35-165 (3) 817 RYAN RD BP-2017-0815
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35 - 165 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-2017-0815
Project# JS-2017-001366
Est.Cost: $1400.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 46173.60 Owner MONSI(A MARTIN J&JOYCE E
Zoning: Applicant: DONALD PELLETIER
AT: 817 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 5020 (413) 538-6002 WC
HOLYOKEMA01041 ISSUED ON:12/30/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:EXT WOOD WALLS 4 CELLULOSE DENSE PACK
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/4 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 12/30/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0815
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE P O BOX 5020 HOLYOKE (413)538-6002
PROPERTY LOCATION 817 RYAN RD
MAP 35 PARCEL 165 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT AP TION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ( 1 b�
Building Permit Filled out
Fee Paid
Tvpeof Construction: EXT WOOD WALL. 4 4 LOSE DENSE PACK
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
INATION 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
Demolition D- .y
i= /
is-34/G
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.
Building Department tc x
Jaren 212 Main Street
e Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR CENOUSH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1lits ono ba camp-e MM
d
• Abp Let Unit
T 1 e c C Mc\ , zea. Ow*aMlbt_
Bexebbe* a Mow
SECTION 2-PROPERTY OWNERSIIMAUTHORIZE6 AGENT
21 Osarr d Reread:
rycore cc\OfS\ZQ 6r) ?Lickn 2d .
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Signature Telephone
ArtiliailaiiniEnlagleecThaWATI
Item EdWated Cost(OMEN)to be Official Use Only
completed b1 permit%$*
I. Enabling -(a)B.I*ig Penne Fee
2.
Eiectrical (b)EalexSMJ Tolal Coot of tel]
Ca ntu:lon rron(6) t/Ct
3. Plumbing ,p MAdl&eg Pani Fee
4. Msiw (H
al VAC) -sacc)b-far
5. Fire Protection O �
6. Total =0 +2+3+4+5) 4 )QC-YM Check Nab /
/
Weber �fS Tills Simeon For ORM On Only
gilding Permit Number Date
leafed:
Signature.
Burly CammbrmaMpederd Seldigs pale
rSECT10N S-CONSTRUCTION SERVICES
▪ Licensed Construction Sunnynor
Pine of time*Inner.(1Y1 013,\d us PI\IQ I Irx
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Sipnnhr Expiration Dela
Telephone
Not Applicable ❑
vD ( ek+i_o C I Ye)
Comm Now Registration Number
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Address ER:inat er!Darya
kAMV\-\3)),S- er , t —lb Telephone �--
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFlOAVWT(r.G.L c.152,f 25C(8))
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 buildup permit
Sired Affidavit Ana<tad Yes ❑ No 0
11. - Hose Owner Eze educt
The current exemption for"homeowners"was extended to include Owaer-oc<woied Pwellinn of one(I) or Iwo(2)families
and to allow such homeowner Ic engage en individual for hire who does not possrss a license,provided that dot owner acts
as supervisor.CMR TM, Sixth Edina Wino 11111.3.5.1.
Definition of Homeowner.Person(s)who own a parcel of land on which bc/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 porion who rm*ructa mere than one hove in a two-yar period Wa4 not be copaldered a homeowner.
Such`homeowner"shall submit to the Building Official,on a term acceptable to the Building Official that he/she(hall be
tsoouible for all such work oer4r1•ed under the bWidine Permit
As acting Conatnetion Suuervior your presence on the job site will he required from time to time,during and upon
completion of the work%r 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 Drnhl of the Massachusrns Gant Laws Annotated,van stay be Gable fat pawns)
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,Stair and local Zoning Laws and Sale of Massachusetts General Laws Annotated.
Homeowner Signature
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05/04/2016 11:40 14135071272 NTON BLD DEPT PAGE 01/01
et-
City of Northampton
Massachusetts i `
34
resaaneorr OF BUILDING rnans'iora
-� 212 win street • linteipsi autitling
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Property Address: O \ ) (C_(yk.yN
Contractor Jr�
Name: \d C>,.� 1 '0Q:k('l.�
Address; kV7� teCA\ �
City, State: r•CCA
Phone: c97
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Property Owner —7,—
Name:
Name' C im^ ✓ \=_\� �
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Address: \Jck, Z •
City, state1C CQ(1
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I. (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_
Contractorsignature G\
Date l a_oL_dS'� yq
The Commonwealth of Massachusetts
Department ofindustrial Accidents
Office of Investigations
( -,r" 600 Washington Street
Boston,MA 02111
www.nmss.gov/dia
Workers' Compensation insurance Affidavit: BuilderatContnctors/EleetricianstPlumbers
Applicant Information r-� fPlease Print Leathly
Name{isatiness!Organitauonindividua( : 1— �1`,,ei'1 e c y\co\ f+ e'.
Address: ,<43 Sufcb11�
city/State/Zip: t-40k Y`tA Phone#: (4 1 5.3e1 G bb 2
Are you an employer?Check t''hefappropriate box: Type of project(required):
I.till T am a employer with '-{ 4. 0 I am a general contractor and I
employees(full and/or part-time).•
have hired the sub-contractors 6. 0 New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g, Q Demolition
workingfor me in any capacity. employees and have workers'
Pa 9. 0 Building addition
f No workers'comp.insurance comp.insurance..
required.] 5. 0 We are a corporation and its 100 Electrical repairs or additions
i.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers comp. right of exemption per MGL /2.0 Roo irs
insurance required.]' c. 1522,§1(4),and we have no
employees.(No workers 13. er__
comp.insurance required.]
.,Ia}applicant that cheeks box a I muss also fill out the section below shots mg their mothers'compensation policy information.
'Homeouncrs who subunit this affidavit indicating they art doing all work and then hire onside wnbactan neat submit a new stature indicating stela
L'ontnciors that check this bet must anachcd an additional sheet smwine the nave 1)i the 6o tan cion and gate whether or not those entities have
cmoIovtes. If the sub-contractors hake employees.they must provide thty workers camp.policy number_
I sun an employer that is providing workers'rompensavoa insamncefor my employees. Below is the polim andlob site
information. (�
insurance Company Name: t iCC- fltneti C.ant_
17—
Policy m or Self-ins.Lis.a^r� tp J 6,Z,�+{U/(Q}'c, 8.399i (, Expiration Date: s /�0/7
lob Site Address: S \ ! Q.�/`� 5.,��1 City/StateiZip:_ 'C t1''C_
Attach a copy of the workers' cors isatioa policy declared..page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGT.c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 anchor 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 c�ar\\*under the pains and penalties of peryary that the information provided above is true end famed
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Phone aC"2` 3 S �tY)
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Official ase only. Do not write in this area,to be completed by city or town official
City or Town: ___ PennitlLlcense a ,
Issuing Authority: Building Department
Contact Person:_
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The OERRICATE E MED AE A ESTTa OF SN*ONLY NO COWERS NO ROOMS UPON TEE CERWCATE
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Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 150319
Type: Individual
Expiration: 324/2018 Tr* 419291
DONALD PELLETIER /DONALD PELLETIER ---� _
1107 MAIN ST = --
HOLYOKE, MA 01040 = --
Update Address and return card.Mark reason for change.
SCA o 201.05/
� Address ❑ Renewal Q Employment ❑ Lost Cord
11
Massachusetts Department of Public Safety
It Board of Building Regulations and Standards
License: CSSL-101876
Construction Supervisor Specialty
DONALD W PELLETIER ilKp
1107 MAIN STREET
HOLYOKE MA 01040/
M'^^ CA-- Expiration:
Commissioner 10/002018
Permit Authorization• 1
mass Form
ens
Site ID: ' 50218084 - .Customer. Joyce Monska
I, Joyce Manske ,owner of the property located at:
{owner's Name,printed)
817 Ryan Rd Florence
(Property Strut Address) - (aryl
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 andjor weatherization
work on my property.
Owner's Signature:
Date:
FOR CLEAResult OFFICE USE ONLY
CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
3k ckast.
Participating Contractor. - Date
CLERaesun • 50 Washington Sheet,Suite 3000 • Westbmaah,MA 01581 • 18004807471
For pace the Only
Rev.102015