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24A-154 • Property Address: 1-1b 1 I,p v o lt n "'e Contractor Name: 1 1..,.�v t S � S S w.. w S S I �r Address: ? t{ L S ., -F Ile- 5 F City, State: 11 o Icy i Y)1 0 4 - Phone: L113 32Z -3t l l Property Owner I Name: rneji a LvldeA Address: I4 N�' I k eve! City, State: IVe /414 a p r rM r4 t t a S I, wi + s & is bi 4 file A• (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 Date 6(/91( • 2001E ZLZTI8SCTt' xvd a: TT OTOZ /CT /80 _ A; • . . . 1. The Commonwealth of Massachusetts 1116 A t : Department of Industrial Accidents U Office of Investigations 600 Washington Street Boston, Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ( ' Name (Business/Organization, individual): 'jJLL , . (, LL_ )/ ' Address: , i --- ,_:?- ..:, \ ,..---, -i \ 'L , . City/State/Zip: - t -- t: _)1'Q ,V-,. \1 11-4 Phone#: ' i -.) ) r--- _ Are you an employer? Check the appropriate hi . Type of project (required): 1. X. I am an employer with _ [ (..) 4 I am a general contractor and I b. New construction employees (full andior part time).* have hired the sub-contractors 7. Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. 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. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself [No workers' comp. right of exemption perm MCL insurance required] + c. 152. § 1(4). and we have no 1 12. Roof repairs employees. [no workers' 13...4 Other ] r) ...., i.cA -1- comp. insurance required.' I 1 ,. ____I L An applicant that checks box #1 must also fill out the section below showing their N o rke rs • compensation policy information. 1 who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have em .lo ees, they must , rovide 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 infrrmation. i , / Insurance Company Name: ( -, ,(, „ L _k , i '-.,,, , ,:; , ,,,..,, L , _ ,,,, z, _ Policy i or Self-ins. Lic. r-:: :,_ IL.,t,:_ :;-4 i--k - i: - z ) .11„ Expiration Date: :VI L / ,-)ii i ') Job Site Address: City 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 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 andlor one year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certifi un ,.. the pai s and penalties of perjury that the information provided above is true and correct. ' Signature: , I I ' i Lk Print Name: Tt ,. .._)il IL-,■_: ''_.'-., 1:) _, 1 (..'_ v ' Phone #: (, ii -:': : .5 1 .,r) - 3 1 i Official use only Do not write in this area to he completed by city or town official ---- City or Town: Permit/license 4: Issuing Authority (circle one): I.Board of Heath 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 Supervisor: Not Applicable ❑ Name of License Holder : tn1 A 2 SL! 0 License Number r 2-9 TIVA/K S Vt ())4 cP's °Li° 9972/ Address Expiration Da qi3-3-zz- 3 111 Signature Telephone 9. Registered Home Improvem t Contractor: Not Applicable ❑ - A pow\ 0Ps 55 v �.�- I CA g Company Name Registration Number 50 14\ Let i /t L Address / � -� Expiratio Date 7 J-13 'C7 a \ . Telephone) - 3Zl 3 t 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 ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of or�e•(1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, p oS1ded 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 reside 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 an:. home in a two -year petlod 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 (W,orkers' 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 perfnit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and al 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 Alter d (s Roofing ❑ Or Doors 1:::1 1 1,, ;) Accessory Bldg. El Demolition ❑ New Signs [D] Decks [C] Siding [0] Other [0] Brief Description of Proposed j Y� / r 5l . Work: 3Sv e tl C l�x�S r� .1_1_01._ � ' % Alteration of existing bedroom Yes � No Adding new bedroom Yes No ) o Attached Narrative Renovating unfinished basement Yes t. No /A1I" 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, .\ C 'D C ?.00 co itit c,l t/1 as Owner of the subject property ,' �1/ hereby authorize 1 i) VM VO c �D n' I c- I P L to ct n my b , in all matt s relative to work authorize by this building perm't application. r7- Si at re of Owner Date I, 1 niovVAG(5 76,Sr w% 4 s 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. tivv.0 s ltlSknA Print Name 19/4,0 Signature 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 DON'T KNOW YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ID DON'T KNOW 0 YES 0 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 0 NO a IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 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. f Department use only City of Northampton Status of Permit: Building 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: n , � t� This section to be completed by office 9.0 00( — / Map Lot Unit 36 KCO Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: { i I I\ G- 1 C ta 4jo 006611_ 1 k�� , .1 �I D1c6c •e (Print ; / Current Mailing Addres A Aid i1(t.44../ Telephone ig attire 2.2 Authorized Agent: . i© t - !, i '2,r/— o ST , )0L�a ✓� iAA n■ o( O Name (Print) / Curr nt Mailing Address: L \r3 -322 - 3 ) \ \ Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ,. . V AS 1 r'1 i 5 C ,) 0 (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) 22 5( ' \O Check Number M f y05 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date W File # BP- 2012 -0190 APPLICANT /CONTACT PERSON ENERGIA LLC ADDRESS /PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111 PROPERTY LOCATION 40 NORFOLK AVE MAP 24A PARCEL 154 001 ZONE URA(1001/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out / �J --- Fee Paid / ° /O Typeof Construction: INSTALL ATTIC FLOOR INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 92540 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 1 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 /4A--.1 Z Y ( 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. 40 NORFOLK AVE - BP- 2012 -0190 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 154 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 -0190 Project # JS- 2012 - 000295 Est. Cost: $2256.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 9975.24 Owner: ARNOLD THOMAS D & AMELIA ENDER Zoning: URA(100)/ Applicant: ENERGIA LLC AT: 40 NORFOLK AVE Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322 -3111 WC HOLYOKEMA01040 ISSUED ON:8/25/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL ATTIC FLOOR 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 8/25/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner xi