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31 2962729 HONEYWELL 1021:47 a.m. 0630 -2010 717
14 HARLOW AVE EP- 2010-0192
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Map: 38B
Loc 288 ELECTRICAL PERMIT
Pit Electrical
Category Remove knob it tube wiring
Permit*/ Electrical
PERMISSION IS HEREBY GRANTED TO:
Project # JS- 2009 - 000450
Est. Coat: Contractor: License:
gee 565.00 RONALD WILLIAMS Journeyman Electrician 11275 B
Owner: BROADBRIDGE ANNE F &
Applicant: RONALD WILLIAMS
AT: 14 HARLOW AVE
Applicaiet Maras Phone Insurance
103 Foot f .wed (4 329 - 1174
WARE M■01082 ISSUE 00 :115&0( :00:08
TO PERFORM THE FOLLOWING WORK:
Remove knob &tube wiring
Call In Date: Date Requested 7aeoeetiun DatatS.iasORI Relutneet?:
Trench/U(4
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Fee TWGM:: Amount DatePaid
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212 Main Street, Phone (413) 587 -1244, Fax (413) 587 -1272 -Inspector of Wins - George Fournier
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"l IDEAL HOME IMPROVEMENT, INC
"Your Home Energy Conservation Specialists"
FAX TRANSMITTAL
To: Louis Hasbrouck From: Laurie Ellis
Fax: 413 -587 -1212 Date: J.ne 30, 2010
Re: Knob and Tube for Anne Woodbridge
Louis,
Attached is the information you requested for K&T deactivation for Anne Broadbridge, 14 Harlow
Ave., Noatha m pton.
Thank you
Laurie Ellis
142 Boyle Rd.
Gdl, MA 01354
413-863-2128
Toll Free: 413- 877 - 863 -2128
www.idea lhomeimurovementinc.cw
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DESCRIPTION OF WORK PERFORMED
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All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications
provided for the above work and was completed in a substantial workmanlike manner for the agreed sum o
Dollars ($ ).
This is a ❑ Partial ❑ Full invoice due and payable by: Year
Month Day
in accordance with our ❑ Agreement ❑ Proposal No. Dated Year
Month Day
�, .. CONTRACa KS I N\
•
The Commonwealth of Massachusetts
•
Department of Industrial Accidents
Office of Investigations
ft 600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): i 6- L.. /1-0N-C__ I ik'(10/ d) Y ,, n t ' N i
Address: /+ 'y
f ,
City /State /Zip: I �' i � (35 4- Phone #: 4-(3 - 330 3 (c
Are you an employer? Cheek the appropriate box: Type of project (required):
1. 2 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
2.0 I am a sole proprietor or partner listed on the attached sheet 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. [] Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. [D We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no 0 nPn
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box 51 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 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: ' t ..t1 ti L& —
Policy # or Self-ins. Lic. #: �� �? ` �-/ Expiration Date: 11 ? 1 1 O
Job Site Address: /4 Y iel rich) (2 VC. City /State /Zip: /110 1
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). C / & 0
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby 506 under the and penalties of perjury that the information provided is true and correct.
Signature: "nt_ � • re se*. Date: of) i O
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Pennit/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 #:
SECTION 8 - CONSTRUCTION SERVICES I
8.1 Ucensed Construction pervisor. r Not Applicable 0
Name of license Holder - -3 � Y Q S E L t t cl
{{ ) q Imo`
License Number
* ■ 60 ��� . ; t l MA �► z J'
Add
�J Expiration Date
g4:3 — Q I a
Si ature Telephone
eiC
9. istered Home Improvement Contractor Not Applicable 0
1 Vi. L ¥1 Mt_ I &it le o i"teN1 i . L cq C _. _ t 9-te 4-0 a.
Company Name Registration Number
Address t Expiration Date
Telephoneh 3` 0t4-4l d
SECTION 10- 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 permit
Signed Affidavit Attached Yes_ £ No_. - -- 0
11. Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner occupied Dwellines 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 buildine 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, von 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, Shur and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House J Addition J Replacement Windows Alteration(s) E Roofing El
Or Doors CI
Accessory Bldg. El Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [Ca
Brief Description of Proposed
Work: Rl9 attic insulaton and wall insulation to R20
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, I / • Ion I1... , as Owner of the subject
hereby authorize Ja... S E ) t S
Y � y �
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner IIP aM" rJ��� Date Ce Mil
I, j&111,03 F! j I S , 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.
--i afne s EIli
P . ame
v�--� �� 6�o //i J
Si n ture of Owner /Agent Date
,_ ffi
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
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 #
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained , Date Issued:
C. Do any signs exist on the property? YES ® 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 ® 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 ® NO ®
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
:City of Northampton Status of Permit:
Bthlding Department Curb Cut/Driveway Permit
-. 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
" - Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
i
-14ctrItizo art. Map Lot Unit
m!° r4-11g/71P , if / D6 l Zone Overlay District
V U Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Anne Broadbridge 14 Harlow Ave., Northampton, MA 01060
Name (Print) Current Mailing Address:
413-587-9219
Telephone
Signature
2.2 Authorized Agent:
l ms
eihs 4 , ; ) , 6o Je_ �. G , 1 1.1`1 q o ( 3
Na i - ' int) Current Mailing Address.
Sig
40
re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 2,639 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 2,639 Check Number /loo `
This Section For Official Use Only
Building Permit Number: Issued:
s
g I
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -1195
APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESS/PHONE 142 BOYLE RD GILL (413) 863 -2128
PROPERTY LOCATION 14 HARLOW AVE
MAP 38B PARCEL 288 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out j / Q' �y '
Fee Paid / �(Od 5�J
Typeof Construction: INSTALL R19 ATTIC INSULATION & R20 WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included: was( WILT t 62)
Owner/ Statement or License 091207
3 sets of Plans / Plot Plan CON T RACt'0 0 M 445T S ^a 6tv\ WI rt.1 A FF I
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF MATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other 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
_ 61 A
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
SLOW AVE BP- 2010 -1195
GIS #: COMMONWEALTH OF MASSACHUSETTS
ap:Block: 38B - 288 A CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -1195
Project # JS- 2010- 001729
Est. Cost: $2639.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. ft.): 6185.52 Owner: BROADBRIDGE ANNE F & DAVID A PETERS
Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC
AT: 14 HARLOW AVE
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863 - 2128
GILLMA01354 ISSUED ON:6/30/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL R19 ATTIC INSULATION & R20 WALLS
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 6/30/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo