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22D-061 3M ryk- imass PERMIT AUTHORIZATION FORM 1, 'Say k, J<t/I't h t ° C4 A-A. ,owner of the property located at: (Owner's Name, printed) q rl �lUrehGt jGaac o'C._ '/aYe , (Property Street Address) (CitylTown) 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. ads-s--;:g2rature /,Z, 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 r Property Addre$s: (-i J Contractor Name: Address: City, State: WC- Phone: �r� 6 c)t Property Owner Name: Address: T�D F 1pre—w -e,-- '-L)cl City, State: 1 y E'_ \C." 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. Contractor signature Date � �b A}�FAll A`TI' Horne Improvement Contractor Law Supplement to Permit Application Suggested AfFdavit for Nome Improvement Contactor Permit Applicition For Office Use Only Name of City/Towu Permit No: (.1 f t? V\C -tL 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. T of Work: �"'" � ' °- - Est Cost �I Address of Work: T- V*)C e"r '44 Owner's Name: Date of Permit i Application: I hereby certify that: Registration is not required for the following reason(s): Work is excluded by law Job under S 1000.00 Building not owner-occupied Owner pulling own perinit X �Other (Specify): a, Notice is hereby given that: WINTERS PULLEM,THEIR UWN PERVtTT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME LV1PROb'EMEN,7 WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRA-M OR GUARAIN7-Y FUND UNDER MGL C. 142 A. Signed under the penalites of perjury: I hereby apply for a r,:rmit as the agent of the owners: `� Imo' Contras 64stratioi (<St Date: .f� x, _ OR Not withstanding the abo,re notice, I hereby apply for a permit as the owner of the above property: Date: Owner: The Commonwealth of Massachuseds Department of Industrial Accidents Office of Investigadons 600 Washington Street tv Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AppUcant Information Please Frint L e blv Name(Business/Organization/Individual): Address: 11,j-7 City/State/Zip: ' �{ � Iv1c S 0)O Phone.#:_`I 13 - `��-1y(�G� [EI an employer?Check the appropriate box: 4. I am a general contractor and I Type of project(required): a employer with ❑ g loyecs(full and/or part-time).* have hired the sub-contractors b ❑New construction a sole proprietor or partner- listed on the attached shee t. 7- []Remodeling and have no employees These subcontractors have g. n Demolition king for me in any capacity. employees and have workers' 9. Bui addition workers'comp.insurance comp.insurance.t ldmg ired] 5. (� We are a corporation and.its I0.0 Electrical repairs or additions a homeowner doing ail work officers have exercised their I LEJ Pltmabing repairs or additions lf. [No workers'comp_ right of exemption per MGL 12Q Roof repairs rance required.]t c. 152,§1(4),and we have no 13.�]Other - �%S employees.[No workers' comp.insurance required.) *Any applicant thatchecks box#1 nnw also fill out the section below showing tbcir worloas'eonVensation policy in€ammdoo. t Notneawntrs who submit this affidavit indicating they arc don all work and then trite Outside contractors tna:,ct stdsmit a new affidavit indicating such. �4Conhactors that chock this box must attached an additional Awe showing the nante of the tors and stole whaaha or not those panties have envloyem If the stab-coninictcrs have anphoyxs,they must provide th or workers,tamp.policy nwTdw I acct an employer that is providing workers'compensation insurance for sty enhployeet Below is the policy and job site information. _ Insurance Company Name: tt .� r`5� Policy#or Self-ins. Lic #: W UJ C. 3 0 L 3 U-7 Expiration Date_ Job Site Address:-14 10 r(' y^,C ,a c4 CityfState/Zi*?:5,, Y— l 3 fi"Vr_- Attach a copy of the workers'compensation policy declaration page(showing the policy number and explratio�date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 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 tlX violator. Be advised that a copy of this statement may be forwarded to the Office of lnvestitzations of the DIA for insurance coverage verification I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature. Date "J�� 7t facial tare only. Do not write in this area, to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: `- ' \ Not Applicablle�❑ Name of License Holder i Y\ � C l,J \ t l 1 License Number � � � �c� ate-- �--� • ��,\�k-� ��a ��- � �N q � I Expiration Date Signature Telephone 9.RealMeMd 800110 Im01o211111110 CORIMctor: Not Applicable l❑ Company Name Registration Number ' Address Expiration Date Telepho l SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,8 25C(S)) 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 qwfnit. Signed Affidavit Attached Yes....... No...... ❑ 11, - Dome 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. Deftnition 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 buildine 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 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 ® DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® 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 Q DON'T KNOW 0 YES I 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 © 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 Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 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 [O] Decks [Q Siding[aj Other[El Brief Description of Propose0 Work: }E )G� \o f— }e ' C�_ S'I c-e t Alteration of existing bedroom 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 housina, complete the foliowina: 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 as Owner of the subject property i hereby authorize _ �� to act on my behalf, in all matters relative to work authorized by this building permit application. 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 perjury. Print Name Signature of Owner/Agent Date 0"$*Xw4 i City of Northampton Building Department y 212 Main Street Room 100 APR - Z ��} :." " Northampton, MA 01060 TWO� 413-587-1240 Fax 413-587-1272 pk7f APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 proaeKv Address: L4 j TMs section to be MY~by ofNce F\C)C-e Y-( Map Lot twit Zane oved")strict Eks St.Diatrict CS Dk d riot SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: S r-\,froy, Kzkk*-, y-,-r— (Ylvy fv,r-�, tortrc-e-- Name(Print) epnent Matlirg Address: Signature 2.2 Authorized Anent: 1 Name(mot) Current Ma"Address: Signature T 3-F&JMTED CO13TRUCTM COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by it applicant 1. Building (a)Building Permit Fee 2. Efedricai (b)Estimated� ta of 66 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) "x_)b� � �- 5. Fire Protection 6. Total=(1 +2+3+4+5) :?q©d - — Check Number This Section For Oftlal Use Only Building Permit Number: Date Issued: Signature.- Builft of&*kVj Date File#BP-2014-1005 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413)538-6002 PROPERTY LOCATION 47 FLORENCE RD MAP 22D PARCEL 061 001 ZONE URA(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL EXT WALL INSULATION New Construction Non Structural interior renovations f Jr Addition to Existiniz Accessory Structure If r1n Al ILI Building Plans Included: Owner/Statement or License 101876 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Loo'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 —DemWition D y ; /V— 9 /` Sign a e of Building Of icial 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. 47 FLORENCE RD BP-2014-1005 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 22D-061 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-2014-1005 Project# JS-2014-001750 Est.Cost: $3400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq. ft.): 15942.96 Owner: MOCHAK SARAH KELLEHER&KRISTIN L KELLEHER-MOCHAK Zoning: URA(100)/WSP(100)/ Applicant: DONALD PELLETIER AT. 47 FLORENCE RD Applicant Address: Phone: Insurance: 1107 MAIN ST (413) 538-6002 WC HOLYOKEMA01040 ISSUED ON:41412014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL EXT WALL INSULATION - final inspection required 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 4/4/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner