29-237 (12) 21 ALAMO CT COMMONWEALTH OF MASSACHUSETTS BP-2021-1827
Map:Block:Lot:29-237-001
Permit: Solid Fuel CITY OF NORTHAMPTON
Appliance
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit # BP-2021-1827 PERMISSION'S HEREBY GRANTED TO:
Project# Contractor: License:
Est.Cost:
Const.Class: Exp.Date:
Use Group: Owner: GEIS DANA J& KIMBERLY A PALME
Lot Size(sq.ft.)
Zoning: WSP Applicant: PALME GEIS DANA J &KIMBERLY A
Applicant Address Phone: Insurance:
21 ALAMO CT
FLORENCE, MA 01062
ISSUED ON:09/03/2021
TO PERFORM THE FOLLOWING WORK:
PELLET STOVE
POST THIS CARD SO 1T 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.
Signature
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Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
City of Northampton Avbi
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DEPARTMENT OE BUILDING INSP2VCTIO' sF k` �,
'`, 212 Main Street • Municipal rguildi, g CI- , "�� ��Y:
\' '�"''-ti "1 Northampton. MA 01060 �FLa O (���,
04 JSp c
APPLICATION FOR SOLID FUEL APPLIANCE IN 'M`' ,' ° Is
Property Information
Owners Name: ,/))41v,- 'I
Address: / f-/4I U &7 filart el' , 44-4'
(No.) (Street Address) /
Phone: Cell: `/� -(5-n -?Arimail: u�.k✓/lzycCS�I?) 7,idi/
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Owners Signature: /��u�, - Date: - /'mod/
Contractor's Information (If pplicable)
Name: Phone:
Construction Supervisor's License #: Expiration:
Home Impr. Contractor License #: Expiration:
Stove Information
Type of Fuel (check all that apply): Wood Pellet X Coal
Location: fl '4<)1 t 17 Freestanding X Insert
Manufacturer: 2/(-4 5iMi7 gZ /'j' j Model: �1 r 3� -
----- FOR BUILDING DEPARTMENT USE ONLY-- --_—_--_-_-_—
Permit# tom!' --Z I "dol.-Mate Applied:� Total all Fees: $
Building Official: 1/eu 1 0'5s Date Issued: 9' 3"26 Z(
Signature of Building Official:
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The Commonwealth of Massachusetts
l L Department of Industrial Accidents
1 Congress Street,Suite 100
e, ' Boston, MA 02114-2017
�_ y ` www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information f Please Print Legibly
Name(Business/Organization/Individual): )�✓�''9 / . (Z �.i S
Address: ,'- _ ) 414100 l
Ciry/StatelZip: ' O
t Zi (? i lr'4 Phone#: t 1,3 — 2_ // `
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in g
8. �Remodeling
any capacity.[No workers'comp.insurance required.]
9. 0 Demolition
3. am a homeowner doing all work myself.(No workers'comp.insurance required.]t
10 El Building addition
4.E] am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1Roof repairs
These sub-contractors have employees and have workers'comp.insurance.= ' ���/r
6.0 We are a corporation and its officers have exercised their right of exemption per MGI_c. 14. Other 14,��L �
152,§1(4),and we have no employees.[No workers'comp.insurance required.] `
*Any applicant that checks box iri must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box m t attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have ployees,they must provide their workers'comp.policy number.
I an:an employer that is providing w ers'compensation insurance for my employees. Below is the policy and job site
information. `'-
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Insurance Company Name: _.=
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State
Attach a copy of the wo compensation policy declaration page(showing the policy nu r and expiration date).
Failure to secu verage as required under MGL c. 152,§25A is a criminal violation punishable by a fin to$1,500.00
and/or -year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of u $250.00 a
da against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby rti under the pa' and pen ties of perjury that the information provided abovee is true and correctSienare: //7i ' l Date: Cl/ `6 2
Phone#: G//3 - 2 — %i �r
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
.
City of Northampton
F(NA41- _
Massachusetts vma4�V,,�'' ` ••
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F ') DEPARTMENT OF 13DII,DING INSPECTIONS e�
212 Main Street • Municipal Building v '''
e . : Northampton, MA 01060 s i
,j� � r F HOMEO ERS'EXEMPTION ELIGIBILITY AFFIDAVIT
I �L.�/✓/V U `-i -5 L Z / s�
jinsert full legal name), born nsert
month, day, year), hereby depose and state the following:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR I10.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns 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 home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel,I acknowledge that I am required to and will act as the supervisor for said project or work.
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Signed under the pains and penalties of perjury on this / day of 5 10� 200 oZ
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(Signs re)