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38B-228 (2) �tasrar ITT M MOO pAfR1gPATINIi mass save CONTRACtIOR �� fir' PERMIT AUTHORIZATION FORM t; Martine Gantrel-Ford ,owner of the property located at: (Owner's Name,printed( 61 Fairview Ave. 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. fL a 1, 4 X Owner's Signature J Date r 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 D�f 0 0� For Office the Only Rev.12132011 --- — -- -- - City of Northampton Massachusetts t .,+( ' w . DEPIR22MEBT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, NA 01060 1 ' _ / w Property Address: 6 / ha l C U I UJ d-Ue. Contractor t Name: Y10.�� Address: 1 `Z>1 cy-"w n City, State: IA 6 V 3 ZZ42_ Phone: Property Owner Name: N14.0 e�-�. G r-,+a l Cjj-Q Address: �`C!�i C�l�1.et. kA City, State: k� b V +1 (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 Qqailxs� Date Office of Gonsuuner Affairs and Business R.egultatie�n 10 park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Ron- 150318 Type: ttufidust ExD n: 304=is Tr1l 248926 DOD PEL.L.ETIER DONALD PELLETIER 1107 MAIM ST HOLYOKE. MA 01044 Update Addrae Sad return acrd.Mark raasrnr fr cbsu1jr- -` A fdrem _- R�M.a1 --� � 1.e0 Card SCA t r 2p241W1 - -- --- - --- ___ -- Massachusetts -Defl2nment of Public Safety Roard Of Building Reguiations and Standards Cnestructine Supervisor Speciath- _icense: ! leim -It I, DONALD T 11417 19AN4 UM 611M BL 3y7it 01� yEy i Y� ifY 1• it lit Cor missimner 10109=18 Men" Conjn 5;; pj�,,Cniem viPeTmir Applicc-Ition it Hoill;2 jMprO-,,Cme-:!� Permit Aprij D; Now. 14-1 A, requirts Pair _4.mo(iernizaDC', irprovem,?nf,removal,or demoLuk-m,or ffit Construction of an addition to any pr--C.ls Un,C%nCT OCC111pi'd building contairting at least one but r(t m�D_p structures Which are Xtacftt I _Lhaurourd-vellingtini,(s)-criostiuctu - to quch residence Or building" be d9ne I-,- .-Jstcred contractors.uith ctrtaiu Cxc"'Pton-S-along 9irb other 'e-plin-ments Cost of Work- _64 -1;-1) ------ ("wric-'s Namn Date or Fmmit I her-h" Ccr-fift tffat- nor �Yjj rtd, for Lh, fbilm ins! reasc-(i)- Work is excluded by 13%% -'dine tot Oj%_,jfr__occupied ner r)ullina 0"-.1 PI-111pil Olh.cr (SPC6fi). .Not,,`r is herby gn"'I OkV\-ERS QR DEALENG WI-1-ij UNREGIS 1 7 K DO�IoT F k VF ACCESS C 71 A C T C I R S FOR L?P L I kC_. F L 4 E C.,4 P R f F N p J TC)T4F A P F i T ATIO�-. P R CKiR:��A OP G,( "t) `�D k I CI 1, C, is' nt e owners: I her.!-bN ipply for m 24 Con.'ractnt C)P,- A,% ncjric.., r"r—i! a' t11C owner of Lie abrP.T Pr"f`*r'V'- Care- 0 , I l i e Uoninionwealth of Massachusetts U Alit rvitit Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, NIA 02114-2017 wwip.mass.govldia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Le2iblv Business/Organization Name: 11EJIf_rL_ vr Address:_______I L!3 y_--rt, L K City/State/Zip: '� 0 e-- Ma 01 V q0 L/13 - 53v- +coo tY P _-----``� Phone #: Are you an employer? Check the appropriate box: Business Type(required): 1 .[O I am a employer with 'i employees (full and/ 5. ❑ Retail or part-time).* G- Restaurant/Bar/Eating Establishment 2.❑ 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.) employees working for me in any capacity. (No workers' comp. insurance required) S. ❑ Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152, §I(4), and we have 10-❑ Manufacturing no employees. (No workers' comp. insurance required)* 4.❑ We are a non-profit organization,staffed by volunteers, 1 1 ❑ Health Care with no employees. (No workers' comp. insurance req_) 12-N Other Any applicant that checks box#t must also fill out the section below showing their workers'compensation policy information. "If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and Stich an organization should check box#I. I am an employer that is providing workers'compensation insurance for m_v employees. Below is the police information. Insurance Company Insurer's Address: %360 3U NA flVe- C ai:it a) City/State/Zip: CI G IC {� W i l"i Policy 0 or Self-ins. Lie. #_ �I Lo C> 3 5�7 --- -- – Expiration Date:— 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 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 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. I do hereby certif, under the pains and penalties of per'ur that the information provided above is true and correct. Signature:_-_ 6j all Phone 4: `tl 3' J 0 C-) – -- - Official use only. Do not ivrite in this area, to be completed by city or town official City or Town: Permit/License it Issuing Authority(circle one): ' I. Board of Health 2. Building Department i. City/Town Clerk 4. Licensing Board S. Selectmen's Office b_ Other Contact Person:___ _ Phone#f: trutc mass.got'�di<t -- sEGT10N 8-CONSTRUCTION SERVICES 81 Licensed Construction SURN160r: Not Applicable ❑ Name of License Helder License Number Add Expiration Date Signature Telephone Not Applicable ❑ Company Name Registration Numbef rtes Expiration Date Telephone 9' 60 SECTION 10-WORKERS,couPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)) Workers Compensation Insurance affidavit mu completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buildi%permit Signed Affidavit Attached Yes....... No...... ❑ 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 108.35.1. 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,thlit he/she shall be responsible for A such work performed under the buiiMma 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 F-1 Replacemen t Windows Alteration(s) F-1 Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [En Decks Siding[p] Other r0 Brief De pcliption of Proposed Work:okt 0A Uyn,tau VV-wmlr> �t✓n�l' "L 1 a s VP-1 C 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 twu>*and or addition to existing housing complete the foliowin s� 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 i 1 � 'k o-Q �QA -U as Owner of the subject properly C� hereby authorize �� - to act on my behalf, in all matters relative to work authorized by this building permit a placation. Signature of Owner DMb 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. 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 he filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: 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 0 DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW © YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , 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 0 NO a 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 Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Building Department w 212 Main S"O _. Room 100 '?u wftmpton, MA 01060 4 587-1240 Fax 413-587-1272 3 N nimel- rRUCT,ALTER,REPAIR,RENOVATE OR DEMOUSH A ONE OR TWO FAM&Y DWELUNG SECTION 1-SITE WORMATiON This to be oorMilded by ofte 1.1 P1"ai111'lyl Addnn-. A" wwp zone Oveft D"10 SECTION 2-PROPERTY OWNERSHPIAUTHORIM AGENT zl Owner of Record: _ Nam cwt' S5-- �""4b"'�� hb cry CunwA MolkV Address: Telephone SECTM 3- COWS L Item Estimated Cast(Dollars)to be OPlasd Use Only =roeted by it applicant 1. Building (a)Bung Permit Fee Z EI(XV01 (b)EWWM TOW Cost of C�onshtxiont 6 3. Plumbing BWkVng Permit Fee 4. Me&mvcall(HVAG) 5.Fire Protections �l 6. Tata1=(1 +2+3+4+5) Check Number This Seetlon For Ot'll w Use Building Permit Number: Date Issued: Signahne: Buono ComwesivaIlropeckor of Bins Date File#BP-2016-0578 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002 PROPERTY LOCATION 61 FAIRVIEW AVE MAP 38B PARCEL 228 001 ZONE URB000)/ 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 ATION 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 Demolition Dela Signa 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. 61 FAIRVIEW AVE BP-2016-0578 GIs#: COMMONWEALTH OF MASSACHUSETTS MM:Block: 38B-228 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-2016-0578 Proiect# JS-2016-000964 Est. Cost: $8000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq.ft.): 5532.12 Owner: FORD ANDREW L&MARTINE GANTREL-FORD Zonin : URB(100)/ Applicant: DONALD PELLETIER AT. 61 FAIRVIEW AVE Applicant Address: Phone: Insurance: P O BOX 5020 (413) 538-6002 WC HOLYOKEMA01041 ISSUED ON.1012812015 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 10/28/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner