29-485 (11) AFFADAVIT
Home Improvement Contrractor Law
Supplement to Permit Application
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only Name of City/Town
Permit No: T—�z
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-existimg owner occupied
building containing at least one but not more than four dwelling unit(s),or to s-trucmres which are adjacent
to such residence or building" be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: l��i),Q l�'1c—`� Est Cost III J -
Address of Work:
Ownces Name: 1Q��o -e- i sl--,na ►�
Date of Permit i Application:
I hereby cettffi-that:
Registration is not required for the following reason(s):
Work is excluded by lacy
Job under S 1000.00
Building not owner-occupied
Owner pulling ow-n permit
�_Other (Specify):
Notice is hereby given that:
OWNERS PULLINO THEIR OWN PERty T OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME 12NTROVE-IEN7 WORK DO NOT HAVE ACCESS
TO THE ARBITRATION PROGRAM OR GUA.RA.tv'TY FUND UNDER 1
MGL C. 142 A.
t
Signed under the penalites of perjury:
I hereby apply for a rormit as the agent of the ouners:
Date: r`'y Contr tiot � �3 t
r
OR
Not withstanding the above notice, I hereby apply for a permit as the mNmer of the above property'
Date: (honer:
w
City of Northampton
. f
Massachusetts "» r
Z"ARMAii' OF BMLDZW 2MWJqG7Z0jFS
212 gain street a Mmieipal Bnimim '
Morthaepton, W► 01060 �x
Property Address: J L5q U � 2�
Contractor
Name: 1 @'c
Address:
City, State: tAO C�) i -� U yb
Phone:
Property Owner ,n
Name: T-� MG.r-
Address: �
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 �,^ 1
mass save
PERMIT AUTHORIZATION FORM
I, Alayne Heishman ,owner of the property located at:
(Owner's Name,printed)
584 Burts Pit Rd Florence
(Property Street Address) (co)
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.
X
Owner's Signature
Date
FOR CSG OFFICE USE ONLY
Conservations Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
Clf`CI
Di
For Office Use On IV
Rev. 12132011
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgadons
600 Washington Street
IF Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plumbers
Applicant Information Please .Print Legibly
Name(Business tC)rgani-ration/tndividual): t- u J��t o,,J' -- boA;fi14 (k), e{! e fit ft�
Address: I t O`7 f -1}A t tJ S .
City/State/Zip: ' 0 I `1L Phone-4. 913 - 153` - L,0GJ
L3. 1 an employer?Check the appropriate box:
Type of project(required):
a employer with `� 4. ❑ I am a general contractor and 1 loyees(full and/or part-time). have hired the sub-contractors 6. ❑ New construction
a sole proprietor or partner- listed on the attached sheet 7_ ❑ Remodeling
and have no emisloyees These sub-contractors have g. ❑Demolition
ing for me in any capacity. employees and have workers' 9. Building addition
workers' comp.insurance comp.insurance.t ired) 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
a horneowner doing all work officers have exercised their t 1.[]Plumbing repairs or additions
ri t of exem tion 12.❑Roof repairs
lf. [No workers'comp. p per MGL ance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.91 Other
comp,insurance required.]
Any apphmnt that checks box d i must also fin out the section below showing their workers'ctxtrQatsation policy infOnne im_
t Horreowners who submit this affidavit indicating they are doing all wotic and than hire outside tontrat:tors moist submit a new affidavit indicating such.
'Contractors that check this box must attached an additional stud showing the name or the sub-contractors and state wheitur or not those entities have
employees. if the sub-contractors have ernplayces,they,trust ptmide their workers'comp.policy number.
I airs an employer that is providing workers'compensation insurance for my employees. Below is the policy tend job site
information, ''� ,,
Insurance Company Name: �O-Isx o :1 t.J S U1LCLVJ C,, Co
Policy#or Self-ins. Lie 3 O L--3 0 Expiration Da-=-
Job Site Address:`. 1J(5� �t ]� I{� City/StatelZin:i
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirati4 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 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 5250.00 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 insurrarras vera a verification. _
I do hereby certi
fy under the pains andpenalties ofperjury that the information provided above is true and correct.
Sinnature: -� - Date: T) l4
'hone#: �fi3 533- uc. —
7jilcial only. Do no t write in this area, to be completed by city or town officiaL
n: Permit/Neense#
Issuing Authority(circle one):
L Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
5.Other
Contact person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9.RReec iistt>ered Home Improvement Contractor: _ Not Applicable ❑
Company Name
I
Registration Number
Ad res�sR/►� Expiration Date
S-��'h u ► '� �i W 'J ' Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit mu be completed and submitted with this application. Failure to provide this affidavit will resuit
in the denial of the issuance of the building4ap6rmit.
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 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-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[pj Other[Orl_�
Brief Description of Proposed �� n
Work:
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 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.
1. 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 ,.
hereby authorize �'�'
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, -,Z:)Zs n��d L� ����� � 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.
v
Print Name
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 tilled 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
Arkin
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW O YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
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 O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO O
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 O
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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
T 7
1 i City of Northampton (Status of Permit-
Building Department Curb CutfDnveway Permit
MAY 222014 M 212 Main Street Seww[Septic Availability _ I(
Room 100 WaterNVell Availability 1
Electric. Plumbing&Gas tion Orthampton, MA 01060 Two Sets of Structural Plans
Inspec
Northampton, MA e 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
/p Map Lot Unit-
��L U
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Signature t
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 mit applicant
1. Buiiding (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of b' -'
Constnlction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued.
Signature:
Building CommissionerAnspector of BcWdrn9s Date
File#BP-2014-1230
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413)538-6002
PROPERTY LOCATION 584 BURTS PIT RD
MAP 29 PARCEL 485 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid _
Buildin 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOIjDQA-TION PRESENTED:
.o 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
Dem De
Signature of Building Off al 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.
584 BURTS PIT RD BP-2014-1230
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 29-485 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catego!j: INSULATION BUILDING PERMIT
Permit# BP-2014-1230
Project# JS-2014-002071
Est. Cost: $1300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq.ft.): 30796.92 Owner: NEISHMAR ALAYNE
Zoning: Applicant: DONALD PELLETIER
AT. 584 BURTS PIT RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538-6002 WC
HOLYOKEMA01040 ISSUED ON.512712014 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:
FeeTvpe: Date Paid: Amount:
Building 5/27/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner