05-066 AFFADAVTI
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: L e ca 4
Date:
Note: 142 A, requires that the ` reconstruction, alteration, renovation, repair, madermZition, conversion
improvement, removal, or demolition, or the construction of an addition to any pre -misting 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. t,,�}, . `
Type of Work: () l(Jl_ V ttNY"` - . - Cost �c C
`/ a -
Address of Work: �'7 r�- a U CSC u () (^ • -
Owls Name: E( SCam. (. V odd
Date of Permit / Application: q D.1
I hereby certify that -
Registration is not required for the following reason(s): •
Work is excluded by law .
• Job under S1000.00
Building not owner - occupied
Owner pulling own permit
X Other (Spy)::
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONrRA.CI FOR APPLICABLE HOME IMPROVEMENT WORK DO 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 ...srmit as the agent of the owners:
Date: Contras stratior k��)3,l�
OR:
Not withstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date: Owner:
•
eft
mass save COMM
PERMIT AUTHORIZATION FORM
1, —/C 4 k c� , owner of the property located at:
c� (Owner's Name, printed)
A9( 1.--6ecits
(Property Street Address) (City/Towii '
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.
Owner's. Signature
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:
16 D-t
Participating Contractor Date
Rev. 12132011
YN - City of Northampton
oar r‘5 St ,
Massachu A. * < �
x '
f KY . �' DEPARTMENT OF BUILDING INSPECTIONS y n,
yi'l 212 Main Street • Municipal Building . , �y,<`
Northampton, MA 01060 W 3f2
Property Address: 1 (.. -UdU U r ' b' -
Contractor
Name: c �d W 'Y
�j w'� \ F'
Address: \ 1v \CY�s- \ 'V--,
` \
City, State: 'A6 \ ` .1 O\ V-' - C . 1 bq d
Phone: 1 S a � ,>o0
Property Owner y
Name: C �J C ._ ( Odd
Address: ( )(`II) 1 Ire F — � '
City, State: ‘---e e_d s G( , D (6S
I, r s 1,, l's?6, ‘"T ∎ k f" (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 1
Date -o
. a t . S' I 'fUV 4$ss►a V imaamt.►HWC.UW
Department of Industrial Accidents
Office of Investigations
•
=IV ' 600 Washington Street
zg
Boston, MA 02111
•:.1 �' www mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Businessiorganizationi xiividual): { 1C' . C .‘ ‘\ ‘e_c
Address: j Neil \'`C \O %C'N c . ok k_ O 1 t'1.
City /State/Z V() k.e, Y■eNtX Phone #:(l 1,� 6 3 6 a
Are yo employer? Check the appropriate box: Type of project (required):
1. e am a employer with � 4. ❑ I am a general contractor and I
6. El New construction
employees (full and/or part - time)_* have hired the sub- contractors Remodelin
2.0I am a s o l e p r o p r i e t o r o r partner_ -_ -- _ -- listed on the attached stems $ 7.
_ 0 g . -- ship and have no employees These sub- contractors have 8. 0 Demolition
working for me in any capacity. workers' comp. insurance. 9. 0 Building addition
[No workers' comp. insurance 5. 0 We are a corporation and its
required.] officers haYe exercised their 10.0 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. er
comp insurance -]
*Arty 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.
I am an employer that is providing workers' compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name: 1 e_ C `1 %0 it' p� ' x.1(1 S CC)
Policy # or Self -ins. Lie. Sa$6L -1(7 S Expiration Date:' a-D1a)
Job Site Address: � a Ud U l d �^� d • City/State/Zip: L f dS
Attach a copy of the 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
tine 51,5(X100- and/or- one -yeac imprisonment, as well .as -civit 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.
/ do hereby cert6 under the pains and penalties of perjury that the information provided above is true and correct
Si nature' � � � Da -
r-
_
Phone
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):
I. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
4
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Constructi Supervisor: Not Applicable ❑
Name of License Holder : x� � W C k ?. ,\ � ( c 13 t
License Number
itCtitom fi • L*1 —C /
Address . Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
1 N 1C3-t . Wog 3l`R__
Address Expiration Date
Telephone � 4 O D�
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 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 ❑ Addition p Replacement Windows Alteration(s) E Roofing IT
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [d]
Wor Description of Proposed S"��+4 � t 6 Ge ( 1 mac_ - VeN
Work: �K�,�U ���� v-. u vS „
I ts r
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
, as Owner of the subject
property
hereby authorize ,� «-' 1` K� (-' J e
to act on my behalf, in all matters relative to work authorized by this building permit application.
S ignature of Owner Date
'■ ' \c14 6-. Ve , { T k 4Z-S'
Z - S , as Owner /Authorized
Agent hereby declare that the statements and infbrmation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner /Agent Date
Section 4. ZONING Atl 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 0 YES
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 ® DON'T KNOW 0 YES Q
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 ® NO
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 (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
; Department use only
RECEIVED City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
SEP 2 i Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
DEPT. OF BUILDING INSPECTION� 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
NORTHAMPTOM MA 01060 F��
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: 72cL Thi s section to be completed by office
L__V I (2, Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
V
Name (Print) Current Mailing Address:
.o, , So -1 )°A (A r4 k) C 1 Z Ott ( 1^, Telephone
Signature F f, ` r- s 1 r't V`, t?ci
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (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) D \ 1 Check Number V dif
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0338
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION 372 AUDUBON RD
MAP 05 PARCEL 066 001 ZONE RR(100)/WSP(100)/WPC4)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid cieg
Typeof 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 P1 of Plan
HE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
NF ATION 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
•
-"Alt 9
1 4 07 A •0<dir
S' I . % uil . • ;.4G icial 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.
372 AUDUBON RD BP-2013-0338
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 05 - 066 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 -0338
Project # JS- 2013- 000537
Est. Cost: $2100.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 142876.80 Owner: JUDD EDGAR R JR & CAROL A
Zoning: RR(100) /WSP(100)/WP(4)/ Applicant: DONALD PELLETIER
AT: 372 AUDUBON RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON:9/25/2012 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 9/25/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner