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24A-069 (2) ratwe mass save COMUCTOIR PERMIT AUTHORIZATION FORM I, S4 /N �V , owner of the property located at: (Owner's Name, printed) yZ - , (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. � - -k nature y// 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: .Q& k 0 � \ Participating Contractor Date Rev. 12132011 OD LA OZ _Ibte ;EnL„ L )ioO©v -.OL v,net �1�• Al-TAD A VIT Horne improvement Contractor Law Supplement to Permit Application • • Suggested A.t7idavit for Home Improvement Contractor Permit Application For Office Use Only He of City / Town Permit No: _ `k4+ ()`ii`^RO Y� 1\-t0 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. 30 Type of Work: "° C4 >() \oc y-- w Est Cost OO • Address of Work: ♦ Owner's Name_ JA kQeN. �!` JCL( Date of Permit i Application: 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 )( Other (Specify): r ..d ci �..- e v \ �„� \ tr y) 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 ,e.rmit as the agent of the owners: Date: .s / ` �"' / Conlxact 4 stratioi OR Not withstanding the above notice, I hereby apply for a permit as the owner of the above property: Date: Owner: Property Address: 6 IC kd p W<YQ6 Name: tractor Y`G r 0, Address: ‘(Y1C'1. \NC\ 1 • City, State: Noi a )c'e rola . 6 . c0 Phone: Q_C Property Owner 5�� )�f�y.�� qc0 k:A. Address: ( 5.\CI e`e 1. t_ j 7E; (( , City, State: C (`V\-QM,* , I, .a ( (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 y�� 1 3 \ 1 IBC �VI •IIIWIlrVT1iI4I1 bf 111uJJ111.1554.1G6W ; Department of Industrial Accidents _ = ; Office of Investigations • =1:11'— 600 Washington Street Boston, MA 02111 rte mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information "� ` Please Print Legibly Name ( Business/ Organization / Individual): Z �vrrJ V-1/4 (,, `Q \\ k C Address: AO`1 0 \ 6 City /State /Z a : b \ v c) e Y ( Phone # :(- ) ,3) 5 s'g 7 " Are yo .11 employer? Check th appropriate box: Type of project (required): 1. M am a employer with 4. ❑ I in a general contractor and I 6. ❑ New construction employees (full and/or part - time).* have hired the sub - contractors 2. ❑ 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. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ 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. ❑ lam 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. ❑ Roof repairs 9 insurance required.] t employees. [No workers' 13. er us CJ loch t (`‘ 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: e. = ° '( �� �� J� S CO .� Policy # or Self -ins. Lic. # :�1 I �� tom., jyt� Expiration Date: a 1 a• J3 Job Site Address: 6 • City/State/Zip:S C`t' \ t\- 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. 1 do hereby certi6 under the pains and penalties of perjury that the information provided above is true and correct )1, . - W 4t Date: ' 1 3 Si_ nature: t' Phone IV (y 1 5 J� 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. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Othcr _ Contact Person: Phone #: SECTION 5- DESCRIPTION OF PROPOSED WORK {check all applicable) New House ❑ Addition ❑ Replacement Windows Alberation(s) ❑ Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other Brief Description of Proposed pp ' Work: ,n p � CI �' S e o.0 C @l l j 9 YN--. A _ 3 1 t i btu C 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 addjltion to :exlsttna 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 . 1. 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 1, ' y VINeLYNA C U01/4, c , as Owner of the subject property hereby authorize \J OVQ \c (Jj to act on my behalf, in all matters relative to work authorized by this building permit application. _ (tici,\Ine Signature of Owner Date ° `cS C �.) - c ) Q. ( , 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. 3 Oct. C a Te. \\e C Print Nam S'Y'Nrc Lv Signature of Owner /Agent Date 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 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 Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES 0 IF YES: enter Book Page and /or Document # 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 Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: 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 ® NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. use only CEI* City of Northampton 106* RE : uilding Department Curb Gr'iveyery o 212 Main Street Se Availabifq - 5 t1 Room 100 Water/Weft Av No hampton, MA 01060 Two Sets of S t z,orr ' 87 -1240 Fax 413 -587 -1272 Piott;e Plans D NOR B K PT N Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit Zone Overlay District 'COC +rcK.rC1p i Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: • • Y1 � 1 Name (Print) _urrent din g ddress ( r a-) C A S Z� • Cl • k�Y�� d Telephone Signature 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 Construct from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) • 5. Fire Protection u v \C� \` 6. Total = (1 + 2 + 3 + 4 + 5) \ 5 (DO Check Number 3 � / () This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0908 APPLICANT /CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002 PROPERTY LOCATION 68 RIDGEWOOD TER MAP 24A PARCEL 069 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out -- S b �� Fee Paid Typeof Construction: INSTALL ATTIC 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 INFO ION 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 hem• ition Delay Signature of Building 4ficial 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. 68 RIDGEWOOD TER BP- 2013 -0908 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A - 069 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 -0908 Project # JS- 2013- 001553 Est. Cost: $1500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq. ft.): 12327.48 Owner: ARVAI STEPHANIE J & LORENA MUNOZ Zoning: URA(100)/ Applicant: DONALD PELLETIER AT: 68 RIDGEWOOD TER Applicant Address: Phone: Insurance: 1107 MAIN ST (413) 538 -6002 WC HOLYOKEMA01040 ISSUED ON:4/10/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC 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 4/10/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner