31A-095 BP-2024-0620
51 VERNON ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
31A-095-001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2024-0620 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2024 Contractor: License:
GOLD STAR INSULATION &
Est. Cost: 5200 CONSTRUCTION LLC 065992
Const.Class: Exp.Date:03/16/2025
Use Group: Owner: M PETEGORSKY STEPHEN&ELIZABETH
Lot Size (sq.ft.)
Zoning: URB/WP Applicant: GOLD STAR INSULATION &CONSTRUCTION LLC
Applicant Address Phone: Insurance:
1 CONGER RD (774)329-4664 6rs7139623
WORCESTER, MA 01602
ISSUED ON: 05/17/2024
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATION
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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
I. RECEIVED
r -
MAY 1 6 2024 he Commonwealth of Massachusetts
Boa of building Regulations and Standards FOR
MUNICIPALITY
�-- Ma chuietts State Building Code, 780 CMR USE
�,., ,i t"r ItlIII niN:r.INNcoFCTIONS
l uildilig'Perrlltifi4pplication To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number..24., a Date Applied:
/iffy/kJ LOSS //ale— 6-17-ZO2 y
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
5 j V unP� 1}—('e-e,1'
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq II) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) City,State,ZIP
Si 1 ran t/(3 P S'L/O(f of 2jer� hw -eld
No.and Street Tele hone Li Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Q cify: -rtlSt.!'A.ficiyl
4 Brief Description of Proposed Work2: ----\C t frii O),b -1 C e(fc)lo .2.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ a-cd I. Building Permit Fee: $ Indicate how fee is determined:
0 Standard City/Town Application Fee
2. Electrical $ Q . 0 Total Project Cost3(Item 6)x multiplier x
3. Plumbing $ ) 2. Other Fees: $
4. Mechanical (HVAC) $ 0 List:
5. Mechanical (Fire $ 0
Suppression) Total All Fees:
Check No. U Check Amoun J Cash Amount:
6. Total Project Cost: $ g (C3 ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) OC.,5 99'
KAli,P4f) License Number 41(:Expira on Date
Name of CSI pp �
�� ! rn `--f V ' ) List CSL Type(see below) V
No.and Street J�` Type Description
(ICY /
�,,/I 1 '� U Unrestricted(Buildings up to 35,000 cu.ft.)
!. S 'je Y► ` ��+1 R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry ,
RC Roofing Covering
WS Window and Siding
u (/ � SF Solid Fuel Burning Appliances
` )V 3I t ( 4�� G.B tom1//C/fro-pi I Insulation
Telephone Email address •Carr% D Demolition
5.2 Register d Home Improvement Contractor(HIC)
6 U S� irk Scit�4-Jr IC 6� $' t a
HIC Registration Number Ex ua on to
HIC putt�Name
an or R�strpnt Name C��
l d 4) rAs 0 'cloud,
No. Street � , __ ^ -7� ,3ai c/cat Email address
ULOCity/Town,State,ZIP Y1'�� Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
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 the building permit.
Signed Affidavit Attached? Yes No ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize �e/�
to act on my behalf,in all matters relative to work autho ed by this uilding permit application.
.-1-C-' eh9--A
?OftSel C// d I(
Print Owner's Name(Electroni Signatur Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
s. ems. cf 7JLdL
Print Owner's or Authdrrzed Agent'stName(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE:
REAR LOT DIMENSION:
REAR YARD
SIDE YARD SIDE YARD
FRONT SETBACK
FRONTAGE
City of Northampton _
c/ sus . rMassachusetts ��/ - ?e
4z DEPARTMENT OF BUILDING INSPECTIONS .212 Main Street • Municipal Building 3 i'
Northampton, MA 01060 sr� -.. �10,
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: (-1 0 W e19,9 z_S-1-- uocr.''1 /il
The debris will be transported by:
Name of Hauler: Li C( f ^r`0' An-Q
Signature of Applicant: Date: E
The Commonwealth of Massachusetts
"�z, Department of Industrial Accidents
=:, la t
E 1 Congress Street,Suite 100
' :{ Boston,il!A 02114-2017
wwl ..mass.gov/die
I%oticers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO RE FILED WITH THE PERcM ITtiNG AUTHORITY,
. nnlicant Inforntatiun Please Print Legibly
Name:ll3usincsa Orpamzaiaon lndtvnitrs!): c1 }a
Address: 1 C � .--
City/State/Zip: L,t1Url 3J in jr- Phone#: a-1 aa _q_ _
Are pin an employer'?`Cheek the apprrsprhate tits: Type of project(required):
t. am a cmpliler with____!p._....._cn ilo}ces tfult aart`or ptut-brae).* 7. a New construction
20 I am a aide proprietor or prmtnerxitip and have no ctrtpluyces w'urking for tine in $. a Remodeling
any caruesty.[No workers'comp. tantrum,: reyttirvdI
30 I am a homeowner doing all Watt myself jU wan oa'comp.insurance requital)'
9. ❑Demolition
4.0 I am a homeowner and will be hiring sxuRrrctora to conduct all wink on nu paug>erty_ I will la Building addition
manna that all ex,ntra tors either have wurkens'coctq i.atievt insurance or ate sole 11a Electrical repairs or additions
proprietor;with no employees_ 12.0 Plumbing repairs or additions
50 t ant a,mi ral contractor and I have hired the sub-cuntrareon listed on the attached sheet 130 Roof repairs
These sub-conttaetunn haw employees.and love workers'comp.irrxuninec.:
14. fi_ let'TA Sciamom
6.0 We an a corporation and its officers have cat:seised their tight of exemption per NMI.c_
i$'_.4144).and we pare no employees.[No workers'comp.inst3rance required.)
"Any applicant that cheeks lox PI must alai tilt out the section tselow shooing their workers'compensation policy information
+Homeownncrs who submit this anima indicating they are doing apt work and then hire outside eemiraotora must sabmit a new affidavit indicating inch.
:Contractors that cheek this box moat.a t.tied an;additional sheet%troy,KT the name of the aub-cuntraetat. and Mate w hether at not thou entities haw
employees If the sub-contractors kkire employees.,they mu,s t+or;id.;t:,cir ,rurkecs'comp.,policy number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: liA.CC., lot Yam-lr �"✓1 _
Policy At or Self-ins.Lie.#: C, 51 IS Ci 4 a3 Expiration Date: g1 �//act
Job Site Address: 1 1,/C Y15-4,1 S e-e I- CityiState.&"Zip: 1I
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under;LMGL e. 152, *25A is a criminal violation punishable by a tine up to 51,500.00
andior one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a
day against the violator.A copy of this statement may be forwarded to the(tuts of Investigations of the DIA for insurance
coverage verification.
!do hereby certify tinder the pains and penalties of perjury that the information prot'ided above is true and correct.
Sienature: Dar.: (SViQd/a 1/
Photo:L. / cYJ (f 4 /
Official use only. Do not write in this area,to be completed by city or town official
('its or Town: Permit/License ti
issuing Authorit (circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
<��M�. City of Northampton
�0.� �5..... S/
?°a. S C'e
Massachusetts 4: e
riu . c
A�` ,. ;
t•' DEPARTMENT OF BUILDING INSPECTIONS 5., ..
,,l' 212 Main Street • Municipal Building vkSSV ,^``tea
Northampton, MA 01060 h
Property Address: .3 [ V ei{,f\c/ 1 S 4- (e.,-e,4-
Contractor n
Name: , )14 �c�-Pi I
Address: / ('G kl ,e(
City, State: J c'{`( S4- - YYl }-
Phone: 71 CI 0-c) 14 CC
Property Owner
Name:
Address: 5I
3-1-feei
City, State: A/D,r gym. (? Al) ni) 0
I, frvel ) (contractor) attest and affirm that the building I intend to
insulate es not haile 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 5/ / V Id-C(