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35-220 (9) 7 Xle f1je,a Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 150319 Type: IntlMdual 3r2412016 Tr4 248925 DONALD PELLETIER DONALD PELLETIER 1107 MAIN ST HOLYOKE, MA 01040 Update Address and return cord.Mark reason for change. --'-I Em joyawat T Lost Card Address Renewal p SCR 1 0 2M-05;7 I CSSL-101676 0014ALD W PELJETU* 1187 MAIN STREET HOLVOKE MA 61NO �X- 10108/2014 05/08/2014 THU B: 23 FAR 4135386010 Remillard Ins. Agency IAvv..r vv. PELUNS-01 DMELLO '`#�C7° °' CERTIFICATE OF LIABILITY INSURANCE a►TEIeeIroDIrYYYI 6t8l2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE RMING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: N the certificate holder Is an ADDITIONAL.INSURED,the policy(les)must be endorsed. N SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an erAorsement. A statement on this certificate does not confer rights to the certificate hokNr In Heu of such s. PRODUCER CMACT FleldEddy Insurance 413 538-7862 310 ,�,; 413 38 5 -6010- 79 Lyman Street _ Z - -I� South Hadley,MA 01075 -- - INSURERS)AFPOROM COVERAGE _ _ NAIC.M- nMRER A;Citizens insurance Co of America 31534 04URED INwRETr a:Hanover Insurance Comp"----- --- 22292 Pelletier insulation INswm c,WESCO Insurance Co 25011 --- Donald 8 Patty dba -- _ --- — -- 1107 Main St INiuRER RSR D: -- Holyoke,MA 01040 MRIURER E: IKWMM Fs COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VMICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. i POLICY SIFF TR TYPE OF NiEURANCE JBIM vim POLICY NWeER 1101611MINYM T9 GENERAL LIABILITY EACX OCCURRENCE _ i 1,000, A X coMneRciAL GENERAL L"a.ITY Z13NOU2391 51512014 51512015 MMMISES it, - S 100, CLAIMSOADE 1K OCCUR MEO EXP(Any av prurt) i Y 6, PERSONAL 6 ACV n/.R)RY_ S 11000, GENERALAGGREQATE $ 2,000, GEML AGGREGATE LIMIT APPLES PER: PRODilCTS-COMPIOP AGG S 2,000, X POLICY 0 My LAX: -'----..._ : _.A..... AUTOkKNaS E LIABILITY commDswAEERF- 6 11000, B — ANYAUTO AM9160781 711012013 711012014 BODILYWURY(PerPaKan) t AL�'0�D X AUTOS BODILY VUURY(Per a dawn) a T� NON-OVOED j-------- HIRED AUTOS AUTOS I 0= ,_.__._..._ .. t X U#MMUA U" X OCCUR EACH OCCURRENCE i 1,000, B EXCESS LIAt rHN9221421 _-_------------... CLA�.�E 7/22/2013 7122/2014 AGGREGATE I DE X T T 10000 a ---1,000, WORKERS COMPENaATOR NC STATU- X OTH. AND EMPLOYERS'LIABILITY _— C ANY PROPMETORIPAWNERIEXECU M YIN _____3063074 7/26/2013 M512014 E.L.EACH ACCIWNT_ $ 600, DFF"RftEMBER EXCLUOI!D? N f A (Manea"III NH) EL.DISEASE-EA EMPLOYE i1__._._____ 500, 'n$a dssaiba,ndar ---"-- RMIT T tub. E L.DISEASE•POLICY L a9T S 600,0 DESCRIPTION OF OPERATIONS r LOCATIONS I VENK:LMS(MtSO ACORD M.AddOW al Rfta1rs Sdnaua,a more apace Is rsgwna} Donald Pelletier,Solo Proprietor,has elected coverage under the workers compensation policy. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Donald Pelletier THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1107 Main SVee ACCORDANCE WITH THE POLICY PROVISIONS. Holyoke,MA 01040 AUTHORIZED REPREMTAWE 01988-2010 ACORD CORPORATION. AN r10 t reserved. ACORD 26(201 Oft) The ACORD name and logo are registered marks of ACORD A-FF-AD A VIT Horne Improvement Contractor Law Supplement to Permit Application Suggested Affidavit for Home Improvement Contractor Permit Application For Ogee Use Only Name of City I"Town Permit No: tC�e CL 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.xsting 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_ Type of Work: "`.1. Y"�j()kat 1N'` •-- Est Cost �I C7 Address of Work: / / '' Owner's Name: Date of Permit i Application: I hereby certify that: Registration is not re;aired for the follo%ing reason(s): Work is excluded by law Job under S 1000.00 Building not owner-occupied Owner pulling o�im permit e, Other (Specif ): _l Notice is hereby given that: O«INTERS PULLINC,THEIR OWN PEP-%TT OR DEAUNIG WTTH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME rviPROVE%,CEIvT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANMY FUND UNDER MGL C. 142 A. Signed under the penalites of perjury: I hereby apply for a vomit as the agent of the o��,ners: - I �� 1 - Date: � Contractor: Registration OR Not withstanding the above notice, I hereby apple for a permit as the OV,ner of the above property: Date: Otir ner: n .ti s¢ w mass save CONRTICIPATING TRACTOR comms throe row eticioncy PERMIT AUTHORIZATION FORM I, Kerry Meehan ,owner of the property located at: (owner's Name,printed) 30 Ladyslipper Ln Florence (Property Street Address) (City) . 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. g! , g"�74 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 Ol ParO fiea Use Only Rev. 12132011 City of Northampton Massachusetts DIEPA92NOWr OF II.aI IIiSPACI`IOINS , 212 !main street • bkwAcipal Building HarthwVbm, MA 01050 Property Address: 3 c� 1-c�C�U A r, r Z P1 Contractor Name: A ) �e Cite Address: 0.l Y— S—f City, stater Phone: Property Owner r Name: Address: ^ City, State: (contractor) attest and affirm that the building 1 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 19 The Commonwealth ofRassuchusetts Department ofrndUStrid,4Cd&nts Ofce of Investigations 600 Washington Street Boston,MA 02111 www.mass-goVdia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectriciaxts/Pltumbers APPUcaut Informs on Piease Print rib ly t r� , NaMe(Business/organiz>�on/tndivec3ual)_ t'_! t+ t2 A S v 0 �0 k. t,C c �U. �1 Address: �-i H City/StatelZip: 4t 4q �Ktr " S 0►L*, Phone#:_y Are you an employer?Check the appropriate box. Type of project(required): 1.[J I am a employer with 4 4. Q I am a general contractor and 1 6. Q New construction employees(M and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no ermloyem 'These sub-contractors have g. Q Demolition working for me in any capacity. employees and have workers' 7 9. Q Building addition (No workers'comp-insurance coup.insi ance.- required-] 5. Q We are a corporation and its I0.0 Ekxlrical repairs or additions 3_❑ I am a homeowner doing all work officers have exercised their I LE)Phmnsing repairs or additions myself; [No workers'comp. - right of exemption per MGL 12.0 Roof repairs 1 insurance required]t c. 152,§1(4),and we have no 13.@ Other -S employees.[No workers' comp.insurance required.] 'Any applicant that checks box tut enure also NOW dw section below snowing ttsar woritawconVatuation policy infornation. t Homeowners who submit this atfWavit indicating they are titer an work ant!�hire O*We coalclots rottatsaianit a near airre3avit inditahag such. tContnrcwrs that crrech this box must ansched art a"doaat alud*oain$the name of dw i and state Whetttrr a 00 thou endues have mMAp yem Ir due sub-cauracmrs have wvbyrxs.they must provide their w a t n'comp-t orcy nu nber 1 am an employer that is providing workers'toruptrnsetian insurance for ary eeraptoyees Belirw is the policy and job site information. Insurance Company Name: �'` C'E i.1`j a;tI-{CV ){. F Ci Policy#or Self-ins.Ur fi• �'iAJ�-- _-�0 L-3 0-7� Expiration Dar= 7/a5 / ct y Sob Site Address:_ S6 h . CityPSratc/Zip:s �' Q( � �C �L '(� Attach a copy of the workers'compensation policy declaration page(showing the policy number and eatpiratio�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$1,500.00 and/or one-year'imprisonment, as well as civil penalties in the form of 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 Investiea6ons of the DIA for insurance coverage vexific-ag I do hereby certijy under the pains and penndties of peh jury that the information provided above is true and correrL Signature � 7��;1✓+c '�-- Date: r 7 �hOIICi ; "I1 53)-1:.'o1. •� 70j7daluse nly. Do not write 1n this area, to be comp ed y city or town offtciat n: Permit/Ucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Constructiio-;nn Su„pervisorw: C', ,r 1 Not Applicable ❑ Name of License Holder:. ` X�� ` �}. \ \` �`� \ License Number Address Expiration Date Signature Telephone r. Not Applicable ❑ �� alit c T � e� \ t� �>) � °? Company Name Registration Number A s Expiration Date Telephone C;lf 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 buildin rmit. 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 Aiteradon(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [EM Decks [Q Siding[p] Other[ Brief Description of Proposed Work: .� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa.If Now house and or addition to existing housing, complete the follow-Ina: 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 party hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date l ?r(1_ (� � � "� 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,, Pri me ' (,j y 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 ® DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON T KNOW ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , 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 0 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 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. K, Depotrtwum only _ ,City of Northampton P Building Department .�' JUN 2 '_ 4 212 Main Street ; ; r E_ ___ Room 100 Electric r � ,,, IrsoectioN rthampton, MA 01060 Two Sw F` 587-1240 Fax 413-587-1272 Ptot S --� APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This asct on to be campief:ed by office Map Lot Unit n zone ovetiay ctct Iran SL Oistri« Ce Dlstria SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: �--V-) Name(Print) Current Mailing Address: Telephone / 2.2 Authorized Aa_ent: t oYVN(k fie$ v, 'b yam!`G• � N (Print) ^ Current Marling Address: Signature Telephone SECT-ION s-ESTIMATED TRWTV"costs Item Estimated Cast(Dollars)to be Official Use Only comPleted by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Constnictlort from 6 SC�C7 3. Plumbing Building Permit Fee 4 GO 5.Fire Protection'nS0\d "A-- 7-\ -Ic-V 6. Total=(1 +2+3+4+5) Check Number This Section For OfWal Use Only Building Permit Number: Date Issued: Signature: Budding Cwwdssic n nsper„Ior of WIdings pate File#BP-2014-1398 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413)538-6002 PROPERTY LOCATION 30 LADYSLIPPER LN MAP 35 PARCEL 220 001 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 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 INF RMATION 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 Demolition 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. 30 LADYSLIPPER LN BP-2014-1398 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 -220 CITY OF NORTHAMPTON Lot:-00 L PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2014-1398 Project# JS-2014-002368 Est.Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq. ft.): 40902.84 Owner: MEEHAN KERRY F&DONNA L Zoning: Applicant: DONALD PELLETIER AT. 30 LADYSLIPPER LN Applicant Address: Phone: Insurance: 1107 MAIN ST (413) 538-6002 WC HOLYOKEMA01040 ISSUED ON.612712014 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 6/27/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner