28-021 44 left
PARTICIPATING
mass save CONTRACTOR
PERMIT AUTHORIZATION FORM
I , 2,41 ,tie. G 'l.61/F_,.. , owner of the property located at:
(Owner's Name, printed)
(Property Street Address) (City/Town)
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property.
. f e.. —
Owner's Signature
4
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
Rev. 12132011
a Isc wII UIWI4r1G{4{4IS U ) 11luJJ{41.1414.1GLW
■ 1m •• Department of Industrial Accidents
; Office of Investigations
= ' 600 Washington Street
:t:r-Z-- •r
'' Boston, MA 02111
=awe w vw. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business / Organization /Individual): r" bt.. \� ? "k e C
Address: \(S “1 0- t f± • �, t �p 6
City /State /Zip: \-4 �/c) k e yyNck Phone #: } ` �j scm a
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a employer with 4. ❑ I am a general contractor and I
6. Q 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 7 . ❑ Remodeling
ship and have no employees These sub - contractors have 8. Q Demolition
working for me in any capacity. workers' comp. insurance.
g Y P tY� 9. 0 Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3. D 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.
tContractors 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- S CO • �-
Policy # or Self -ins. Lie. 7s. te)yc)�, Expiration Date: "5" 4
Job Site Address: tI C Y �' "' . City /State/Zip: r C l" r_?
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 certi& under the pains and ppenalties of that the information provided above is true and correct
Signature: iNLr. Date: i \ ti
Phone #: ' )
Official use only. 1)0 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 /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
•
AFFAD A VIT
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) ( L_
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.
C
Type of Work: OS( ) k�fi Est Cost C)
Address of Work;
Owner's Name: Cwt 'V' C, C i.) (c,e { kp t _-` .
i
Date of Permit / Application: � -- 1 I
I hereby certify that:
Registration is not rzciuired for the following reason(s):
Work is excluded by law
Job under S 1000.00
Building not owner - occupied
Owner pulling own permit
X Other (Specify): add e \,;10 k3
Notice is hereby given that:
OWNERS PULL[NC: THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME [MPROVEMENT WORK IX) 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 r ermit as the agent of the owners:
Date: /_ 1 4 Contract I stiatior IS
OR:
Not withstanding the above notice, I hereby apply for a permit as the owner of the above property
Date: Owner:
Property Address: C. 40 r- 1'-- k\ \l_ kt.1
Contractor. i f '�'`
Name: : ZiTr Il_ a c�, () • \-, '',' c..) _ -
Address: 1 \,D M Q -A , (2 \ ./--- 5- - .
City, Stater 13 c/0, .
Phone: S
Property Owner •
Name: Cf~'v'`y.= i '- , (3cSE �� ) k )
Address: 6 c ('> ' __. v.( <\ ` r , '
City, State: kA ;',. \ \ 0--._ , c I) k cLY-4 t>
i, c c ate,, C1 C J P, \, `, r 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 bejnsulated and
that I have provided the property owner with a copy of this affidavit.
Contractor signature c,---, c r,, _ \ .
T i'Y') .`' )(, -„1.)\•
S ..\
._',) A 5 - --
Date O - f 2 .--
•
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) n
License Number Expiration Date
Name of Holder / List CSL. T (see belo w CD. L 2 /7 ±.) yp )
Z.T \ss't Type Description
ti Unrestricted (up to 35,000 Cu. Ft.)
R Restricted I &2 Family Dwelling
Si ,_ r, M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
Register rd Home Imprn%e ent Contractor (HIC) \
�A )_'� ve-F
HIC Company Name or HIC Registrant Nparg Registration Number
:.,
NIA _�` ` �r.C�� - Expiration Date
►gnature Telephone
SECTION 6: 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 building permit.
Signed Affidavit Attached? Yes '❑ No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, A `-`�� i j k � "q( � ( _ , as Owner of the subject property hereby
authorize ', O ) t ` ct Lr > �, j` \ r to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner ( f ^ -1. Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I, f ' 1� j '0( . � t -g) , k' ` { , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf. t (
• -.11 M 116211 . 6
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations I I0.R6 and 110.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
0
'■ J UL \ 1 1111 \
V 756- 131-)11‘ -. ‘-; mt,10
\ NOSTH ' -
The Commonwealth of Massachusetts
Board of Building Regulations and Standards AM
Massachusetts Slate Building Code, 780 CUR
Revised Sept 2011
----- ''
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One or Two Dwelling
Building Permit Number. ' ' --- .. - ' -- : . '.---' - :" - .-...] Date Applied:
-.
ati Official (Ptiot Name) ,.' --- ' 777 . - ' - - : i': z .----` - ' ' .*--- ' '...' ::
- SECTION 1: 81011C 011 .s. :-..,: '" ''',..--,: ------‘;',..:.-- : ::•= 1.. " -- ' :::_:
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1.1a Is this an accepted street? yes _ _ _ no * ‘ ' ;,-- '.. - - k..',.-i- "- "::-. 1:1
,,et, 'c-,.-.S:: ' ' - 74 - = - T."4.4... - .
.!.-....,, - -. ,..• 2..-.'
13 Budding Setbedts (ft) , f
Front Yard Side Tanis Rear Yard
Required 1 Provided Requited 1 Provided Requited 1 Provided
. i
14 Water Supply: (M.O.L C. 40, § 54) L7 Flood Zone Istenstetion: LS Sewage Disposal System:
Zone: Outside Flood Zone? 1
Public 0 Private 0 Municipal 0 on site &spinal system 0 I
Check ifyes0
i Li Owner' of Raarrch
6u-L.,_ • )c) c e vc_ , I
Name (Print) City, State, 72P
690 r. -Lie:r\ r"- '
No. and Street Telephone Etna Address
1
:-: : ; ' --, * i ,,• ' - PROPOSED wowelcheik 0 that amply)
New Construction Cl Existing Bolding -;; Owner-Occupied 0 1 Repairs(s) 13 I Maude:Ks) CI 1 Addition 0
Demolition 0 Accessmy Bldg. 0 Number ofUnits I Other 0 Specify:
BriefDescription of P10P0sed %A c I b $,-: c ci Ick 6.= V \
( I 0 - 1\:...) Ov 1 C ' Pico
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(Labor and Materials) s ±----:-.; - ': ,•-,-- - - -- . ...., - --- -.3;:'` --\..`.- -"
I. Building S I . A - •: - =' - '' - ':* 1 -144,-0P1!**...,....dsterin*d:,':
poignant CitylTawaApptintionftp
2. Eleenical - $
,0 1014,1110ieq.64--at511 6) x mlOtija X
3. Plumbing $ 2 - 0 4 1 1411 1 0. 1 01: -5 '----- .----- -,-.- ' -. -- .1 , ..-- ,.. z I_ , '.--,..: • :'.-- ' . -.: i :
4. Mechanical (HVAC) . $ bat
S. Mechanical (Fire ---_-- ' -
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, (__)_„; Check No. 01 14ellieoic AllbX1111L - Cash. Ammmt -
6 ' M ta l Pr eicet C6 st : 3 DrIOD DPW bi Pall -- -' -- 1:30atstawkig Balm= Due: '- ' -
i
File # BP- 2013 -0072
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION 690 RYAN RD
MAP 28 PARCEL 021 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out (./N
Fee Paid
Tvpeof Construction: INSTALL ATTIC FLOOR 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOOIATION PRESENTED:
pproved 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
(i /
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.
690 RYAN RD BP- 2013 -0072
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 28 - 021 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 PERIVIIT
Permit # BP- 2013 -0072
Project # JS- 2013- 000102
Est. Cost: $2900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 36633.96 Owner: PURSEGLOVE CANDECE
Zoning: Applicant: DONALD PELLETIER
AT: 690 RYAN RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON :7/20/2012 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 7/20/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner