43-125 (2) II GREENLEAF DR BP-2017-0485
GIS a: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:43- 125 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 a BP-2017-0485
Project a JS-2017-000803
Est. Cost: $55.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group DONALD PELLETIER 101876
Lot Size(so. ft.): 48351.60 Owner: STRUMAN MAUREEN
Zoning: Applicant: DONALD PELLETIER
AT: 11 GREENLEAF DR
Applicant Address: Phone: Insurance:
P 0 BOX 5020 (413) 538-6002 WC
H O LYO K E MA01041 ISSUED ON:10/14/2016 0:00:00
TO PERFORM THE FOLLOWING WORK OPEN ATTIC ADD 4" CELLULOSE 44
PROPAVENTS, 2" POLYISCS TO KNEE WALLS
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:
FeeTvae: Date Paid: Amount:
Building 10/14/2016 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0485
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE P O BOX 5020 HOLYOKE (413)538-6002
PROPERTY LOCATION 11 GREENL.EAF DR
MAP 43 PARCEL 125 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
P RMI_APPI CAT ONC ECKL(ST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid '7//�a!'"'<
Feedine Permit Filled out `�-'�J C
Fee Paid
Tvpcof Construction: OPEN ATTJC AUD 4"CELLULOSE 44 P OP€VENT 2" ' YIS ,S 0 KNEE
WALLS
New Construction
Non Structural interior renovations
Additio to ar ' fn
_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
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
eptic 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 Delay
f f7I7;/7
Signature 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,
oepabnart use only
City of Northampton Sties of Permit
T` -1L Building Department Cab Cul/Driveway Permit
•
" ' 212 Main Street Se*erSSeptc Aveledify
W' Room 100 Waenwea Availability
.mpton, MA 01000 Teo Sea of Structural Plan
phone 413-587-1240 Fax 413-587-1272 PIDufiite Plena
Odea Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOUSH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Tib section to be complebid by Glace
1.1 Ranertv ANDME :
•6 Ce en I ea-1 Nap .._ Lot___... Unit
Zone Overlay Datrkl
flore ncc root
Er St District CO District
SECTION 2-PROPERTY OWNHL4MPYAITTHOtt®AGENT
takeoffs!at Record:
rncLu ree`r• S* c ur-nQ n \ \ CRer‘ eac
Nene(Pal) Coal Wang Address:
r�S( exC SIT)ecJ 1- K! 16
22 Authorized Agent •
r-Oa>b 1d w Y'e l efl ("" -n
Name(PMI) Careen wing Adam:
T,..,,,,, i}y1 ,Q a �. c -ss.�c�
6iPeWe Teeptve
SECTION 3-ESTIMATED CON5TRUCfIONCOSM
Item Estimated Cont(Dollars)to Pe Official Use Only
canptcted by Permit applicant
1. Siting (a)Wildly PemW Fee
2. Electrical (b)Estimated Total Cora) 'Yl �D'-Ci
conawtien ham(e
3. Plumbing Risking Perlin FN
4. Mechanical(HVAC) y
5.Fie f4Wn j5 0W
nb ,yM r
6, Total=(1 +2+3+4+5) Check Wawa L/y/3 66 ..
This Section Far OM*IMS Only
Se ding Permit Nuttier Date
Issued:
Signature,
9 Carrariatranerffrosatax d Fangs Data
05/04/2016 11:40 14135071272 NTON Etc DEPT PAGE 01/01
City of Northampton
.x✓_
Massachusetts .. '
•
+.�iaarrr or DUXLWWC zaacsrrraes
212 rain Strout . $aseipal Building A:
Northampton, It 020600 �7>%w-0)t+'�
Property Addresses t \ G Ce P .(\ \ QCc-F C .
Contra
Name:etor t.) y r \,Gt . U ) t l,fl'St e c,..-
Address.
.'Address. t1D'–) WO. \ f S-J' -
City, State: k4 01 .-1 D v n \N^`-\ >
Phone. '-' S ,C----') gb0
Property Owner
Name: YN"e U Ce e Q Si.(U 'nrq C)
Address: I \ 6 Cern /ekf ti' r.
City, State: -- k'b c enc 2_. \ll ..d\ 1 0 \D ri.)---
I.)ct– \CI tJ et 1 e±,P ( (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 Gr"'\ - t f /t C� c crcSZA$1.,..----MDate 10—r` iC
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aDOFiem4)
New Nouse ❑ Addition ❑ �R Doors Windows
AlbRoofingtid(s) I I Roofing n
Accessory Bldg. ❑ Demolition D New signs IC] Decks IO Siding SDI oder Ef:r-
Wortief Description of
tit IC. Gck oposed i'—j to lose ` f 7tp• n S o194'7(sC Yt r^Ai
AMetim of misting bedroom__Yes No Adding new bedroom Yes No
Attached Namara Renovating unfinished basemen Yes No
Plans Attached Roll -Sheet
it if New house and or addition to existing housing. complete the following:
a. Use of building:One Family Two Family Omer
b Number at IOCRIe in each lardy unit Runner of Bathrooms
c Is Vere a garage attached?
d Proposed Square footage of new costiform. Dimensions
e. Number of stories?
I. Method of heating? Fireplaces or Woods ehess Number of each
g Er.eigy Conservation Compliance. Massdreck Energy Complanca form attached?
h. Type of canstrron
i. Is construction within 100 ft of wetlands?___Yes No. Is construction within 100 yr. tloodpain Yes No
j. Depth of basement or cellar door below finished grade
k. Will baking conhtm to the BuAdin g and Zoning requlatiora? Yee No
I. Septic Tank_ Cary Sewer Private well City seder Supphy
SECTION 7a-OYyIER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
reThct J re e rl Si( U hce`A fl as Ower of the subject
Property
hereby authorize 'O \d \e\1 et I
to.an my behalf,in ell nears redeye to lark authorized by IIS tending permit a*psnation.
S 4' > l• neer, or _ 1 �
Sigurd ere el Ower o.e
a-r•O \CI- W Q\\ trt" 'e I as Ower/Autnr¢ed
Agent hereby dean tet the statements and Information on the Awegdrg application are true and accurate,to the(est of my knaMedge
and tetrad
•
Signed under the pains and perjury.
\CA N .) \\e* k QC
Sig Suss of owerdAgea Dee
SECTION 1-CONSTRUCTION SERVICES
0.1 Liewtwd Gat n ctlm\Ou : a
nendee �y NApplicable 0
Nana of Uwe*rloldd: 'V�r�l 1t.` l vl Re let`l ec ivi aid .
uranse Number
1 ( 07 ma 1 r c'{- - ID-S- I�
N (31 t)4..? ,r-res\ 5 ?.>S 60(De7 Ferman�
Siamese �r
i r (L)r(L) �, •
1.RealaNnd Home Improvement Contractor. Not Applicable ❑
iter \d Let R�\ 1e- te r I563f "�
Gamtsny Nmna . . Registration Number
+e11Ies 0141- e ✓ 3- ?`71 - /C5
Acidness Expiaeon Date
ter» rim . n i-vl•elacce s5BSmD--
SECHOrf 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(Y.G.L c.152,f 25C(5))
Walters Compensation Insurance affidavit mud be completed and submitted vat this app i tion. Failure to provide this affidavit will resod
in the denial of We issuance ce the budding permit
Signed Affidavit Attached Yes ❑ No 0
11. - Home Owner Exemption
The curtail uranprion fir'hmm>wnen"was extended to include Owser-occmgad 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 aces
u woervieer.CI1llt 711, Soh Editioe Sectio. 118.33.1.
Defyitio.of Homeowner.Pesos(s)who own a parcel of land on which hershe resides a 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
vumacs.A yenta who eomrl7len.arc ale One boar e a two-rear pored Jan not be soasiderad a bomeawoer.
Such'fianaownce shall submit to the Building Official,on a form acceptable to the Building Official,that berth. : d be
repooible ler r eath Mirk nerWrwied oder the SAW,/permit.
As acting Condnittesi SaperviDer your presence on the job site will be required from time to time,during and upon
completion of the work fa which this permit is issued.
Also be advised that with ieference to CLQ 152(Wakes'C r -i°—) .d Chaptr 153(Liability etEmployers to
Employees for injuries not resulting in Death)of the Massachusetts(knurl Laws Annotated,you may be liable for person(s)
you hire to perform work fpr you tender this permit.
The undersigned'homeowner cetifies and assumes responsibility fix canpliaoce with the State Building Code City of
Northampton Ordinances,Sate and focal Zoning Laws and State of Masswinsab General taws Annotated.
Hommwoer Signature
Section 4. ZONING All information Yat Be Completed.Permit Can Be Denied Due To Irwmi Aete Information
Eating Proposed Required by Zoning
The maws,m an met m by
awad'vw omsraoa
(MI Size
Frontage
Setbacks Lpym
Side L: R:
R1
Building Height
Bldg.Squats Footage
Open Space Footage 9L
(Lot sea maws Bldg k pawed
Parkins)
If of Puking Spans
Fill:
(whew a Locenon
A. Has a Special Permit/Variance/Ffnding ever been issued for/on the site?
NC) 0 DONT KNOW 0 YES Q
IF YES, date Issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES Q
IF YES: enter Book Page and/or Document a
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?
Need to be obtained 0 Obtained 0 , Data issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe sire, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO Q
IF YES, describe sire, type and location:
E. NMI the construction activity disturb( rg.grading,ozcavatico,or Rag)over 1 acre or is ii pan of a common plan
that will dattab over 1 acre? YES C NO Q
IF YES.sten a N rthampton Slam Wafer Management Permit kern the DPW is required.
Aftidkvi1 S Hos Mplo.mar Coearwefv Permit Appliance
Pods LW Only
!tomb N..
Blebs 6goew.mmrl Caber. s Law V- 16 ren d
sepplmrr t Permit Application N
►GL a142A aria OM Es
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owpns MELLOW 11MOI OWN PERMIT CM DEALING WITH UMMOISTERED CONTRACTORS FOR
APPLICABLE HORN ettbOVf@IT WORK DO NOT HAVE ACCESS TO THE ARBMIAT10N PROGRAM
OR GUARANTY FUND MGT*MOI.G I CA.
Siwwa am pewMbe of pigmy:
I beery*ply/it.pock a r el of Mho ar-
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OR:
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i7.er Owme Plme PM*Rai
ac CERTIFICATE OF LIABILITY INSURANCE ;ZF$p1p I
TMS CERTWICAIE i ESIILD AS A NATTER OF IaOTIMA110N ONLY AM CONFERS ME NUTS WON THE CERTIFICATE
HOLDER TME airrecTE DOE4 MOT AFRIMAIIVELV OR M!BATNELY AMEQ EXTEND OR ALTER THE COVERAGE
AFFORDED GT TIE moo MOW TIPS ILMETIFICATE OF BOUBASCE 111MS NOT CONSTITUTE A CONTRACT BETWEEN
THE RSDINGINSWEE!NIL ANHION®REPRERENIATIVE OR PNCCUCNA AND THE CERTHCATENOLDER
IMPORTANT: M w eMaab bolder Y a AOORENAL UNUREP,dw pc&$. }m t b*abrad. N.t1EROGATION B WANED,
a6TPetb beWaFrW 4.40111". OwpeFep,a.l6 peados may____a aMawinct A MHebRiwA m NP cam*dew
net par b w aka ka Hatlb aOw el Ica claMala44
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PELtLETIER DONALD OSA eMMeR p: _-
PElkTIERRHaEAPON
MIT MAIN ST awATale:
HOLYOKE.MA 01040 NORM t
MwRRe P:
COenRABms __ taro S1Emouits masa mask
as IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BE NAV HAW BEEN ISSUED TO THE INSURED NAMED
ABOVE FOR 711E PO CY PER/00 INDICATED NOTWITHSTANDING ANT REOUIRewM, TERM OR COROMON OF ANY
CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TMS CERTIFTGTE MAY BE ISSUED OR MAY PERTAIN. THE
INSURANCE AFFORDED BY THE POUCIES DESCRIED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND
CLNEMTMNI9 or SUCH pO res_UNITS SHOWN MAY HAVE SEEN RE)I)CED NY PAID(LAMS.
aR 1'n•E OsawMYCE IAPB'SYS P CTR. MIXT EP
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THE WORMS(COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR PE,LETIER DONALD
CERTIFICATE HOLLER SANCEUAllei
DONALD6PATRK7A PEt1EfIFA SHOULD ARY OF THE ABOVE OEIDERNIED POLLICES BE
:1 01 UMW ST CANCEL.® $EEXPIRATION TIE IFRITION CUTE T/EREOp
HDLYOHP„MA 4/Ob NOTICE I LL NA W HE
OEUVEREO ACCORCPPF 1/1111 T
PORGY PROYIMOIa.
AiiHlRil®AaMIRATNe
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CORPORATION M CAS nNant
HARD E{3 Iasi The CORD nom and loge w nlibiM Gab e1
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giite W. a dIp/71,ado.
e4 , Office of Consumer Affairs and Business Regulation
4c 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 150319
_ - Type: Individual
Expiration: 3/24/2018 TM 419291
DONALD PELLETIER
DONALD PELLETIER
1107 MAIN ST
HOLYOKE, MA 01040
Update Address and return card.Mark reason for change
scar 0 20110501 - r Address CRenewal I] Employment n Lost Card
Massachusetts Department of Public Safety
�V Board of Building Regulations and Standards
License' CSSvsr
ConstructionnSupervisor Specialty
C1114\ y
DONALD W PELLETIER
1107 MAIN STREET `2,
HOLYOKE MA 01040/ �i
r-' CA__ Expiration:
Commissioner 10/08/2018
The Commonwealth of Massachusetts
-: Department of Industrial Accidents
.` iy„ .. . OfficeofInvestigations
hitt 600 Washington Street
;:s Boston,MA 0211!
• • ' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ` — "
Please Print Legibly
NameiBusinessrOrganimtionfIndividual{: L^ t—'P l\Je \i l Q c -t+1%. 0`C} \ 6 e1. _
Address: V-,13 c, T-r^&\NA ._
City/State/Zip: U 1 l. 6 le, - Phone#: 4 S qG avTID--
Are you an employer?Check the� t appropriate box: Type of project(required):
I.Nei am a employer with `•t 4. 0 I am a general contractor and 1
employees(full arcVor pan-time).' have hired the sub-contractors 6. ❑Nein construction
2.❑ I partner-a sole proprietor or partner- listedon the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity_ employees and have workers' 4. ❑Ekrikiirtg addition
(No workers comp, insurance comp.insurance.'
required] 5. 0 We are a corporation and its 1R❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers'con right of exemption per MGL
D 12.5 Roi3peairs
insurance required.]* c.employees.
j and we have
employees.INo workers' i3. her
comp.insurance required.)
'.Ant armhole(that checks box al must also ria ore the section below showing their woken'compmsatwm policy iaformmion.
'Homeowners who sohmn this affidavit indicating they arc doing ail work nod Men bite outside wnwcton mast submit a new affidavit indicating such.
;Contractors that check this box must smelted an additioW sheet showing the ora of the wbwoaecron and state whew or not Nom entities have
emniaveestribe subamn ecten have employees.they must provide Men workers comp.policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information 1:\ tl�
Insurance Company Name:_..!..C^'kms 't'1 m et' C.
Polices a or Self-ins. Lic.a: (RS (a u Q J9 C339(11 91 Expiration Date: ri� Q17
Job Site Address: 1 I 6 Ce en teaf C . Citvismceizip:Ktt)re V'C-' •
Attach a copy of the workers'compensation polity 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 SI500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verifwaion.
ow—
... _. _ _ _ _. __ _.. _ r • _ _ .. _
I do hereby cenif under the pains and penalties of perjury that the information pmrided above Is true end correct
Sitnature: £CY7ilLgaa `� 3 Date: I. - 3 ' / kms.
Mame S •SC'S6/W,,,)
Official use only. Do not write in this area,to be completed by city or town official
City or Town: _ _ _ _ PermittLicemc#
Issuing Authority: Building Department
Contact Person:
/
Permit Authorization 1
iMilk -1
mass a Form
WI
Site ID: S00050228678 Customer: MAUREEN STURMAN
1, MAUREEN STURMAN ,owner of the property located at:
(Owners tame.panted}
11 Greenleaf Dr FLORENCE
(Property Street Address) IOty)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a budding permit to perform insulation and/or weatheritation
work on my property.
.."
—
Cila
LChtnxtsSlgnature: � ..
I Date: - 14-\ to
FOR CLEAResuk OFFICE USE ONLY
CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
e ❑
Cl4Mneh • SO Washington Sniet.Suite 3000 • Westborough,MA 015810 1800480.7472 ®1
for O9ke use Only
. Rev.102015
'Ft MOM
kH 3< - _ ,. -._
In accordant: wins rhe prnvibions of la'aE, c 40, S 54, a coliL$ion of Buldiag Fermis
Number is that the debris result-int; from this work shall be disposed of ha
a properly Itemised solid ,caste di s,-osat, facility as earthed b, MOT, :
The debris !4111 ha disposed of in:
C_+'{i:btev 4 t3 S 4tcbc St. a-};iq k Oct. G .^`i�
LOCATION ON TACIT ;' ...__
Signature of Applicant ._.. -Pate
As a rescir of the -ovisiona of Met., a 40. S a4, '. event. iedp that as a c oncliuLO Si
Ripi'din_ Permit Pfbrabe .i debris reSulhng from the s?115Yuction
activity governed by this to i�_G1n Permit hats be disposes] of ha a pmpe_y licensed solid
waste disposal facility, as defined by I!_2L c t 111, S L`6A.
I certtify that i will tot`:': theBM-Min '✓:- ' 1 v tic incistbs
inasrnpn3 ofttie?e et_cn of the .lid waste oto. stat fiOnlit -her thea h „_.,oic ficin
the said constit cine activity shall be disposed t:i1 shall submit the auproo iatL
attachment to the Budding Permit. {� //
t� laC) lir 1L/ (1 tp
Date Stigtatere. o`' reit Applicant
(Path P OR TY L- i-t_ FOLLOWING INFORMATION)
---Name of'e_.pit Adehcana
eylewi Iail.
Firm_smite, if any
d 4009-8£9- 1.4uogeinsul tet e eJ d85'OL St bL PC