The URL can be used to link to this page

29-461 (9) cssror A MOOO mass save COUTRAC11IR PERMIT AUTHORIZATION FORM I, James Lacaprucia ,owner of the property located at: (Owner's Name.printed) SS Crestview Dr 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 e Own signature / 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: Participating Contractor Date C7i For office Use Only Rev.12132011'�_�__Y____�___ Pe-'re Improvement Contractor U"7 Si;VVlc-ncnt to Permit Application St'49rsfef! Arfi(Livii fkrr ffkym,,! fmpmc,ernenf Conj-jc-tor Pcr-rnit Ajp1Jc--31;')n F,r cit" !T")-u P-rnl Note: I42 A, rrquirts that the" recoms"(:.,ioa,alteration,renovation,rcp r, modlrjj`ratiC[J, :cIT<%-n-1;013 improvement, removal,or demolition,or the construction of an addition to any pre-C.(Isting owner occupied building conWning at kX'St One but not move thaa 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. At -[}-pe of Wort". Est Cosa� ---71 7— Address of Work- Owner's Name.- Date of Permit i AppiicJtl 01" I hercbN certift that Rcgistxtrion rict r. , tired (,3r folloving reawn(i) Work is e.KcW&d b-.- la%k job under S 10WA Building tot ov,ner-occupied ______----Owner pulling own permit kj --X�---Other Notice is hereby gi%en that'. okv\,rERS FULLING Tl Ia OWNpE&Mff OR UEALDIG Wrl-ij uNREGTSTE�-D CO-t- ,,()T fLkvr ACCESS -kCT0RjS roc APPLICABLE WINE BOROVEMEN,I WORK DO - TO-Pry RF IT-P ATI(R" PP,0GRA M OP.GUXP-A-N n' FM Nff)UNDER NfGL (7 142 A. �igned sander the pen2litcs Of Perilir, I hereby apply for 3 crMit 2S the agent of Che o%vners: r)wc- Contractor OR 1:of withstx-idinz the abl)%e notice, pippi% �r 0 the a Perl- fv-rmit a-� the owner f PT) Date. !,xr City of Northampton Massachusottar{rc re�►aas MIT or rwzrtlzw xMWPxCrzWS 212 lain Stmt . Mmicipal Boil3inq "artAamptoe, M► 01060 Property Address: `a � C v Contractor ' Name: Address: City, State: Phone: Property Owner Name: ��G`t`�f �- .1�✓�(„)C.l c-1 Address:. City, state: e-rO . I, ,_,pfya ll w f-1 I b-4z c (contractor) atlt and affirm that the budding I intend to insulate does not have any open air(knob and tune)wiring in the spaces to be insulated and that I have Provided the Property owner with a copy of this affidavit. Contractor signature LWAR� Date The CommonweaUh of Massachuseas Dqw tent of Industrial Aeddents Office of 1nVCWg4dVnS id 600 Washington Street Boston,M.4 02111 www.mass gowldia Workers' Compensation Insurance Afffdavft: Builders/Contractors/Electricians/Ptumbers Applicant Information ��LL Please Print Ie ibl Name(Bws irtesal�Orpaeizatioerllrtdividual): 2Tt 0. t 4 n3 Address: l +,"7 !✓��}. rJfi. _ _ _ city/state/zip: 1-6 Iw 4 K e- poL 010`{0 Ph©,e#: q,3 /''co D- Are you an employer?Check the appropriate box: Type of proje d(required): I.'9 1 am a employer with, 4 4- ❑ 1 am a general contractor and I employees(bill and/or part time).• have hired the sub-co fors 6. ❑New construction 2.❑ I am a sole propriexor or paMm- listed on the attached sheet. 7. ❑Remodeling ship and have no employees TI>ese sub-cer:stractnrs haves 8. ❑Dmaotition working for M in my capacity. OW1opm teed have workers' [No wodcc s'comp.insure= camp. .t []Building addition required..] 5. ❑ We are;a cmporation and its 10-❑ElccUkal repairs or additions 3.❑ I aam a homeowner doing all work of iicets have exercised their t 1.0 Phmtb*g repairs or additions myself [No worl=s'comp. right of exemption per MGL 12.0 Roof repairs insuraance ]t c. 152,j 1(4),and we have no I3.®Othe:r STNS O+�J�ors employees.[No workers' insu ance required ;Any-Any AppJlc==,that check boa 91 roust am fig oa do sac*o bean,showltta eldr worbM'caanVwWAiae policy k6m atim. wbo x*a*this dfih-h iaditap>aa they are doing al!tuarlt and tYeo hire satside crosactars raoa sabmit a sear sifrdavit indiartinst such. tCoat,Actors dot ohm*this ban nu*o- I addldmel god s dwmmw ardts mbo s rim mead area whodw or mat dwse esdtia bare employees. If Mto are arpiayeex,(bay w and pmvide their +narkaes'camp,powq awnI I as:an employer 1*M prvvhffmg worikem'compatsolm bsaanaatee for cry employee( Before is tke p'olic3'and joh sire iafarmatlon. Insurance Company Name: e se O as u AaAtA_ Policy#or Self-ins. Lie. t,�(A)Co 306-5 0-7 kt x�irat;an 1 ? 61 aoi Job Site Address:— S S C f es-4ua 8,Z f, Ctty/$tats/I,gy: I lz� rie 0/t C- *(.��'�J�- Attach a copy of the waiters'compensation polity deelaratisa page(showlag the policy number and expiration date). Failure to socum coverage as required ender St don 25A of MGL c. 152 can kad to tbt:impoiital of aiminal pmahies of a fine up to S 1,500.00 anNorr 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 Investirtations of tltc PIA feet ias rtacc oovoratte ndagia l do hereby certrA nder the psins M d ANN eparjruy 1h4d the lnfsr w,adM provided shorn is tree and covert. Signature: &LA Datc: 5-7 Ph LBnard e only. o not write lit is area, to a conrP y cdy or Lower vp7ciaL wn. Permit/lAcemte# thority(circle one): Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector rson: Phone#: SEC71ON 8•CONSTRUCTION SERVICES 8.1 ucensed Cons uedon SuaKVianr Not Applicable ❑ License Number `� -�• �� kzs -q.- -t-6 Address —� r Expiration Die SSE Signature Telephone _ Not Applicable ❑ r ---ts-b��L9 ComPwrtn Nume Registration Nurntler � uc-,� !�l % - -�—�6— I 1� cels_s �; N Expiration Date it .l� �J��- _/'� Telephone 'j SECTION 10-WORKERS'COWENSATION INSURANCE AFFIDAVIT(M.G.L.c.M 26C(6)) Workers Compensation Insurance affidavit must be plated and submitted with this application.Failure to provide this affidavit wig result in the denial of the issuance of the budding Signed Affidavit Attached Yes.... No...... ❑ The current exemption for"homeowners"was extended to include Owner-occuaead DwdSoofone(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 oetraon who eo*Arwcts mare than one borne in a two-year Period sball not be considered a bomoowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.that 6el*e shall be mpom0k for ail a ich work Perforaedd wader the building Permit. As acting Cowttr'dke SwPervisor 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 Dearth)of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for you under this permit. 7'he 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 acwlicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[L7] Other p Brief s� Work:Description Y`Pro,pqV'-/%h t_ A rlof T`J i ' �LJ�j"l�� -�1 co to&S Kee-4 S .d Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet LRa.If New house and or addition to existino housing, gomodete the followlna: 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 stones? 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 Im Q 4� as Owner of the subject property -r hereby authorize d (q f E to act on my behalf, in all matters relative to work authoriz y this building permit application. V��e__, 1 Signature of Owner Date v I , 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.. LIJ e.0 PriL��t Nm �.-- Signature of Owner/Agent Date Section 4. ZONING Alt 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 a 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 0 DONT KNOW 0 YES 0 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 Q 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 conshuction acW4 disturb(gearing,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. City of Northampton Building Department tea., 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 plogw- APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION This seciex+to be rarrtpiel9stl by office 1.1 Map Lot lit Zone 0ve1"lx*vw Elm St. - CS Mbi* SECTION 2-PROPERTY OV049MWIAUTHORUW AGENT A 2.1 of Record: �� CceSiL k LLD� . Na (Print) C�adwV Add�,�� Teiepn«ie 2.2 AutltarizW Agent: U � �� D� - r (Print) Current Mailing Address: '5�9 , D fl � -';:�7.,%C�z - Signature Telephone SECTION 3-ESTIMATED 99111ML&M COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Elec tlical (b)Estimated Total Cost Conftdjon frog 6 3. Plumbing Building Permit Fee 4. Mechanical(WAC) 5.Fire Protection rk 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Building ermit Number. Date g Issued: Signature: Bu +g CwwftaiwwArapkW of Builfts Date File#BP-2015-1328 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002 PROPERTY LOCATION 55 CRESTVIEW DR MAP 29 PARCEL 461 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 4 —'- 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 INFO ATION PRESENTED: _ ppprroved 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 li ' Delay Signature of Buildi fficial 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. 55 CRESTVIEW DR BP-2015-1328 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-461 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categog: INSULATION BUILDING PERMIT Permit# BP-2015-1328 Project# JS-2015-002423 Est. Cost: $3200.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sg. ft.): 10018.80 Owner: LACAPRUCIA JAMES M&ELIZABETH Zoning: Applicant: DONALD PELLETIER AT. 55 CRESTVIEW DR Applicant Address: Phone: Insurance: P O BOX 5020 (413) 538-6002 WC HOLYOKEMA01041 ISSUED ON.611912015 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 Sienature: FeeTyne: Date Paid: Amount: Building 6/19/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner