23B-050 •
Property Address: 15 (3e r/ S ) i rc.. k rra NI - Wore
Contractor
Name: f-' .- INAbyfeitiepi r
Address: /4jA f yJe .
City. State: Cvi t j Mpt
Phone: 4 - ac-�1`s
Property Owner ric 1 ict
Name: ',
Address: 9 J YQome
rks- h tee_ e rrC
City, State: l `� Y -x'14 C t '' - 0 1 d (ri
CI I, f .�r E t pa S (contractor) attest and affirm that the building I intend
to insulate does not have ahy open air (knob and tube) wiring in the spaces to be insulated and
that I have provided the property owner with a Dopy of this affidavit.
Contr or i nature
'ere
Date 0763%3
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1
600 Washington Street
Boston, MA 02111
www inass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Aunlicant Information } n Please Print Legibly
Name ( Business /Organizatioo/lndividual): / �- . C_ � N I its / b Y e i e .iV
Address: (+ 60\/
City /State/Zip: U I r - 0 135 - Phone # : ( 41 i 2
Are you an employer? Check lie appropriate box: Type of project (required):
{�
I . am a employer with � 4. 0 I am a general contractor and I
employees (MI and/or part- time).* have hired the sub - contractors 6. [3 New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. p• iastttartce. t
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 110 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 rust 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 suck
tConttactors that check this box must attached an additional sheet showing the name of the sub - contractors and std whether or not those entities have
employees- If the snb-contracmrs have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for n y employees. Below is the policy and job site
information.
insurance Company Name: . /1.f_ L„` I —
Policy # or Self -ins. Lic. #: �� -1 � { y Expiration Date: / l / i 7/-)
Job Site Address:_ 15 & ra h, K /-C yr Cit l '? ot3 "1 0/66
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
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 c '! under the , , t! and penalties ofperjury that the iht nand onn prot'idid above is true and correct
/
Signature: 4 ---- re c Date / 0 /i
t
Phone #: ,.3 2
Offiral use only. Do not write in this area, to be completed by city or town o
City or Town: Permit/License #
Issuing Authority (circle one):
L 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 •
8.1 Licensed Construction S peMsor. Not Applicable ❑
Name of License Holder : ...- O �\ S ` (' ( �
l License N umber
1010 (4(1)
Address 1 Expiration Date
i 9-R- `. -3 -� ta;e
Sigrfature Telephone
9.4 ' to • d Home Im + rovement Contractor: I Not Applicable 0
- -V tl t--1C. \ MM r G e,t" .Its 1 , _ ..
& L `� 61 C___. t `i—(, 4.0
Company Name t Registration Number
I�, �,
I \i l� ea_ 1 , 11 v 4 Oi3�f •-- t- —�4- - F (t
Address Expiration Date
r
t
Telephone (3 (3�.1!-c)i a---z,
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (181.G.L c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submit 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 Dwellinss 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 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
I
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors 0 /
Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [l] Siding ED] Other [ ]Ld1
Work°� r. I (io 3) . J ✓.v n 09 Ciins,Ja.hrm .3 eQ/lgoy
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
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
N a h CAI), I 1 t afx_ , as Owner of the subject
property
hereby authorize --_ �� i S D' L S
to act on my behalf, in all ma! - rs - •five to work authorized by this building permit a li tion.
lf/ JO
Signature of Owner Date
`GL Y' `) (1■ t 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.
tam 5 k
Print me
yigna 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 L YES 0
IF YES, date issued:`,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW (3 YES 0
IF YES: enter Book ' Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO l
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (dearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO C
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
,
Department use only
, . City of Northampton Status of Permit:
\ Building Department Curb Cut/Driveway Permit
212 Malin Street Sewer /Septic Availability
Room 100 WaterNVeil Availability
c, IV�rthampton, MA 01060 Two Sets of Structural Plans
ohe 413 587 - 1240 Fax 413 - 587 - 1272 Plot/Site Plans
V Other Specify
■
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOUSH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
I) 5 f3u ks blr.& Map Lot Unit
I
F/ /"�/ 0 r � � , ryM ,r 0 �J / U I c �1 Zone Overlay District
( / / / f � 1 Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ri a� ( i /l
iy ar XIS & rics1), re . Pry 1- /cker) � tit. -
v Name (Print) J Current Mailing Address:
,/� 4. A _ - / Telephone G
Signature r . .. ,y/ i g - ® h
2.2 Authorized Anent:
--i& VY,Os ' l I t S N \ 60 /IC tee Ct `I , 4 ai -
—
ilk
e (Print) Current Mailing Address:
C'� ` t - 1 3- 3 - l i k)-
ign. ture Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building J 9 0, iA (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) / 91,0 , ,2 Check Number / `l, g r 3 .-- 5 --
This Section For Official Use Only
Date
Building Permit Number: Isued:
Signature:
Building Commissioner/Inspector of Buildings Date
,
File # BP- 2010 -1196
APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESS/PHONE 142 BOYLE RD GILL (413) 863 -2128
PROPERTY LOCATION 45 BERKSHIRE TER
MAP 23B PARCEL 050 001 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 / /��
Fee Paid ! �✓
Typeof Construction: INSTALL ATTIC INSULATION TO R 23 & GABEL VENTING,DUCT & BASEMENT
INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure EU..lt-
Building Plans Included: Pr-ter—TO (`j c
Owner/ Statement or License 091207 _ • _
3 sets of Plans / Plot Plan CC N i WV •
0 5 T rAAc j � "'� l W r � l N �T ktC NV 1 T
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO4 MATION PRESENTED:
L./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
14 0 -1 A -A--67 610 hi)
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.
+ r
45 BERKS 4 BP- 2010 -1196
GIS #: COMMONWEALTH OF MASSACHUSETTS
):Block: 23B - 050 F 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 -1196
Project # JS- 2010- 001730
Est. Cost: $1961.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. ft.): 6534.00 Owner: CAHILLANE MARIA T
Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC
AT: 45 BERKSHIRE TER
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 ATTIC INSULATION TO R 23 & GABEL
VENTING,DUCT & BASEMENT 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 6/30/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
45 BERKSHIRE TERR BP- 2009 -1104
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23B - 050 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTtREI)CONTRACTORS
Permit: Building ' DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2009 -1104
Project # JS- 2009 - 001600
Est. Cost: $5100.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 6534.00 Owner: CAHILLANE MARIA T
Zonis: �1RB(1001/ y nniicant• (A'-1 I..ANF T
AT 45 BERKSHIRE TERR
Applicant Address: . Phone: Insurance:
45 BERKSHIRE TERR (413) 582 -0484 0
FLORENCEMA01062 ISSUED ON:
TO PERFORM THE FOLLOWING WORK :REPAIR EXISTING DECK & ADD 150 SQ FT
DECK
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: C 01.<: 61 (S q C
Rough: Rough: House # Foundation:. 1 I
Driveway Final: J � , + i
Final:
Final: Fina
•
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: oil:
Final: Smoke: Final: e l k - q-" /5 -Q
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI0157 OF
ANY OF ITS RULES AND REGULATIONS. �_ io
Certificate of Occu.anc Signature:
FeeType: Date Paid: Amount:
Building $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo