37-022 (2) THE COMMONWEALTH OF MASSACHUSETTS
Board of Building Regulations and Standards
* Registration No:
1t' Home Improvement Contractor Registration I rogram
x =i,...! 1 1 Ashburton Place,Room 1301
,E�=jT Boston, MA 02108 Effective Date: ___
Application for Registration as a Home Impiovement Expiration Date:
Contractor or Subcontractor-MGL Chapter 142A, 780 CMR R6
(PLEASE READ BOTH PAGES CAREFULLY)
Date Processed:
Cir I gu\id
1. BUSINESS NAME: �l+ �� l�J‘lP.� c�
Print the name in which the applic t is conducting business (SEE INSTRUCTIONS) //���j
2. Mailing Address: G-7 l ?cv,..4scjci ( tI � ( Lj 1 ) _6___X:569 /
�A 1 /' [ Area Code Telephone Number
3. City J-eVe f e , State: /1 Zip: 0 lJ u
4. Street Address(if different):
(Print street name and number,a P.O.Box is not acceptable for address)City State Zip
5. Applicant type: ? Individual . DBA ? Partnership ? Trust ? Private Corporation ? Public Corporation
? Limited Liability Partnership ? Limited Liability Corporation
Please Check One (See instructions regarding enclosing a city or town registration under DBA or"fictitious name"law-MGL c 110,§5&6)
6. Social Security or Federal ID Numbe ill---1 (see back) 7. Number of Employees 0 --L
(See instructions)
8. Have you registered previously under this law?
If so,under what? Name: Registration No:
9. Individual responsible for Home Improvement Contracts: _ Si-arY1/4._ _LAMA
(Six instructions) (( Last First MI Social Security No.
ra
10. Title of individual responsible for Home Improvement Contcts: vcil'e l let i
11. Does the applicant or responsible individual hold any other construction related state,city,town licenses or registrations? ? Yes ? No
Type of License or registration Issued By License or Expiration Date Name of License Holder
-registration number
[O115 C'\'-v% '1 rv,W Alle, i"7 )9 L 10 /r /O T I�II, S- - riot.
12. List all partners,trustees,officers,directors and major owners(10%or greater of ownership)of an applicant partnership or corporation below.
Use additional paper if necessary. (See instructions below) Check here if you wish to receive an application for additional ID cards for key
persons. ?
Last I First Middle Initial l Title in Applicant Business %Owner Address
l
13. Is the applicant claiming exemption from the registration fee?(See instructions) Y . Yes ? No
14. Registration fee enclosed: $ (see note#1,of instructions) Guaranty Fund fee enclosed: $ 1 Ce),(X) (see note#2,of
instructions)
If necessary,include two separate certified checks or money orders-one marked"Registration Fee";one marked"Guaranty Fund". See
instructions for the fee amounts.Make all certified checks or money orders payable to"Commonwealth of Massachusetts". PERSONAL
OR BUSINESS CHECKS WILL BE ACCEPTED BUT WILL REQUIRE AN ADDITIONAL TEN(10)DAYS TO PROCESS.
rsuant o Ma :.c tusett General Laws Chapter 62C§49A, I certify under the penalties of perjury that 1,
to my I- .t - ,.•'edge belief have filed all state tax returns and paid all state taxes required under law.
w, i .A 6/ /06'
Signature of applicant or applicant's representative Title held with applicant Date
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DEPARTMENT OP BUILDING INSPECTIONS • -- '
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212 Main Street - Municipal Building
Northarript,9n, Mass. 01060
IMO s
woman's COMPENSATION MS TIRA_N Ch A FFID A VII' .
I, L4,d7--- crAtA4 54i-11
•• __•___
(li=sx/permitt=)
Al_i_r_h_z_pr_iwipal p - -sksiden-Gar.:
Ale,vo .--y
6) 7-E-./tivir).)fic&— 1-1-Xt . LD
/ 4 tz1.4-‘4.14 (phone ) 41/3'6.,,e«
(scr=ucity/staiehrip)
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do hereby certify, under the pains and penalties of perjury, l_hi
VI am an employer providing the following, ‘i:orker's compensation coveraie for my .
•
employees working on this job. ,
...
Atg ilidtv,1 iv (,) 7O1-1811 0_006
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(1nsurza=Company) . (Policy Number) (a-piraion Dave)
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( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the corm-actors listed below who have the following worker's comPensznon policies:
(Name of Coiv_:-.1c-Lo:-) (Insurance Coinpa_rryr?oLicy Nam -z ) (F...::plcauon Date)
- .
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(Name of Contractor) ansurancc CompanyiPolic-y Nr) (Ex-pintion Dare) .
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(NZI.Me of Contracto;) (1.D.surance aropau)ipoLey Nambe.r) (Ex-pu-acios Date)
(Name of Contractor) (Lasuran. Comparriffolicy Numbes) - (E.\-pication D )
(ctlacili nettliticced sne if noecet.i.ry to ineitt&irsioniu-ion pertaining to..1.1 occer---canrs) • 2
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( ) I am a sole proprietor and have no one working for me.
( ) I aln..a home owner perforraing all the work myself.
NOTE:21=-4.c be cwzre ti.',:v•inic homeowner:wino<employ pcsenat.to dn m......=reatocc,=_-e-....tr-too c•repair work on t cis...riling of
cot macro thcc 1....-c•-..=its to v.-bac:Et the bocaoo,vocr r4.=oc co the gral.oes appartra=tbo r..-r no(g=e--.1.1.,coo:de-eel to bc
=ployca undc-.the wa-k.cea.occcp=..a:iaa Act(G LI j2....=I(5))..pplics.ciao try a booscosvoc-Ito:lic=ca4 cc porsaii rcz.y evidence the
legaJ rt.=of co.=plorx-under tho Workoe•Coclo.00..alicro.Act_
I under:taut that a.copy or tb.i.•cratcoaccrt oln y bo for-N-..rti.d to tbo D.citruio.ceit of InAm-ria Aceidect&01:Go.of Innaiocio for tito
coverage vcriGe=tioo and Oat Lilt=to secure'coverage teo?...ier sccciota 25A of MOL 152 cua lcd to tho impositiod of cioiall PcadLic'
once.i.e.ing of a fine°Cup to Sl....500.00 and/or iseprinoontoczn()Cup LO OCc yr_t.r Lod civil pcaillici in he form of a Stop Watt Ord cr Lod a
1=0(5100.00 L ezy Lpinst coc.
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction S ervisor: Not Applicable ❑
w\ 1 a
Name of License Holder: '� �.
License Number
'44' COCWOJA\IL \kc 11\\ ir I\ \,4tVt I tAl /1kOQs 4 C57 191.,
Address Expiration Date
1011X 07
Signature Telephone
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LW-6:Z.6- 5o17
5017
9.Registered Home Improvement Contractor:, Not Applicable ❑
Company Name Registration Number
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 > 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 he,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
.. Y
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing n
Or Doors CI
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other
Brief Description of Proposed rs.
Work: f1"--"dZ L ' -4k
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 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/�CON ITRA�CT/OR APPLIES FOR BUILDING PERMIT
• 1, t,(X tw V�V , as Owner of the subject
property
hereby authorize
to act on y behalf, in all m tters relative to work authorized by this building per it ap lication.
• ,anktl/ ✓ b�r q o 6
Signature of Owner • Date
,as @wrier/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
Signature of 0A a iAgent 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 no
Open Space Footage 07
(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 ® DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 a- DON'T KNOW ® YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ® , Date Issued:
C. Do any signs exist on the property? YES 0 NO
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 er ~
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,a ca ion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water) Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
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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
) i f� tires � ZC2 ! !ti'�y
Map Lot Unit
Zone Overlay District
A/1,4 net
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ,,gg
/°vl t A L& )Cr% M!sts', 4.4L+1 "L 47 1 Pe ✓. c .
Name(Print) V/ Current Mailing Address:
• W' V Telephone ! r 3 .. s-
Signature 7 �f
2.2 Authorized Anent: C/Ct)-
-7J=/= 4-`% J7 LA?v) ( j y.S° y&:'k./.jc J }..c
Name(Print) et 1 � �� ���1r Current Mailing Address:
"o '?)- f)e.
Signature e 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 . ' Y6) (b)Estimated Total Cost of
/ 22/ / / Construction from(6)
3. Plumbing.' Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) it"),„ )t/y. Y ej Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
4A4 P BP-2007-0121
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
4., ,
Lot:-020
Permit: Building
Category: SOLAR ELECTRIC SYSTEM BUILDING PERMIT
Permit# BP-2007-0121
Project# JS-2006-1981
Est.Cost: $17744.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: VILLAGE POWER DESIGN 087192
Lot Size(sq.ft.): Owner: LEV MARTA MANGAN&
Zoning: SR Applicant: VILLAGE POWER DESIGN
AT: 600 FLORENCE RD-20 MTN LAUREL PATH
Applicant Address: Phone: Insurance:
72 BAKER RD (877) 765-2784 WC
SHUTESBURYMA01072 ISSUED ON:8/1/2006 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SOLAR ELECTRIC SYS ON 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:
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 8/1/2006 0:00:00 $50.001570
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo