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43-137 rn � i�� R a � ,. ,e-. , fg.. �° a ..s�`,r ... .,... ,�,: .. r" '� � e Y �� _ . �� .. mass save vairna>n►m�e CONfRAMIll PERMIT AUTHORIZATION FORM I, William Tuman ,owner of the property located at: (Owner's Name,printed) 61 Longfellow Dr. Northampton (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 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: I Participating Contractor Date awl IN For Office Use Only Rev.12132011 Sii,pplcmen', tv Pcnrlir Appliartion A.Midn."'it for Hornt- hinproverneii,Comma Per-mit Arrliz-:Iti011 N, ;rlc of C i, Tolvll Note.- 142 A, requires LhAt Lite recorLitv-lctl:)a, 1knation, renovation,repair, moderni,-bc-Lk. improvement,removal,or demolition,or the cousinction of an addition to any pre-elastin.,,owner Oc-Cl-Tied building containing at least one but not more than four divelling unit(s).or to structures Which are adjacent to such residence or building" be done by registered contractors,with certain exceptions,along witb other require rnews. N—,,<of Work.- ",ass Est Cost Addicss of Work-: —�e-Vs Lkj Owner's D*,ite of Permit i Application: V6 1 hercb,, ccrtifv that is f3c, T!Cj!—e for t follo%im!renscnW� Work is excludes by law. ',3b ur-..dcr 5 1 Nif),o'0 cot o1%n-rxCupied 0-w7er pullira F�nrlit Other (Spcclf�). Notice is herby given tbat'. OWNERS KILING THEHR ClViNNPERNUT OR DEALING W11-H UNREGISTERED CON, —iP-AC-I-0PS FOR APPLICA,01 L'n- HOME CMPIRC VE MEN 17 WORK Do NOT HAVE ACCESS TO P A R F 111-P-A-FION M GUARA , ' FU.",F)UNDER NIGL C. 142 A. Sip,-:i the perwlites of P.-,dljr, I hereb,, apply for a cralit as the qcolcnt of Che owners: C, !..late, OR: tile'IL, F,wrmit of thc owner of the aNuve propertv- Date: City of Northampton Massachusetts 4 s n�aR2mKNr Or B"LnDrIFG ZNSPJDcrzosrs 212 thin Street • NbDicipal Building Northampton, WK 01060 Property Address: LPSOc�'Q l O lO Contnwor Name: ^-)0- ' d 0i Address: A k o-) �� r) t City, State: r-A6 10 4Q Vim^^ , O ICHb Phone: Property Owner Name: l j A\ Address: City, State: I, L rMkdt tJ 'C)-«Va I IP 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 pn-)� Date The Commonwealth of Massachusetts Department of Industrial Accidents Office of-Investigations 600 Washington Street Boston,MA #2111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lz ibi 1, Name(Business/Organization/Individual): ,P& fJ 164- 104 Address: It 01 1Ft n) )fi. City/State/Zip: Li 0 K �a �ii3`�o Phone.#: Arc you an employer?Check the appropriate box: Type of project(required): 1.10 1 am a employer with -1 4. ❑ I am a general contractor and 1 have hired the sub-contractors b_ ❑New construction employees(full,and/or part-time).* . 2_❑ I am a sole proprietor or partner- Iisted on the attached sheet 7_ ❑Remodeling ship nd have no employees These sub-contractors have P t $. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.# 9. E]Building addition required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required_)t c. 152,§1(4),and we have no 13.�Other employees.fNo workers' comp,insurance required.] 'Any applicant that checks box#1 must also fill out the section below slowing their workers'compensation policy information_ t Hornem"ers who submit this affidavit indicating they are doing all work and theft hire outside conalictors must a new affidavit indicating such. tContnctors that check this box mutt attached an additional shat stowing the name of the sub-contractors and state whatha 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. ,,J 1 Insurance Company Name: K e S C 0 ITNS U"Alt R._ Policy At or Self-ins. Lic.#: C'30(92 0_7 L4 Exviration Date: -11.2s /coo/J Job Site Address: City/State/Zip: V�"expiration j Attach a copy of the workers' compensation policy det:Iaration page(showing the policy numbte). 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$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 Investigations of the DIA for insurance coverage verification I do hereby cert� nder the pains and naMes of perjury that the information provided above is true and correct Sl_ gnature: Date: — n '- Phone#,_ ` 3 5 3g- (000-4- _ Fonly. Do not write in this area, to be completed y city or town officiaL n: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction-Supervisor: - Not Applicable ❑ Name of Uoerse Holder: y Y�+��` oj kL \ A t 0 I�` � License Number Add Expiration Date 6J ( � Signature Telephone 9.Reahkind HOMO 111112MM2211A COK&ACIRE Not Applicable ❑ Company Name Registration Number Address Expiration Date �1 VD V Telephone ll�t 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 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 Accessory Bldg. ❑ Demolition ❑ New Signs [C3] Decks [0 Siding[p] Other[ Brief Descx,ipption of P,rQposed t p� _(, p Work:_n Wk)o� Cl."1 u� �l C6 i tG i l yQa C, t C asA (2; Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ea.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 CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize d) �cLvd to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner --� Date ('J '3)SZ_wPA i Ll 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 Naamme-_ ^'rO 1�. 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 Q DONT KNOW Q YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO () DONT KNOW a YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO o DONT KNOW O YES Q 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 ® 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 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 Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton rrll �, �1) ( Building [)apartment 212 Main Street F� 2 0 2015 Room 100 ampton, MA 01060 EteCttic,Piumbing&t3 � 587-1240 Fax 413-587-1272 Northampt on, . APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOUSH A ONE OR TWO FAMLY DWELUNG SECTION I-SITE INFORMATION 1 A Property Address: This ncftn to be cam id by OMM -- � �\��i � Map Lot Unit Zone 4vo ft EIa St Obb*t CB WGUict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Cumeo Address: - l elephone 2.2 Authorized Awnt: mercy.\ct w (Print) Currerrt Mailing Addms: �4 606 Signature Telephone SECTION 3-ESTIMA=QQWM=I0N COSTS Item Estimated Cost(Dollars)to be official Use Only completed by it applicant 1. Building (a)Building Permit Fee 2. EleariCal (b)Estimated Total Cost of Construction Pram 6 3. Plumbing Btdtdng Permit Fee 4. Mechanical(HVAC) �C t a -✓- 5.Fire Protection 6. Total=0 +2+13+4+5} Check Number This Section For Oflida!Use Onty Building rmit Number. Date '� Issued. Signature: Bu'kiing Cormrtisaionafinspector of Buildings Date File#BP-2015-0811 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002 PROPERTY LOCATION 61 LONGFELLOW DR MAP 43 PARCEL 137 001 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 Tyneof 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 INFOR�SATION PRESENTED: pproved 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 emolition Delay atu e o ildi ffic' 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. 61 LONGFELLOW DR BP-2015-0811 GIs#: COMMONWEALTH OF MASSACHUSETTS MapBlock:43 - 137 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-2015-0811 Project# JS-2015-001575 Est. Cost: $3700.00 Fee:$55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sa.ft.): 42209.64 Owner: TUMAN E WILLIAM&LINDA J Zonin Applicant: DONALD PELLETIER AT. 61 LONGFELLOW DR Applicant Address: Phone: Insurance: P O BOX 5020 (41 3) 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 Occupant Signature: FeeTvpe• 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 NEW