05-064 Property Address: 4- 1 ' CVO U ` _ocd •
Contractor
Name: sra. kci t r;) t_t.e+1•i
Address: \ NC"
City, State: OA YT'' \cam, 1 �
Phone:
Property Owner
Name: Q2 . cs3 \N('
Address: '`1 la C O 1
City, State: j-- �d S Orr), . Cm y �j
1, C)J'v \ci j \-0' o V ('' (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 <„ LA °
Date
- - _ 741 - - - O, o'�ev ' atio _ - - -
e f '= 600W -,fit - • - -_ -
. - , BOOM, 1A 82111 - - '
www mss .gam
- - - Wmk rs' Compensation Inwaaee Aff da vi _ 1
-mE1021 - . - - -
Name ,bOa 169 6 � -Ph- e:ee.„ - . " . _ ..
, L . - - - Addy's& 1101 IYIAI 1.) '4"; _. .
- City �zp: Iai.e - . O i#: I .b = ilii
cow
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0 -I am as earploy w tt - . al QQ-: I sat a ecal ccatractot mdI �' ( -
- Lave hired the Sulkontnictors - -G. ❑ Ncwc�
ar no'! _
(fiztl p ).* _ hi' Pod clniheattached sheet 7. ❑ Rig
2 ❑ I am a sane proQrielnrorpat -
ship and have no employees - These solr--oontiactors_ave - - - - . - - -
8 `� Memo
working for me in any : - _ _and bav+e wxs' 9_
[No woricas'• insurance . insurance O lmi # - - Building -
IPOTeti 5. 0 We we a Corporation and its - _ 100 Ele i Xe isas-arad ion
- ID I am aLomea uner doingall Vrodr * erica* have exercised their - 11:Q PLlmbiagmpails or-additions - •
myself_ [No dof per Mr. - •
- It ri ' . v 152,$i(4),andwellareno - 12.., tbib - - warless, - 13.in [ iesS `+0.'.l c'�.- Y"
en 1
*M9 psteat divots itcall nest aboMI °Wisp scull= below showing Sick wodoste aoeapeenao. policy infar as_ •
- tHoeeowms who si ut aafdavitimMew gEttlyaobdaai¢al wadrand lbw lire amide cos6aretossavt aaewaffidavita g di.
dot check Ibis box slat tdfed*aaadOW- N dabeetalinviegdicmoo oldioseb. oomIaGrsandsleretabadsaarsmtIbooeattiar
• =ployMM Me NilFOOSraaloss have :apiaryega, ►maetproridettniE swateas: comp. parity numbm; - -
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. lianas employer that isprllNka*: ' err insm ie, jes'rrll e s yea. - Bela► it fitepailey aad**s8e
` . Insuranie CompanyN - fecin itIO 10 1 k CO =
parSelf-41m. Lil~. #: - 1 V1 C 3 aVP t / ° S — - - - . -1 X //a - .
. J o b S i t e Address: . - - - - - • -
At ach a espy Of the marlaars' -casepesmatioa P i e t 9 page ( the parmymirnehermad d e). _ -
- Failure to se xe caws required midaflectim25A o c. 152 can loadte ihe imposition ofahnired pe ofa - .
fine np tu mr inmrinonment, as well as civil pe affiesintie WORKORDE .andafiim e
. ofnpto$250 00 a day against the violator. Be advised that a copy .ofthis statement may - be Rewarded the Office of - - - -.
hivestigationeafthe DIA•for insurance ooh Ana.
•
Ids hereby a wader ate pins end " . efpesimy t ai tie i tfor aa6ioatpt+o's�ldedabare alma and carted _
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a '1 CA) A LI, T D - -
Rhone . VS) :S"• &X) - -"
• .ffkia lose oak Delentariteiealms area, 0•beeviap ted frieityaearttrea, ai _ -
• .. City or Tawss:: - Perak/Lk awe 0 - • "y: - - - -
f C•antaet Penal e ' Phones: (413) 4994440 - -
SECTION $ CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: • Not Applicable ❑
Name of License Holder : � C� ' \N LL) A R 1 e (3 8 - 1 6
License Number
o \ �1 r i ( :j t-10V NCA ID-
Address Expiration Date
Signature Telephone
o ` r ii o Not Applicable ❑
� .� , .aveinenfi� � �on ra` r �-° �"' R� � ,. �m� a. � �
ww �� cam . � �� �F_! C ► � J 1 °■
Company Name Registration Number
•
Addy s Expiration Date
`-'v► 4 Telephone `'
2: v4 ! ..� `wt - 5 - Loh t
SECTION 1f- WORKERS' COMI?ENSATION INSURANCE AEFIDAVIT G L c 152, § 25C(6)) r a `...
Workers Compensation Insurance affidavit must completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building it.
Signed Affidavit Attached Yes No ❑
le' V ! , ° ,9 11� ice
The current exemption for "homeowners" was extended to include Owner - occupied 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 acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own 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 homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for 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 Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
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, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
•
4
SECTION 5 DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks IP Siding [0] Other)
Brief Description of Proposed •
Work: 0Q * i e -v J l - Qi I( 6 r cf' 11
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
a if eW.;tipuse.an o exis ou st ng, . :comp`Ieteshe5at owing
a. Use of building : One Family � Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each '
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNERAUTHORIZATION, TO BE COMPLETED WHEN
OWNERS AG OR CONTRACTOR AP.PL1ES FOR BUILDING PERM1T .
5 Coe p\ , as Owner of the subject
property
hereby authorize d
to act on m behalf, in all matters relative to work authorized by this building permit a•plica ion.
b - 3
Signature of 'owner Date
•
1 r `C`C)1/4 . \ (>� c l e_`- Y `Q , as Owner /Authorized
Agent hereby declare 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.
Print Nam
/90 pcJieli-ii t
Signature of Owner /Agent Date
i R
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ,i
Existing Proposed Required by'Loning
This column to be filled in•b ^• ''
Building Department
Lot Size i e <
Frontage I , sl
Setbacks Front ! € 1-
Side L:' R: L.--1 L:i . R:! L__i
Rear I 1 1 1 1
Building Height i 1 , . I I
s � r
Bldg. Square Footage 1---1 { i % 7-1 i
Open Space Footage - 1 % =
(Lot area minus bldg & paved
parking)
# of Parking Spaces [ f
Fill: ----- --- .
(volume & Location) I i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #1
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?
Needs to be obtained 0 Obtained , Date Issued:
I
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
File #/ ''- 2012 -0701
APPT. ':\NT /CONTACT PERSON DONALD PELLETIER
ADI ;S /PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PRO' TY LOCATION 412 AUDUBON RD
MAP PARCEL 064 001 ZONE RR(100) //WP/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZOI`. ORM FILLED OUT
Fee 1
Buil, crmit Filled out ([f t f ,�I 5--
Fee i / b�
Type, 'onstruction: INSTALL OPEN ATTIC INSULATION
New ,struction
)n Structural interior renovations
' I l i o n to Existing
sory Structure
Buil '`':ins Included:
Statement or License 101876
s of Plans / Plot Plan
THI. .LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF' "[ION PRESENTED:
ed Additional permits required (see below)
NING BOARD PERMIT REQUIRED UNDER: §
nediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
NG BOARD PERMIT REQUIRED UNDER: §
ng Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
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 Delay
Si I Building • cial Date
Note , ce of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requ is and obtain all required permits from Board of Health, Conservation Commission, Department
of p rks and other applicable permit granting authorities.
* Var are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Plan )evelopment for more information.
412 AUDUBON RD BP- 2012 -0701
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05 - 064 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- 2012 -0701
Project # JS- 2012- 001233
Est. Cost: $1838.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 189921.60 Owner: COHEN JOSEPH D & CATHY J
Zoning: RR(100) //WP/WSP Applicant: DONALD PELLETIER
AT: 412 AUDUBON RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON:2/7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL OPEN ATTIC INSULATION
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:
FeeType: Date Paid: Amount:
Building 2/7/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner