10B-070 SHE City of Northampton -_
-,s
I . Massachusetts r ` 4
%44:4. .� DEPARTMENT OF BUILDING INSPECTIONS r ^r
212 Main Street • Municipal Building S ��
* Northampton, M8 01060 S1 :W 3n ^�
Property Address: \ C 64
Contractor
Name: Y ( s, ' VC.«W t
Address: i \ �� tY \ �--> , 4 -
City, State: Y . • c ko.
Phone: ( t `SIc r
Property Owner
Name: Oe
Address: ` 6 � . �P C `A
City, State: L eci 5 t Ck • 1O S
1, o Nc�. C.xU 1Q. ( (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 r�
Date
‘a
v d ti009885E Lt l uopinsul Jei}eiled ett :80 Z L 91.190
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AFFAD AVIT
Home Improvement Contractor Law
Supplement to Permit Application -
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Suggested Affidavit for Home Improvement Contractor Perrnit Application
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For Office Use Only Name of City / Town
Permit No: _ Leed5 V'-(C .
Date:
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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. 30
Type of Work: }(\ j(),)C '' i • Est Cost ; s Co
Address of Work: > (x) OJ -Q •
Owner's Name: C k f l S $ o
Date of Permit i Application: - 1
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I hereby certify that:
Registration is not required for the following reason(s):
Work is excluded by law
Job under 51000.00
Building not owner- occupied
Owner pulling own permit -
){ Other (Specify): v r�
s � .. , 10 1 ,Se
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 GUARANTY 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: tO i Contract /9li J J . 4 stratiol 15 to
OR
Not withstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date: Owner:
�. 1 , ,e �.- tresseswis rw Ssiani t/J !►l NJJ Lit./IIIJ GM)
Department of Industrial Accidents
a,� : Office of Investigations
'�= _, 600 Washington Street
—.1,..., Boston, MA 02111
:''• www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business! Organization /Individual): `� r.r . \c- (A,, \\ » C
Address: r \0'1 “10- \ `n :-t • k--jcAWkL' 0 \ 6
City /State /Z' p: N l
o \ \ c- k-- e 'CC X Phone #: ) :) 5 s a
Are yo employer? Check the appropriate box: Type of project (required):
1. am a employer with 4. ❑ 1 am a general contractor and I 6. ❑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. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
officers have exercised their 10.❑ Electrical repairs or additions
required.] o
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 .At) k k6 a,/,
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.
1 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 Q- ‘`- Y-0 VD , sicm 5 C3
Policy # or Self -ins. Lic. #: --- T - LO C,._ j ca. yam' Expiration Date: D5 r
Job Site Address: \ 6 L .A r - 1 City/State/Zip: ii.__e_€d b1 .0 i b C �J
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 certi6 under the pains and � penalties of perjury that the information provided above is true and correct
Signature: j)k>atf2.4k_(A) '�,,,) � 3 p ,.�2 tt, Date; kb — \ C " i cT
Phone #: ( -)\'') S 2
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 /Pown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ____
Contact Person: Phone #: _.
OCT -11 -2012 06:44 From:413- 789 -2023 Page:5 /5
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Supervi s � o rtj ` Q, r: r� Not Applicable ❑
Name of License Motder . L�l� C7C'\..�„_. (
License Number
ress ? Expiration Date
si Telephone
9. Ranistered'Home Improvement Contractor:_ Not Applicable ❑
Company Name Registration Number
���-A l Nr �* - \ \(J J —�_ `. tit . V 10 TI ? �7 r � - - �!'t
dress Expiration Date
\C L}� C. r`
�c Telephone S
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 26C(6))
Workers Compensation Insurance affidavit mus • - completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin• • mit.
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,
ns supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of I lumenwner: 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 rson who constructs more than one home in n two- enr cried shaft not be considered a homeowner.
Such "homeowner" Shull submit to the Building Official, on a form acceptable to the Building Official, that he/she shall !
responsible for all such work performed under the building permit.
As acting construction Si pery or 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 thus with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
h;arployees for injuries not resulting in Death) or the Massachusetts General Laws Annotated. you may be liable !or person(s)
yuu hire to perfurui 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 Luca/ lotting 1.aws and State of Massachusetts General Laws Annotated.
Ho meo wner Signature - -
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OCT - 11 - 2012 06:44 From:413 -789 -2023 Page:4 /5
SECTION S. DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition Replacement Windows Alteration(s) 1 Roofing n
Or Doors 0
Accessory Bldg IT Demolition ❑ New Signs [0] Decks (q Siding (0) Othor [1%1
Brief Description of Proposed
2't `
Work. X V t 1 wet) cv++' c Z�s l 1 ( C t l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea. If New iouse and or addition to existing housini comulete the followins�.
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
�t•aM�J��K?
��� , as Owner of the subject
property rte► N1-4c&-•--1-44=1--1 `
hereby authorize 1 "�.•+XrZ'a"_
� O\AO-�d w �� 'eT e
to at on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, -\ O ` V.A.k �•'� , as Owner/Authorized
Agent hereby declarc that tho 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.
1 a \d CLJ e ANt * t c
'Print Name
•■•',Nr\C9S>-) , CD--
Signature of OwneaAgont 020
OCT -11 -2012 06:44 From:413- 789 -2023 Page :3 /5
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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 tilled in by
Building Department
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Lot Size —. .. .... —. _....
..J I
Frontage I_.. ._. �...
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Setbacks Front - f --
Side L,: ." R: L,:. K:._._J I
Rear
Height f
-
Bldg. Square Footage - r__} % - 1
Open Space Footage --
(Lot ureu minus bldg & paved J I_- L-
parking) _
1 • _ s
11 of Parking Spaces -
Fill: r .... ,I
(volume & Locatin) - -- ''' - - .
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DON'T 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
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IF YES: enter Book Page ' and /or Document # •
B. Does the site contain a brook, body of water or wetlands? NO a DON'T KNOW 0 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued: I
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 O NO p
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 Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
OCT -11 -2012 06:44 Fr om: 413-789-2023 Page:2 /5
• NED
'^ • Departrnent'use only • ;-'� -
Ci of Northampton Status; of Permit: "' •
c, Buil i ing Department Curb Cut/Driveway Permit .
2 Main Street Sewe flSeptic,Av�ajlabiliry •
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� � � F BUC�D N�' MA 01C Opm 100 1Nater/Wall- Availability.:__ - ' • . .
NOA7�AMP70N Northampton, MA 01060 Twa eets -Plans 4 --
phone 413- 587 -1240 Fax 413- 587 -1272 PIpuSite inane 1- -1
Other ;Specir-.- -- `, s, . . . •
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOt_1SH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
• • This section to bo complotod by office
1.1 Pr000rty Address' 16 Water St.
Leeds, MA 01053 Map Lot unit
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Zone Overlay District
Elm St. District CB District_
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record:
Christin Chri%toph 16 Water St. Leeds, MA 01053
Name (Print) Current Mailing Addryss.
... 4•�iLaLI •M
Telephone
Signature
2.2 Autho Agent:
Name (Print) Current Malting 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 D P so 0
. Construction tromp , t
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) V --
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) a� Check Number 5561 #0Q
Thls Section For Official Use Only pi 33 g
Oat° � /
B °>
uilding Permit Number. Issued:
Signature
Building Commissioner /inspector of Buildings Date
File # BP- 2013 -0463
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION 16 WATER ST
MAP 10B PARCEL 070 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out idO 7 3� �L�
Fee Paid `�(r $L5
Typeof Construction: INSULATE WALLS
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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
;2
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.
16 WATER ST BP- 2013 -0463
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B - 070 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 -0463
Project # JS- 2013- 000744
Est. Cost: $2250.00
Fee: $30.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft): 7535.88 Owner: CHRISTOPH CHRISTIN
Zoning: URB(100)/ Applicant: DONALD PELLETIER
AT: 16 WATER ST
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON :10/24/2012 0 :00 :00
TO PERFORM THE FOLLOWING WORK: INSULATE WALLS
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 10/24/2012 0:00:00 $30.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner