The URL can be used to link to this page

17A-042 (2) Property Address: ( `� ( C Contractor l e ` r AcI ' c �� Name: �` Address: 1 1 City, State: 3 ( 1 C) k'e vynt . a ( 0<-4L Phone: %6 (33 Property Owner 1 Name: \C 11 Y� Vic\ . �J k. �'�'� PLC j Address: 1 d (1 d{ d' City, State: \ (2 I, � c � L J 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 signature ( , Date � ^. AFFAD A VTT Horne Improvement Contractor Law Supplement to Permit Application Sugpestod Affidavit for Home Improvement Contractor Permit Application For Office Use Only Name of City / Town Permit No: 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: 'K r.JC� \( ,' 1' tb"`,--- -, Est Cost etc4 j, C ) Address of Work: • . Owner's Name: M • I kekS 'l c(7 Date of Permit / Application: I hereby certify that: Registration is nor r?quired for the following reason(s): Work is excluded by law Job under $ 1000.00 Building not owner- occupied Ov,ner pulling own permit r - Other (Specify): O �. \ \ u k3> Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK IX) NOT HAVE ACCESS TO TILE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL C. 142 A. Signed under the penalites of perjury: I hereby apply for a ,,ormit as the agent of the owners: Date: Contract/ (111 I stratio1 (j _ OR_ Not withstanding the above notice, I hereby apply for a permit as the owner of the above property: Date: Owner: �\ 1 Ilf. �..VIIMIWI {I-vYHI• v/ a.a•wvv wv.� -�.. .... �. Department of Industrial Accidents Office of Investigations 7 — . 6 00 Washington Street `` Boston, MA 02111 0 •• ,r t a' u ww, mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business/ Organization /Individual): L (.3 r— \c4 r \ \E C Address: \O c'CNCt -1 YC * ' c3. City /State/Zip: Hbt � �' Phone #:C) 1 .,) S - js a _ Are ou an employer? Check the appropriate box: Type of project (required): I am a employer with 4. ❑ I am a general contractor and I 6. 0 New construction employees (full and /or part - time).* have hired the sub - contractors :. ❑ 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 aci workers' comp. insurance. B Y �P t5`� k 9. [] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions I. ❑ 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' 13Othei, t) nil Z� comp. insurance required.) kny applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :ontractors that check this box must attached an additional sheet showing the name of the sub - contractors and their workers' comp. policy information. am an employer that is providing workers' compensation insurance for my employee}` Below is the policy and job site }formation. isurance Company Name: ' - ( .- "'h S CC ' olicy # or Self -ins. Lic. # :fit a, j- 6 &4() < Expiration Date:_ )b Site Address:_ \ e�- ` � � I CVCT 1� d City /State/Zip: F \'a C evr Q ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 I up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct gnature: t ,-Q � - Date: hone Official use only. /)o not write in this area, to he completed by city or town official City or Town: __— Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CityTD•own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicabl€ ` ❑ Name of License Holder : �� C )..._` w QT t C k W ! 6 License Number • at vk� , g - l� Address Expiration Date (SL,)* \ Signature Telephone Not Applicable ❑ Company Name Registration Number Address Expiration Date \\C 1 k"e 11- d (i 90 Telephone g % - SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT Mat- L. G. '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 ❑ l 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 D Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition El New Signs [O] Decks [C] Siding ED] Other Brief Description of Proposed I \ t 1 Work: p p - Y � �1 1 , C 1 �1 l Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 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 constructibn 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 la.- OWNER AUTHORIZATION - TO COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, \teNeNe, ( 'i \(-1 d`` hIOLS kA `i"\ , as Owner of the subject property \ ,� i hereby authorize c* 1J . °r's�. \t y to act on my behalf, in all matters relative to work authorized by this building permit application. 4 Signature of Owner Date 1, C l C , 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. ` Y i L►;j CQ 2 � Pn Na � me ON & (A j — �-- ) Signature of Owner /Agent Date r Section 4. ZONING All information Must Be Completed. Permit Can Be Denied Due To Incomplete Information - Existing .. Proposed Required by Zotfing This column to be filled in by Building Department Lot Size 1 H I I Frontage 1 II , H I Setbacks Front I� I I I I Side L:I 1 R:I 1 L= R:I I I 1 1 1 ,, 1 I I I 1 1 Building Height I I J• I I I Bldg: Square Footage ` I I I 1 I I I I I I - -Space_Footage- - - . - - Y� - I I (Lot area miens bldg & paved 1 I I1 1 I I .. 1 parking) # of Parking Spaces I 1 I 1 1 1 Fill: (volume & Location) A. Has a Special.Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW .,.0 YES Q IF YES, date issued:I IF YES: Was the permit recorded at the Registry of Deeds? . NO 0 DONT KNOW . YES Q IF YES: enter Book 1 I Page I and /or Document #1 B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained i0 , Date Issued: _ C. Do any signs exist on the property? YES © NO Q IF YES, describe size, type and location: D. ; _Are_there any proposed changes to or_additions.of_signsintended for the. property ? YES Q NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filing) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , —__ City of Northampton , „ h, r ' , ?s _ - Y , uilding Department -1t a -._ ; 212 Main Street _ Room 100 °�,_ l . , . L su ~ --- csiwas N. a mpton, MA 01060 i D ENoRT J F ,�: _ 587 - 1 240 Fax 413 - 5 87 - 1 27 2 i� APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTTON1 =SITEiNFORAMM1Ok _ 1.1 Property Address: This-section -to E - compteta� 1rM3p pt z� U u „--- i � TS J � d � }—) CI' ; , f rte, -i . a .- ; t - . s �t ,, ,b -41 - c � fi ' --� ` -'� p 1. SECTaO�i- I'ROPERT-Y Oti RSHIP AU` I{O O E 2.1 Owner of Record: HQ_\ -.d0 ��.S k� , �� e ( ('-ta lit � dcoie Pc' Name ( . r Ge > 9 Address: `��"/ t . 4 ; Z Telephone Signature 2.2 Authorized Anent: Name (Print) Current Mailing Address Signature Telephone Item Estimated Cost (Dollars) to be = OId ltse3 completed by permit applicant -_ _ 1. Building - _ 2. Elec - ' 1 . , To , al C s t _ - 3. Plumbing 4. Mechanical (HVAC) <t C I r . . CD 5. Fire Protection i _ • 6. Total= (1 +2 +3 +4 +5) th ISumber ...... ... o This fSection Fo lel - t Building Permit Number _ Oates , Issueilt. Signature: l3 • , File # BP- 2013 -0238 APPLICANT /CONTACT PERSON DONALD PELLETIER ADDRESS /PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002 PROPERTY LOCATION 192 BRIDGE RD MAP 17A PARCEL 042 001 ZONE RI(100)/URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 30 q OM- Fee Paid Typeof Construction: INSTALL 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 INF9RMATION PRESENTED: 1/ 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 / of ; ,�,z Signature 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. 192 BRIDGE RD BP- 2013 -0238 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 042 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- 2013 -0238 Project # JS- 2013- 000389 Est. Cost: $946.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq. ft.): 14984.64 Owner: MEEHAN LUCY & JAMES A MEEHAN & HARRIET H MEEHAN Zoning: RI(100)/URA(100)/ Applicant: DONALD PELLETIER AT: 192 BRIDGE RD Applicant Address: Phone: Insurance: 1107 MAIN ST (413) 538 -6002 WC HOLYOKEMA01040 ISSUED ON:8/31/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 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 8/31/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner