17A-285 (2) Property Address: 65' k
Contractor
Name: V \d .fie. \ \ )P t
Address: \ O (i k y �f
City, State: k*S\ 90 . ` M VC)
Phone: 'y -v�--
Property Owner
Name: rO;c*Nr C 1f\ \ Ci �t■\
Address: 6 6'6 Si •
City, State: \ \ (e O 0 \ -
I, L ovNekkek I.e.,) ?tk r y. c (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 i)Lt
Date
. =LA .a sac a...../seasswararrussars. 11) 471411.10144,4114•JCSAZ
Department of Industrial Accidents
1 , = ice - • .
0 ='
l Office of Investigations
' 600 Washington Street
Boostton,,�lph A 0211 �1
-i_5. Wi ma s.g�Nia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): r Z �0Y-.0.► - \c& ( \\ , (:"
Address: 1 \C)-1 1 c+. V44>k - . 0 l c
City/State/Zip: Hotyc) e Nry-,0„ Phone # :CV 1R) 5 3
Are you an employer? Check the appropriate box: Type of project (required):
L ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors 2 ❑Remodeling
2.0 I am a sole proprietor orpartner- - listed on the attached sheet.
ship and have no employees These sub - contractors have 8. ❑ Demolition-
working for me in any capacity. workers' comp. insurance. 9 ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself [No workers' comp, c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box Si must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information.
l am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 1 L Q V YN> \<D ii..
�.J Z-Y S CO -
Policy 11 or Self -ins. Lie. #: C Sag6c-1)S Expiration Date:" a)c.J )
)I
Job Site Address: Q 7 6i J--x- k---f (—/-- - " City/State✓Lip: 1 J O le V16- ( LA '�
!attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ineup_to imprisonment,as- well -ns oivi(penalties-in- the-form oft STOP WORIE ORDER-anda-fine --
)f up to $ 250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
'nvestigations of the DIA for insurance coverage verification.
r do hereby certify under the pains and p of perjury that the information provided above is true and correct.
signature: ) V:P,00. Date: l >
'hone #: ('-)1'0 s-st8,6Loa
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/Lieense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
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AFFADAVIT
Home Improvement Contractor Law
Supplement to Permit Application
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only Name of City / Town
Permit No:
Date:
Note: 142 A, requires that the " reconstruction, alteration, renovation, repair, Modernization, conversion
improvement, removal, or demolition, or the construction of an addition to any pre-existing owner occupied
building containing at least one but not more than four dwelling units), or to structures which are adjacent
to such residence or building" be done by registered c ontractors, with certain exceptions, along with other
requirements_ "� 1
Type of Work: C &) �� ��`+r""' Est Cost C J v
Address of Work: &y IA_
Owner's Name: t X \'l f_'
Date of Permit / Application: S 137 I o -
I hereby certify that
Registration is not rez wired for the following reason(s):
Work is excluded by law
. Job under S1000.00
Building not owner- occupied
Owner piling own permit
X Other (Specify) _C -A.0%
Notice is hereby given that: .
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS
TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER
MGL C. - 142 A. -
Signed under the penalites of perjury.
I hereby apply for a r ermit as the agent of the owners:
Date: SH " Con ftJjjtI i4stra& r S?314
OR:
Not withstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date: Owner:
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The Commomvealth of Massadmsetts
Board of Building Regulations and Standards AIM
. i . Massachusetts State Building Cede, 780 CMR
Revised Scot 2011
'"
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Fonoly Dwelling
Building • -......,,., . ..... , --:.... Apphed: . • ' - -
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'SECTION 1: 81:18 INFORMATION....;-.1:
1.1 Propesty Addresc -----,- .:,",.&-: - .- -- --rz-7 - --- , ,.... ---..------- -
Z--elCK-*Q .'-t: - , '::.:;`_':.=1*''''''
1.1als this an accepted street? - no . t
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1.5 Building Setbacks (It). c i
- FrontYani SideYwoh Rear Yard
Itemized Provided Required Provided Requhed 'Provided
I -
1.6 Water Supply: (M.G.L e. 40, §54) L7 Rood Zane InSmmation: 1.8 Sewage Dismal System: t
Ptitlie 0 Private 0 Zone : Outside Flood 7412e2 Municipal 0 On site &rapport system 0 I
Check ifyes0
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2.1 Owner' of Recur*
i
` v■ Nu, ‘c..-) 7-? )7i "F \ ('"\ pC ? I40\, 0 D ---- -
Name (Print) City, Side, 22P
6 - Ay za Ife_ -f- •
No. and Street - Telephone Email Address
-.; *.`!-"-::,--. SECTION3i DESclUPT194,91r PROPOSED 9fiRD WORle.—(ctheek4Alat ZIPPY) ::.t:=.
i
New Constructio' a 0 Pvivting Building Owner-Occupied 0 I Repairs(s) Cl I Alteration(s) c I Addition 0 . I
Demolition 0 AccessulY Bldg. Cl Number ofilnitt I Other Cl Specify:_
BriefDescriptien of Proposed Wade: 0 "VIII e v. 0.- i^ ■ C '-'' '1.-. \ k 6 • • av ilukDr_ _
• -tc 1 ‘ A'o ;ZKTIV(k ..)-t c-,
I
. - • - --- -- - _-_,-,:,...;---; :...,-_-,"--- :‘ -:' ."--;.-.=:-.=
aarlati A EsmiiiieD comitucnopicosTs.. ---,.,-. - -- -_--
Item Estimated Costs: --- - - - - :‘W.--.::;::: : 1 :- -; : k . _!i_egeist ---1- _thilly -..-- _ -. . :: :: ,1 74 . 1(:$ ‘ :'-' : :: . - : Vi-. : NI s - - :
(Labor and Materials) '- -- ' -- • !.:- : - - - ...,..1;:..:- - - . -.. „:... .
1. Building - $ 1 --INI*41*Iggt reg 4 :fE: *v*4
- 0 swan' OtraciwitAppOsiltipm-Yes 3_.:c..: - : :::.!:•- : y, , , - ; .
2_ Electrical - $ • -- -• - ---- — xi _ ..‘
• -
Tolal PiPiect (Ater (item 6) x nuOtiPlier '. "' x
.. . - - __:...-::-..- :..----:::;-.
3. Plumbing $ 2. _Otbeitretec S - ~ :--:.--:-. ----:: --: --_`-,..--% . %.:::,..---
4. Mechanical (HVAC) -S
..-.. -- --.--
5. Mechanical (Fire : ., - - - ::-. -.. - -- - -_,, .-.: • . - -- ---
l AU Fees $
Suppression) $ Total - - -- -
Check Check Amount - Cash Amount
- --,-,--
6. Total Project Cost: S ,t)31:2) 0 Pail in Pal: ' -- El Ontstanting &dance Du= -
_ --
64 LAKE ST BP- 2012 -0791
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 285 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 -0791
Project # JS- 2012 - 001383
Est. Cost: $2200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 13372.92 Owner: RIZZA DOMENICA
Zoning: URB Applicant: DONALD PELLETIER
AT: 64 LAKE ST
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON :3/13/2012 0 :00 :00
TO PERFORM THE FOLLOWING WORK :INSULATE ATTIC
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 3/13/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner