12C-057 Property Address: - c \ d j-
Contractor
Name: ,
��X�y�Ca�C'� t�) C'���w'
Address: )6 PAQ \ Nr
City, State: ( j ■ CY
Phone:
Property Owner
Name: tCC,� 6c):27_
Name:
Address: V CO SAD
`
City, State: `— CC' Y''C `C— \O r
I, 7 J@`s`t'kvi i h 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 signatur jeSk eri
Date
The Commonwealth of Massacbwetls
, a. -.. Department l
ent ofIndu riA
.� ofIisve gatinns -
aa 600 iY ashirtgton Strad
_`fie' -: Boston, M4 02111
Workers' Conweinsalion Insurance Affidavit: den/ContractO • • - --- hunters ., -.- - --- --
Applicant Information 1 �} Please Print :Lea ibly
Name ( Business /Organization/Individ o l): 01J l9' le (,L) ■ 1 d -P t e z.
Address: 1101 A i 0 $.
City /State/Zip: I ,.,t n I'{ R., C 0' I D 0 Phone #: `1 - 5 3S £ 00D.
Are you an employer? Check the appropriate boz:
1. J� employer I am a with 4. Q I run a general contractor and I Type of project (required):
F r1 N...R:- .wetmeti
2. I am a sole proprietor or partner- listed on the attached sheet. 7, 0 Remodeling
ship and have no employees Thole sub-contractors have 1 8. >0 Demolition-
,...'a.;.'.. c....- , ; .. <+.:+., � --- -- ; ti a hr:-,:e - workers' �.
eq we d . ] camp. woe 5. corporation and its 10.0 Electrical repairs oradditions 0' officers We are s c have exercised their 1 i. plumbing or additi�
3. ❑ 1 am a hontexive�nec rinina an Inn* - � mL ��
insurance required.] t c.152, e1(4), and we have no 13. ruPaus 1(1. `SLA 1
employees. [No workers?
"...)� "' ie.?hcr. sY?a[Itlired.1
*Any applicant that chocks box #1 must also fill out the section below showing their waters componsaitius coin ptiwy sukumation.
t Homeowners who submit this affidavit s they are doing all work and than hire outside connector: most submit anew affidavit indicating such
tContractors that check this box mast attached an additional shed showing the name of the sub-cars and state whether or not those entities have
employees, lithe sub-es ,.h.. , -__'-_ - - _ ' ' _ _'" . _.:: -'mss.
I ant an employer tJiat is proved tg workers' coaq, tion insurance for my employees. Below is the policy and job siie
T • -•- . -.Szm .- 17i, e? to j t, ^. 1en, i r $ 0v. n ! IN
u
Policy # or Self -ins- Lie- # �,. 3 c� R 4 0 S Expi Date 1 /i lS 1 I a-
' < � ru o 1 C �- � 1. �,: k�c ,.
Job ,,. twua.a..
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required tender Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
TTP
in to Cl <AA AA ..<:..t! one <,.......- ....�,.. -..... _ --.11 -.- _.. -._1 __ -_L•__ .a__ ..r_. _ _r _ elm......• nro-sr. :r �-.r.m - _ • - .'- ,
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.
signature- LX - RkS Q t r Date '
Phone It: \ r *' ' S -_.. use only Do am wile in this area to be completed by city or town official
..a v1 iuwa: _ PermitiLt+censc #
Issung Authority: Banding Department
I Contact Person: ' Phone #: (413) 499 -9440
•
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: j D \/ Q
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- e'dsfing owner occupied
building containing at least one but not more than four dwelling unit(s), or to structures which are adjacent
to such residence or building" be done by registered contractors, with certain exceptions, along with other
requirements.
Type of Work: t 1St � 1a �� Est Cost . ) 0
Address of Work: �, f
Owner's Name: b Q cc ck? \ \
Date of Permit / Application: 3 ') ..
I hereby certify that
Registration is not required for the following reason(s):
Work is excluded by law
Job under S1000.00
Building not owner- occupied -
OKner pulling own permit nn
)( Other (Specify): �
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 ,.omit as the agent of the owners:
`
Date: v Contra e ( � sfratioi � co3 !ot.
OR:
Not withstanding the above notice, I hereby apply for a permit as the owner of the above property
Date: Owner:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
Not Ap
1, •— ) Name of License Holder : L>v' `� � , \e �\ �'C ( C ) b `
License Number
k \D intA kNi*N vi k r
Address Expiration Date
s
Signature Telephone
9. Repast Home Improvement * +; C O Contractor Not Applicable 319
r kC
Company Name _ t Registration Numbe
Address Expiration Date
Telephone
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 per
Signed Affidavit Attached Yes No ❑
11. - Home Owner Exemption
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding [D] Other
Brief Wo k Descripti Dt' o1 "S�t s G v ‘NN-I ( eJC 1 &At /9 Z-4-Si n i I 7 ! Ce/ hih, „ `— -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes 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 - Y\Sli\ &h Y
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
1, e 1 I- _. �? CC 2 Z ∎ I I o ,,, , as Owner of the subject
property
hereby authorize ; ( ( � `-' uu ' " %ve \e (' 1 c-
to act on my behalf, in all matte s relative to work authorized by this building permit application.
A tate -4 r* ' / '2 ., Z // 1/4-3 / ( ji a"
Signatu e of Owner ) Date
I, doeu 4 64 2-7,11 4 (- 0 0 ' - t "d a. ) P 11 Q r , 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.
Si ned under the pains and penalties of perjury.
bee c.t, 6-1-4 G -2,+11 r a L ,' e ∎ Iftk e
Print ame /
Lete-fri i 4144 Si, (,
3//(0 i t - 2_—
Signat re of Owner /Agent Date
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
IF YES: enter Book Page and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES NO I
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
4
RECEIVED Department use only
- C o.f Northampton Status o #Permit:
Z 6 Bull ing Department Curb Cut/Dr Permit WA 2 Main Street S went epticAvailability
O roFeunaNC3Ptsn Room 100 Water/Well Availability
SON MA 01050 ,a mpton, MA 01060 Two Sets ofStructural Plans
phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
Other Spec
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
L
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
G BQc - ' w i • � Map Lot Unit
1( � ,5 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
"(-- Name \C (� `�� 11 i f rnck - =1- •• i�b >0)4k-
Name (Print) Current Mailing Address: Telephone
Signature
2. c c3 ` C�C�
Nam ri \ Current Mailing Address: g74 . . . -
Signature f/ 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
2. Electrical (b) Ettal of
Construction stimaed To from Cost (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) _SID .) 0 Check Number 1/4301 r j ��
This Sect For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0823
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS /PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION 26 HAROLD ST
MAP 12C PARCEL 057 001 ZONE RI(100)/URA(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 30// 4:
Typeof Construction: INSTALL WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 101876
3 sets of Plans / Plot Plan
THE F9L- LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN RMATION 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
1 on D
Signature of Buildi g fficial 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.
26 HAROLD ST BP- 2012 -0823
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C - 057 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 -0823
Project # JS- 2012 - 001451
Est. Cost: $2850.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 10628.64 Owner: GAZZILLO REBECCA L & DAVID R
Zoning: RI(100)/URAU100)/WSP(100)/ Applicant: DONALD PELLETIER
AT: 26 HAROLD ST
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 - 6002 WC
HOLYOKEMA01040 ISSUED ON:3/28/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WALL 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 3/28/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner