The URL can be used to link to this page

30C-056 (6) ,ef/RrpR mass v PCONTRAC'TOR SiY�t'E'ROO�lttlitCY t�.�?td.3t � PERMIT AUTHORIZATION FORM 1, Robert Greene ,owner of the property located at: (Owner's Name,printed) 113 Clement St 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. X � owner's Signatu 0�1�1 ,s 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: 2&n,Z� Participating Contractor Date 0�+0 FarorotA use-Only Rev. 12132011 City of Northampton Massachusetts c nMPAR2290r OF BUZLDZW J3Z9PZCrZCWS 212 Main Street • Municipal Building northawpton, Mu 01060 Property Address: Contractor Name: & Address: City, State: Phone: Property Owner Name: c7�C Gam``• 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 , , � _ j Lrjprove:neqt Conmictor Law Si,pplc!ncril to Pcrrmii Applic-Iflion A I ii f�r ont fppoei C On aa, ,r Permit A rp anon C)r rr Na;ne of C'i t-, P,-,rrj[ No Note- 142 A, requirr—, dwt the recon.�tpxtioni, altziation,renovation,repair, rnodernizali 0 2 mvmvernent, reniovA or dernolitioa,or the wrivruction of an addition to any pre-enlisting ewner CC bLfflding containing at least one but not more than four dwelling unit(s).or to structures which are 34jaCent to such residence or building' be done by registered contractors,pith certain exccptions,along with other mquimrneru-s, t D pe of W,:)UL_ Est Cost Add-r-css of Work Owrer's Name- Date or Permit i Appiics[.;,)1I T hereb-, ccrtifv dhat- Re-o"ist-rz,,[ion is ncr for 0he following, WorK is excluded by late ot ui--1 dcr Ifs t}.i0 rot —CN,%-ier pulling own ptnnif Nonce is hereby given that: 0'W"IRS PfJLL[.Nc(,TIfR OWN-NPERNUT OR DEALING WI-1-H UNREGIS TERED pv :K 0 OT Fk VE ACCESS CE COY-i'PAC%170P�S FOR APPLICAPLE 1`10,M! - TPCVE.�IEN—t WOP D SS TO 7MTF APPITRATION PROGF-AM of-. F11INF)UNDER NICTIL, C. 142- A. Slagnc.d rsrtapr the penalites of p--njiir.. hereb% apply rot ac,mil as the agent of t:�e ovmcrs: , Re gistratiol Contractor 0R t•,o( 'N �ld�mz t,�C:qbw' notice: I- �1% 2 permit as the owner of the aTx,--'e prf)fxr' La pf' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street UV Boston,MA 02111 www massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _� Please z r inn Le gib Name(Business/Organization/Individual): QTt tj s tj I , i O Address: 1 City/State/Zip: -6 1ta 0 K e- p& Oi®qa Phone.#: ` 13" 5 33- t 26,0 D_ Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 4 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7_ ❑Remodeling slop and have no employees These sub-contractors have $. []Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.$ E]Building addition required.) 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L[]Plumbing repairs or additions elf o workers'co right of exemption per MGL insurance`s I uired. t c. 152 §1(4) and we have no 12.❑Roof repairs i employees.(No workers' 13.[R Other JM S U 18 r3 comp.insurance required.] Any applicant that checks box#1 must also fill out the section below showing their workers'compertsadon policy information. t Homeowners who subrrtit this affidavit indicating they are doing all work and that hire outside contractors moststibirtit a new affidavit indicating such. tContractom that check this box must attached an additional shat showing the name orthe sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees_ Below is the policy and job site information. Insurance Company Name: S L' D NS U ut*,,t ._ Policy#or Self-ins. Lie.M . UA_A)C aJ' d(9'-;5 6 7`7 Expiration Data: o S ljoj Sob Site Address: J itn Q 1/� S-\-City/State/Zip: Attach a copy of the workers' compensation policy 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 irnposibou 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 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. 1 do hereby certify under the pains and ftenauie, of perjury that the information provided above is true and correct Si nature: d Date: _ Phone#: 3 ° 3` - (Coc )- _ Official use only. Do not write in this area, to be compLefedZy city or town official City or Town: Permit/License# 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 8.1 Licensed Constructioonn�Supervis`or. Not Applicable ❑ Name of Ucense Holder: l )©'n .l\ � l I I � \ ! ( f.2—) License Number Add Expiration Date Signature Telephone 8.Regh tared Home hnpraYetnald Contractor; Not Applicable ❑ )—VR ±f e Company Name Registration Number Icc Address ^� Expiration iration Date �� Y Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit must be pleted and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building pe 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 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [C] Siding[p] Other!FJ/ Brief Description of Pro sed ! � i Work: d l�� l`,✓! �{� 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. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS SAAGENT \OR CONTRACTOR APPLIES FOR BUILDING PERMIT 6 as Owner of the subject property hereby authorize r to act on iy� y behalf, in aU matters relatto work authorized by this building permit application. Signature of Owner Date ra IN W � as Owner/Authorized Agent hereby declare that the statements and information on the foregoing tipplication are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. 6 co Print Natne Abmcly &J �- 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 "lo 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 Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T 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 0 DONT KNOW Q YES 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 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 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. t r �f City of Northampton of Building Department ` x 212 Main Street FEB 2 0 2015 Room 100 Northampton, MA 01060 : . ic,Plumbing&Gas Inp 13-587-1240 Fax 413-587-1272 Northampton,AAA 01 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: f This ssuSbn be CORWIsted by olflce a v p'��` `�`� MOP Lot Unit C '�C Zone Overiardt Db11^Ict Elm sc t ktft CIS SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Ovnw of Recall: 'i�D he(-+ G el-,Name(Print) Current Mailing Address: \NAl V a, S ( I- signature 2.2 Authorized Agent Name(Print) Current Mailing Address: Signature Teleowne T Item Estimated Cost(Dollars)to be official Use Only completed by it applicant 1. Building (a)Building Permit Fee 2. EleCt iCal (b)ESOMated Total Cost of Constnftn 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection & Total=0 +2+: +4+5) iCheckNumber This Section For OftM Use Only Date Building Permit Number Issued., Signature: Buffing of gate File#BP-2015-0812 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002 PROPERTY LOCATION 113 CLEMENT ST MAP 30C PARCEL 056 001 ZONE SR(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 ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessoa 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 INFO AMATION 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 De olition D Signat e of uildi g 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. 113 CLEMENT ST BP-2015-0812 GIs#: COMMONWEALTH OF MASSACHUSETTS M -.Block: 30C-056 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: INSULATION BUILDING PERMIT Permit# BP-2015-0812 Project# JS-2015-001576 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq.ft.): 14853.96 Owner. GREENE ROBERT A&PATTY A Zoning: SR(100)/ Applicant: DONALD PELLETIER AT. 113 CLEMENT ST Applicant Address: Phone: Insurance: P O BOX 5020 (413) 538-6002 WC HOLYOKEMA01041 ISSUED ON.•212312015 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 Sip-nature: FeeType: Date Paid: Amount: Building 2/23/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner