23A-012 (10) BP-2024-1064
28 PARK ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
23A-012-001 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-2024-1064 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2024 Contractor: License:
GOLD STAR INSULATION &
Est. Cost: 850 CONSTRUCTION LLC 065992
Const.Class: Exp.Date: 03/16/2025
Use Group: Owner: HOMMES CHARLES D&VICKI BAUM-HOMMES
Lot Size(sq.ft.)
Zoning: URB Applicant: GOLD STAR INSULATION &CONSTRUCTION LLC
Applicant Address Phone: Insurance:
I CONGER RD (774)329-4664 6rs7139623
WORCESTER, MA 01602
ISSUED ON: 08/21/2024
TO PERFORM THE FOLLOWING WORK:
I NSULATI ON/W EATH ERIZATION
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: I inal:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: 172-
Fees Paid: S75.00
212 Main Strcct,Phone(413)587-1240.Fax:(413)587-1272
Office of the Building Commissioner
G
D ep
AMrati City ptonC R
� \
.'- i Building I nt O , ,,,,,
212 Main ,
.. ... .
7" z'Room 100 ^ �� DNSULA TION
;.. Northampton, MA 01 `nATr\
phone 413-587-1240 Fax 413- fib-#, ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FA LY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zone Overlay District
,„ ` 6c,,,_ Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
v\c- C' \\ nnrf\eS a (6 f1GI' l' , /Yin
Name(Print) CurreJM4,0„6 ,,,,_
Address:N6r1in-e- S7aac,
' Telephone
Signature
2.2 Authorized Agent:
nr- ea' weill 7 L:- c..J&rcecS-W MP-
Name(Print) Current Mailing ress:
. --)r---) 1,( 99, 1/1 4,Li,
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building � (a) Building Permit Fee
C
2. Electrical (b)Estimated Total Cost of
0 Construction from(6)
3. Plumbing V Building Permit Fee
41
4. Mechanical(HVAC) '
5. Fire Protection
6. Total =(1 +2+3+4+5) t] Check Number —10 7
/y� This Section For Official Use Only
Building Permit Number: 6o.4~ /tZ V Date
Issued:
Signature: `''"',�_ a -Ze - —1
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not Applicable 0
Name of License Holder: V--'el.., \ _ r\L-e-1\ s: s-/�a-
License Number
�1 ,ram\ 3c� 3 lig dsAddress ExpiratioDate
V_. , A4\,\/ 7 7 4 , -.Q) 14. .c (/
Signature Telephone
9.Registered Ho mle
Improvement Contractor: Not Applicable 0
0 IJ id c-C 4—C"{ - .‘r\-CO tOV''( ) on
Comp Name Registrati a u ber
Cn ( r �) �arC - --v- c)-- S aq
Address ( Expiratio Dat
Telephone 17 ti3 q-.Q
SECTION 5-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 of the building mit.
Signed Affidavit Attached Yes No 0
Brief Description of Proposed Work NOTE:E: INSULATION ONL Y
c\cA k-1 \f c d' e-QA 61 iti9C Cc - f d Se0--
I, LeCt -(* `- L._ ,JV l , as Owner/Authorized
Agent here dare 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.
C re-►/ Fr . 1`
Print Name A4Y1.
S? dig
Signature of Owner/Agent Date
\A I. U ' IYil —t:/S ,as Owner of the subject
property
hereby authorize b' ` t e_i
to act on mybehalf, in II a e�ive to work authorized y hist buildingpermit application.
by PP
Signature of Owner Date
City of Northampton
Massachusetts �' s►-
DEPARTMENT OF BUILDING INSPECTIONS h ;f
212 Main Street •Municipal Building v 5'b
� „» Northampton, MA 01060 � ,60¢
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
a -
(Please print house number and street name)
Is to be disposed of at:
WOV..54e-- c(V)I\ f\e'r 11174W
(Please print name and location of fa i )
Or will be disposed of in a dumpster onsite rented or leased from:
5 dd -1-ef'' `- lr\S V 4-GY)
(Company Name and Address)
Signature ermit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
=4:4
e. 7 Boston,MA 02114-2017
-" www mass.gov/dia
INIB
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business./Organization/Individual): O/ £ Y1 ecd
Address: I C O)1(5 _ f
City/State/Zip: 4>oC — VY' Phone#: 1 2 3-eiL q
Are you an employer?Check the appropriate box:
Type of project(required):
1.akraTira employer with C employees(full and/or part-time).* 7. ❑New construction
20 I am a sole proprietor or partnership and have no employees working for me in
8. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 i am a homeowner doing all work myself.[No workers'comp.insurance required.]
9. ❑Demolition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole I I.❑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 �R repairs
b insurance.:These sub-contractors have employees and have workers'comp.insance.: � I
6.❑ officers We are a corporation and its have exercised their right of exemption per MGL c. 14.t=!Othei rJ 01
152,*1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 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 must 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 employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:__.�� '' -j1i CCM 99
Policy#or Self-ins.Lic.#: C "71 3 v Expiration Date: J J1! dj
Job Site Address: 'P 0 17O\( SkCe--CA City/State/Zip:_FI GC
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
l do hereby certify un er the pains and penalties of perjury that the information provided abov is true a d correct.te
Si nature: Date: a c41
Phone
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
Massachusetts
t. , ,.
a x
se DEPARTMENT OF BUILDING INSPECTIONS
r 212 Main Street es Municipal Building yiJ. Aa
Northampton, MA 01060 r''W =�8 \�
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: - r (� 4 y
s4-reii---
Contractor n ^ I
Name: 62-7(/2 ` egbt if)l
Address: \ c yJ�‘-.
City, State: - L(- ' TINA
Phone: 4-f ( D-a) q -C 4'Lf
Property
Name: Owner v ( / I ,\ G pin, e/3
Address: fk4 '6- - --1r &'
City, State: fO( Z 4 t-c r
I, L a 1 1 (contractor) attest and affirm that the building I intend to
insulate"does not hea,
e 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 4 a- b I d- 1/