /.)— i �-� AhT•AD A VIT Horne Improvement Conu-acror Law Supplement to Permit Application Suggested Affidavit for Home Improvement Contractor Pe-grit Application For Office Use Only Name of City I Town Permit No: V"4-(_ � ■ 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 cccupied 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. ZC(5 Type of Work: `y j0 v " Est Cost ().- Address of Work: )q, S 1pFe ( r • Owner's Name: '�i �• G' Date of Permit/ Application: — I hereby certify that: Registration is not required for the following reason(s): Work is excluded by lax Job under S1000.00 Building not owner-occupied Owner pulling own permit )( Other (Specify): (Xd c e k l o k is? Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS 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,errnit as the agent of the owners: Date: 5 -Da/ Contracl stratioi t a OR: Not withstanding the above notice, I hereby apply for a permit as the owner of the above property. Date: Owner: . r+. \ t IIG ....VI/ aiwear. stars VJ irAss.saast-/aaJGILJ 0���--- Department of Industrial Accidents _ Office of Investigations =all== ' � 600 Washington Street ��= •= Boston, MA 02111 we* www noass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plum bers Applicant Information �^ Please Print Legibly Name(Business!Organization/Individual): r - . \c � \1t 1 \e Address:_ 1(>°`i �`i �C± . o�'�k a \ City/State/Ztp: \ f C,.. e - Phone #:(51 /3) ,j 3 6 Are yo employer?Check the appropriate box: Type of project(required): 1. M 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. t 7. 0 Remodeling ship and have no employees These sub-contractors have 8. C] Demolition working for me in any capacity. workers'comp. insurance. 9. Q Building addition [No workers'comp. insurance 5. [] We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3•❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.❑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.a er t 1011 1 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. I-Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: J C3 Policy if or Self-ins. Lic. Expiration Date: ( r DC'1:5-' Job Site Address: -) klc( ( . 1A A . City/State/Zip: k' 'c7 C P v`f' e iNv'' Attach a copy of the workers'co pensatipil cy 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 S1,500.00 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. I do hereby cert fy under the pains and penalties of perjury that the information provided above is true and correct. j Sf , = r Signature: ' -t- Date: r Phone#: Official use only. 1)o not write in this area, to be completed by city or town official City or Town: _ Permit/License# _ Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. (.:ity/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: �_ _ __ __ __.__-- Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: I``-.. -} Not Applicable ❑ Name of License Holder: .) . c x-1 l I E 1 l l O 1 License Number 10-(z- 1.9 Addr s - Expiration Date Signature Telephone u • iu • !r ct• : Not Applicable ❑ Company Name Registration Numbe Address �/ Expiration Date Na (� `1 ()I v 5 Telephone s 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 it. Signed Affidavit Attached Yes 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 faun 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-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing UJ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [q Siding[0] Other Brief Description of Proposed �y NA Work: c�Qe"nCd 1_] c -t CeI(✓/ 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 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR r CONTRACTOR APPLIES FOR BUILDING PERMIT I, 1\� Jf C7 )SC Y ' , as Owner of the subject property hereby authorize t7Y`CAVt ( s- � �� `e � -e C to act on my behalf, in all matters_elative to work authorized by this building permit application. 3 Signature of Owner , Date 1 r-, I, �_�� )(\\d Lk I R� \�� \t ( ,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 penaltiesof perjury. (ki Print Name ,-5)( Q 0(06L) 3 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 % 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 Q DONT KNOW © YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO Q 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 C) NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit tt3\3 uilding Department Curb Cut/Driveway Permit s 212 Main Street Sewer/Septic Availability &gas«sc e tNO`� Room 100 WaterMiell Availability p1�me�.o MA '0 orthampton, MA 01060 Two Sets of Structural Plans evisv\Nortral" phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans 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 sMap Lot Unit ( Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: /-e.-xdt.(Sh \pp.R c rt . Name(Print) 1 Current it Ad s r �� � l Telephone Signature I 2.2 Authorized Argent: 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) �SV\0.1-i 5. Fire Protection U / ,{✓ 6. Total=(1 +2+3+4+5) �� Check Number 37016 OV515 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0406 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413)538-6002 PROPERTY LOCATION 58 LADYSLIPPER LN MAP 35 PARCEL 227 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �� Fee Paid �9 a 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 Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management i ' i•• bla or /°' __?"-a Signa e 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. 58 LADYSLIPPER LN BP-2014-0406 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35-227 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-2014-0406 Project# JS-2014-000695 Est. Cost: $2700.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq. ft.): 32452.20 Owner: ZASHIN LYNN S&AMY P JACOBSON Zoning: Applicant: DONALD PELLETIER AT: 58 LADYSLIPPER LN Applicant Address: Phone: Insurance: 1107 MAIN ST (413) 538-6002 WC HOLYOKEMA01040 ISSUED ON:10/4/2013 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 10/4/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner