35-077 . ' _ - OP ID: LL
CERTIFICATE OF LIABILITY INSURANCE 1 DATE pirma r;r4
051311//1
-.SATE IS ISSUED AS A MATTER OF NATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
... tTIF1CATE DOES NOT AFFMMATIVELY OR NEGATIVELY AM1M, EXTBta OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTWICATE OF INSIMANCE DOES NOT CONSTITUTE A CONTRACT BE1WEEN THE ISSUING (S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: WO* certificate holder is an ADORIONAL INSURED, the poOg(ies) must be endorsed. N StIROGATION IS WAIVED, subject to
-the terms andi of the policy, certain policies mew require an endorsement. A stateless* on this crape does not corder rights to the
certificate holder in Neu of such ). - PRODUCER - 413438 - 7862 MACONTACT
IM
Remillard Insurance Agcy, Inc - - 413 - 638 -7179 r PHHOONE J ra iial:
79 Lyman Street __ - SNAIL
SWOT" Hadley, MOE 01075 + • - - -
Stephen E. Radon -
cDasro_o
anussua AFFORDING COVERAGE MSC a.
- - Donald Pelletier & Patricia INBVIER Hanover insurance Company 22292
a:Tedtnotogy Ins Co _
;T' 1107 -Main St SMUNER c:
Holyoke, MA 01040
INSURECF: - .
COVERAGES - CIBITWCATENUMBER: REVISION :-
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VIeTH RESPECT TO WISCH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY TIE POLICES DESCRIBED HEREIN W SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICES. LIMITS S HOWN MAY HAVE BEER REDUCED BY P1VD CLAI#S_ ..
-milk RIM - OF R POuCV 1p1 EM t t l� 1 ISSIMENVYYM MRS
- ENSMRAL UNRULY - - EACH OCCURRENCE S 1,000,000
A.- X coweseviGENERALuABILITV ;- 2:13149092391 - _ 0510911 05/05/12 t t s 100,000
-- I -MADE I X I OCCUR WED ISIP ,ON , $ - 5,000
- PE SONAL &ADV WARLY s 1,000,000
- ." GENERAL AGGREGATE S 2,000,000
GEM AC SAIE LIMIT APPUES PEM PRODUCTS - COLWIOPASS $ 2,000,000
POLcYn Loc s
roeeec A nY • - Sr S 1
A NYAtro. - AWN9160781 . 0711W11 O7t1OP12
BODILY NUDELY (Per P N $
ALL OWNED AUTOS ROOM RUURYPPeraoddsrti $
X SrHEDUID - PNOPHiiYDAN GE S
X _IDLED AUTOS. per accident) '
_ _
_ 1 U ALIAa- _ « - - I s .
• EXCESS UAB CLAIMS-MADE - AGGREGATE S
DEOUCTWE S .
— RETEMOr s - $
amines COMPENSATION X 1iteR (X - -
AND EMPLOYERS' UNRULY _
B p MIA T 07/25/11 072 L.
5/12 E E osAt AMIDE, _ $ 500,
' talandatory Is El- DISEASE - EAEMPLOYEE S 500, 4
�1 OF OPERATIONS below EL Dom- POLICY UNIT _ S 500,0. >
• -
DESCRIPTION OF °PRI MMOMSIL+OCAiIORSIVBBDLES Wads ACORD WI. Additional Aepides Sebsduis. U awe space lsnstoied) -
Installation Of insulation
CERTIFICATE HOLDER CANCELLATION
.
- SHOULD ANY OF THE ABOVE DESCRIBED PAS BE CANCELLED BEFORE -
---..-. TIE OCPIRATION DATE THEREOF. NOTICE
Dorinid & Patricia PeNetier ACCORDANCE WITH THE POLICY PROVISIONS. WILL BE DELIVERED IN
1107 Plain St .
Holyoke, MA 01040. � , Atrn mama REPRESENTATIVE
019 ACORD CORPORATION. AN rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
•
` - Office of Consumer Affairs and usi ness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
- Registration: 150319
Type: individual
- Expiration: 3/242014 Tr0 222191
DONALD PELLETIER
DONALD PELLETIER
1107 MAIN ST
HOLYOKE, MA 01040
- = Update Address and return card. Mark reason for change.
0 Address Q Renewal D Employment Q Lost Card
DPS-CA1 0 5OM- 04!04- G101216 //,,,,�� s,
Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
>> = !,. HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to
Registration. 150319 Type: Office of Consumer Affairs and Business Regulation
� —
t :: � Expiration: - 9/24t2Q14 Individual 10 Park Plaza - Suite 5170
_
' - -= : Boston, MA 02116
DO ` LD PELLETIER
DONALD PELI_E11EE D
1107 MAIN ST Q ... 0 f51'LQKC W. ! 1 3L• _!J`�ti[ .�_
HOLYOKE, MA 01040 Unde seeretary Not valid without signature
l lassachusiats - Department of Public Safetc
• Board of Building Regulations and Standards
Construction Supervisor Specialty License
License: CS SL 101876 • -
1 Restricted to: IC
DONALD PELLETIER «.
1107 MAIN STREET
HOLYOKE, MA 01040 f
dark - -° Expiration; 10/812012
t +aumi��ismer - T.r#: 101876
Property Address: < yo
(�
Contractor
Nam L 'Y``c \C uj 1 Q C
Address: \ \ V C &, o('
City, State: \C \-/ 1�cA o
0
Phone:
Property Pro Owner ten, ` S
Name: � \ l� �\ l `g
Address: c� �- �� fi 1�C
Cit State: I 0 f e V 'Q L/k- -\(}
I, t ' ) \ (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
; r!
AFFADAVIT
Y '
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: C .4. 'O 0'.
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 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: j la_k k '\e- Est Cost
Address of Work
'6"4--)D yc
Owner's Name: 1 C. .• C l t '� � Ca -'k
Date of Permit i Application: V
•
I hereby certify that:
Registration is not required for the following reason(s):
Work is excluded by law
Job under $ 1000.00
Building not owner-occupied
Owner pulling own permit
){ Other (Specify): U �7
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 GUARA flY FUND UNDER
MGL C. 142 A
Signed under the penalites of perjury:
I hereby apply for a r crmit as the agent of the owners:
Date: Contract s � st atioi I.] l 63 !
OR:
Not withstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date: Owner:
ems` A CM. a.vIMgWI6YVGI4Urs U) M MJJULraHJCa/J
N r Department of Industrial Accidents
-t Office of Investigations
—''irt'_ 600 Washington Street
Boston, MA 02111
'e 0. . www. ntass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business / Organization /Individual): 1 \ (,J k \'e*ww.0
Address: MY IC \O- h Qk , 1V.Ac1 kt._ O 1
City/State/Zip: \-;ttVv Phone ) 3) Cj SS
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. p 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. t 2 - ❑ Remodeling
ship and have no employees These sub - contractors have 8. 0 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 100 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 #1 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.
!Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp. policy information.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: t E C Y 1� ' Z� S CO
Policy # or Self -ins. Lic. # : C a <E)C-it) < ' Expiration Date: – Ito
Job Site Address: ZS � ` � � "1 11 • City/St ate/Zip : ( vy u•-
f'A
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
if 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 certib under the pains and penalties oo that the information provided above is true and correct
( iianature: W 1 - & �p � tl� u t �'� Date: rp)O 1 C
'hone #: `4 )
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/('own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone IL:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: i - / . No { t Applicable ❑
Name of License Holder �b�`� (� f � t \ ! , le v
License Number
Address / Expiration Date
Signature Telephone
9:aReq�stered;iome,lmprovement Contractor xw , _, , , -; _ 4 Not Applicable ❑
Company Name ,, Registration Number
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 permi
Signed Affidavit Attached Yes No ❑
1144 ?om Owner X mption
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
res , onsible for all such work , erformed under the buildinl ermit.
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
.a
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) ,
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks E0 Siding [O] Other [ J
Brief Description of Proposed ` t i ii
Work: er+ Lk/0k\ \ S -p,.r4a1 r Y `be\As e p r f ! aJ)JS *
Alteration of existing bedroom Yes • No Adding new bedroom Yes � - No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
satlf ew;house and addition to existinq:ho'usinq comp'ete>the'followinq':
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 FORBUILDING PERMIT
I, OA 1 C l e I I 1 ' ) 0 V` (.' , as Owner of the subject
property � � % j l p
hereby authorize % \ . \t'& i' // �J t o t `l �
( tc
to act on my behalf, i ' : r:.; ' e to o" uthorized by this building permit application.
Signature of Owne EMfir !1 i ' Date
I, — F - VOCJI. \d '.J Qk l ` f. Ni e. ( 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 an penalties of perjury.
rb ., ,. \ CA i lie \ IP l !- i "e r
Print Na - '
Z.ly 9-p
Signatu • • Owner Agent Date
.. ,
A, .,-
....
.. ,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To IncompleteriniormatiOn
la: .. ' .
Existing Proposed Required by 'Zoning
This column to 130 in by
Building Departs
I
Lot Size
Frontage
7 i
Setbacks Front
Side L:. ; R: L:; R:'
1 ,
Rear
Building Height
:-----
Bldg. Square Footage
. ,
Open Space Footage
(Lot area minus bldg & paved
parking)
,---,
# of Parking Spaces
„ ... .
Fill: i; 0
(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 ; i Page i and/or Document #1
B. Does the site contain a brook, body of water or wetlands? NO (D 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
0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: I
I
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
..
_ De p a rture) use only# , .,4
City of Northampton Stat of Permit:
Building Department Cu , �G u Drivewa ertni k t � RECEIVED
2012 212 Main Street Sewer ept v la biltt y � � ; �
Room 100 Wate e A vaila b i lit y `; �� i � ^ � � , � t .
Northampton, MA 0141060 - 587 -
Two S . f St ctur a � ��-
DC .PT. Of BUILDING INSPE on 413- 587 -1240 Fax 31272 PJo '' [an d
NORTHAMPTON, MA 01060 Other S ecl
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This se ction to be completed by office
1.1 Property Address:
�C; �� 1 � J� �'� (J Map . r Lot U ni t
Zone Ov Distract t
:Elm S t. Di CB Distract ' " " � 1
•
S ECTION 2 PROPERTY OWNERSHIP /AUTHORIZED A
2. Owner of Record:
nK
Name (Print) Current Mailin Addres �_ , it2 s...0 ova() ,13,t,ziTo ,.
c..,..t.y.t s i / Teleph
Signature /
2.2 Authorized Agent: '
O + n o \c C (-t_ I �'�' , �. i (`cam 1' t "�1' �
N me (Print) Mailing ess:
Addr
Signature Telephone
S EC T ION 3 - ES TIMATED"CONSTRUCTION COSTS
Item Estimated C (Dollars) t o be Officia Use O nly .
comp by permit applicant
1. Building (a)' Buildin Permit Fee
2. Electrical (b) Esti Total Cost of
C o nstr u c ti on f rom .(o)
3. Plumbing Buildin P ,
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 -1-,.5) , 1 7 j V.T. s7 Check Number
This S ec t i on For Officia Us Only
Build Per
=Date
j Number _ _... _ . � Issued.
,. .;
Sign
Buil Commission /Inspector of Buildings Date .,('cr- £ . /
I S {ACV (d/�
1/6q
R os v
, i
rs,p �� (� r Re , Re
842 RYAN RD BP-2012-0894
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 - 077 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 -0894
Project # JS- 2012 - 001578
Est. Cost: $1105.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 19906.92 Owner: GOMBERG BARBARA & MICHELLE SOLOMON
Zoning: Applicant: DONALD PELLETIER
AT: 842 RYAN RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON:4/23/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE WALLS - FINAL INSPECTION
REPORT REQUIRED
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 4/23/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner