35-302 (9) 80 WOODLAND DR BP-2016-1304
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-302 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-2016-1304
Proiect# JS-2016-002246
Est. Cost:$4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 197762.40 Owner: HALLSTEIN DENICE
zoning: Applicant: DONALD PELLETIER
AT. 80 WOODLAND DR
Applicant Address: Phone: Insurance:
P 0 BOX 5020 (413) 538-6002 WC
HOLYOKEMA01041 ISSUED ON.511012016 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 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:
Cas: 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 Siviature:
FeeType: Date Paid: Amount:
Building 5/10/2016 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2016-1304
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE P 0 BOX 5020 HOLYOKE01041 (413)538-6002
PROPERTY LOCATION 80 WOODLAND DR
MAP 35 PARCEL 302 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid #-7n
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildina Plans included:
Owner/Statement or License 101876
3 sets of Plans 1/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Signa ure 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.
t
~arsvi Department
= 11_/�(� 7 77
Main Street y .
Room 100
MAY 9 N mpton, MA 01060 M
phone 41 58 -1240 Fuc 413-587!-1272
DEPT OF BUILDING INSPECTIONS
NCRTHAMPTON M
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE iFiFORMATIDai
1.1 l�tll TMS do!� by dito
g p map Lat UnIt
-Q am SL abbkt cat wstriat
SECTION 2-PROPERTY OWNERSI*FVAUTHOPdZED AGENT
2.1 Owner of Racmd:
Mame(Print) Cum t Meiling Address:
it xTeieptwne
Name(Print) a Current Ma&p Address. �� 1
5�C ('1 �� W l y S '11 S 6
Signatiye T"Vhone
SECTION 3-9N=
Item Estimated Coat(Doffs)t4 be Offidal Use Only
SW-
I. Building -1�vi 5"_kJtr� l`� Y`--'', (a)Bung Permit Fee
2_ EhXtCai (b)Eft"TOW Cost Of
c«, «,h@s
3. Plumbing RtMdlrg Perna Fee
4. Medianical(HVAC)
5.Fire Protection
B_ Total=(1 +2+3+4+5) Check Number
This Seedw For OlfA"Use Only
Building Permit Number: Date
n9 Issued:
Signature.
BkAdinp d&Adinps Date
i
i
SECTION 5-DESCRIPTION OF PROPOSED WORD 10140 All Op,��,►
Now House Addition ❑ Repiacernent Windows Aitera"sj ❑ Roofing F-1Or Doors',
'J
Accessory Bldg. ❑ Demolition ❑ New Sigros [[A Decks [[] Siding[pl Other[or-
--Brief Description of Pr sed � �� t l
Work: P
Alteration of existing bedroom Yes No Addi g new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
bat.
a. Use of building: One Family Two Family^� Other
b. Number of rooms in each family unit: Numbetr 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
i
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i
i. Is construction within 100 It,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 7s-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING
as Owner of the
property subject
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application,
ure of Owner Date
1, � C`! � ve
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.
0 .
Print Name
Signature of OwneiiAgent Date
i
l SECTION 8-CONSTRUCTION SERVICES
$_.11..icenaed Const vcco"Supervisor. Not Applicable ❑
Name of tag Holder: "iJ� \c �� 1 �b -6
License Number
Arid � k Expiration Date
Signature Telephone
Not Applicable ❑
Compamr No Registration Number
Address Upiration tate
_ K
SECTION 10-WORKERS'COUPENSATION INSURANCE AFFID VIT(M.t's.L.c,151,#25C(6))
Workers Compensation Insurance affidavit m t be completed andubmitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building4rmit.
Signed Affidavit Attached Yes....... No...... ❑
t HOW ..OWNTEE
The current exemption for"homeowners"was extended to include Owayr-occupied E?welfinrzs of one(t) or two(2)families
and to allow such homeowner to engage an individual foe hire who does not possess a license,provided that the owner acts
as su rvisor.CMR 780Sixth Edition Soc
09nI .l.
Definition of Hameawner:Person(s)who own a parte 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,a ched or detached structures accessory to such use and/or farm
structures.A person wh tructs mon than one in a two-year period a 11 woA be Sgesidered a ho wn r.
Such"homeowner"shall submit to the Building Officials on a form acceptable to the Building Official,that he/she shall be
responsible for Ass tch work performed under the bAkUng,germiL
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 Annotatd,you tatty be babk 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.
i
Homeowner Signature ---
Ilse Cotntrionweafth of Massachusetts
Department of'Indu.,virialAccidenis
lyfJ Office of Investigations
I Congress Street, Suite 100
Boston, M11 02114-2017
www.mais.gotldia
Workers' Couipensation Insurance Affidavit: General Businesses
Please Print Legibly
Rusiness/Organization Narric: ;Y,0:5 v oA X>'tJ
Address.----- i-L4 3 J �fo L K
City/Statc/Zip:___ �6 14_A 0 "a olpqo Phone 4i + 3 'v C)
Are you an employer? Check the appropriate box: Business Type (required):
I am a employer with employ 5. Retail
ec-s(full and/
or pail time}." (
Restaurant/Bar/Eating Establishment
to I ain a sole proprietor or partnership and have nc)
ernplovecs work inn for Me in any capacity 0117fice and/or Sales(incl. real estate, atito, etc
jNoworkers' comp msuran(erequirecil 8 Non-profit
We are a corfxo-ancin and its offteers have exercised 9_ L f,--nieriainment
their right of exemption per c, 152, §1(4), and %ve have10.❑ Manutacturing
no employees, f`No workers' corrip. 111SUrance requited'}— I I
4, We are a non-profit Organization, staffed by volonteers, Health Care
12 I�A
th no employees. [No worker�,' comp, insurance req.) Other
w 1
'Any applicant that�.h, s txix#1 must JISO fill out the section below showing their workers*compensation policy infonnation,
**If the corporate officers have exempted themselves,but the coritca-at ion has other employees,a workers'compensation policy is requirt(i and suet,an
Organization should check box 4 1
rim an employer that is providing workers'compensation insurance for my emplolvees. Below is the policy information.
Insurer's Address: <b0 -0 L) Fazt A) >AZ
ity/state/ztp: 3 CV e 14 11 I 1y
Policy 0 or self-Ins. I 1c. I#-W_(A) Expiration 1)ate� /���
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required tinder Section 25A of MU.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 MA for insurance coverage verification.
I do herebj,certify, under th e pains and d penaIties of"perjury that th e information provided ave is true and correct.
19444"Oe_ fi&PL-CLU jla� - '9 7
L)-ate: -
Ph Aq 1
Official it.ve only. IM not write in thiv area, to be completed by city or town official
City or Tovin:
issuing Authority (circle,one):
I. Board of licalth 2. Huddinp
liti-partment 3. City/-Fown Clerk 4. Licensing Board 5, Selectmen's Office
6. Other
Contact Person: Phone
05/04/2016 11:40 14135871272 NTON BLD DEPT PAGE 01/01
City of Northampton
Massachusetts
D£PAFd*dCW OF BVILDSNG INSPECTIONS
212 Main Stroot • !Municipal Building �..•w
Northampton, MR 01060
Property Address:
Contractor
Name
Address: _'CvV-k X. --
City, State:
Phone:
Property Owner
Name: ��1`�\C' I�IC�•\1,5� � i
Address:
City, States ��C� 3 X3`4 ZS
I.`66"a" Uj -P r (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
Affidavit for Home v C,onl W.W Pcm*Appfimfion
For ofSue Use Only
Feraait NO.
Date
Suppkmad to Ptarmic Apptit adw .
MGL c.142A nequirw dwA the"
Mb�. 40Mby
� �a
Type of work: `��}k. e .t cwt s z5
wmrn.a of work: d C jz)��i /n in Q/ D c
Owner Name. ,' Hcdi S4-9 r
Date of Permit Ate:
I hereby wtify that:
is not regained for the followim mwon(s):
work cwbded by law
Job ander 51,000
0w-
Notice
wNotice is hereby given then:
OWNERS PUI.WNG THEIR OWN PERMIT OR OEALJNG W rH UNREGISTERED CONTRACTORS FOR
APPLICABLE HOI1R',tMPROYFMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM
OR GUARANTY FUND UNDER.MGL c.142A.
Signed ander pt hies of perjury-
I hereby apply for a permit as the agent of the owner.
Date Contractor Name — Registratim No.
OR:
Notwithstanding the above notice,I horoby apply for a pars*as The owner of the above property:
nate owners Nasre Paling Permit
X05/04/2016 08:59 STAPLES 1193 PAGE 09
Permit Authorization ��'' un"441,
mass saw Form �
50%Pw upgot"eKA «a
Site 10; 50005018.4020 Customer: OIENICE HALLSTEIN
I. DENICE HALLSTEIN ,owner of the property located at:
(owners Name.printed)
90 Woodland Or FLORENCE
Wroperty Street Address) (M)
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.
Owner's Signature: —
Date:
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Partmpating Contractor Ddte
• Of'C�
WI
For otAaa use Doty
COnsmatlon SerWM GMuP • S0 W891,1P ton Sure;5ulte 1000 • Weabortmeh.MA 0]561 w LOOD 490.7472
Rev.062015 '"'