11A-058 AFFAD A VIT
Horne improvement Contractor Law
Supplement to Permit Application
Suggested Affidavit for Home Improvement Contractor Permit A- pplimtion
For Office Use Only Narne of City / Town
Permit No: _ Le c o YY
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_ d
Type of Work:, ) 0. } ! , 1C "N Est. Cost a 6
Address of Work: 4 f - .. 001
01
Owner's Narne: 0 "\rk ( 4 rt't{xt_. k
Date of Permit i Application: (3
I hereby certif that:
Registration is not required for the following reason(s):
Work is excluded by law
Job under S 1000.00
Building not owner- occupied
Owner pulling own permit 11 j
)( Other (Specify): --
d e \lt.� 3 (,)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME D4PROVEMENT 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 ,,ormit as the agent of the owners:
� .r ?�
Date: ‘4 - ' � � Contract i stra0oa ,, 33 j
OR
Not withstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date: Owner:
•
POMPOMS
mass save CONTRACTOR
PERMIT AUTHORIZATION FORM
I / - e , c- /4 , , ,, a S / � - . owner of the property located at.
(Owners Name, printed)
�i ) r"
!, ,r , 4iJJNv e ecYS
(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.
Owner's Signature
3/.2 7_3 -
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
Property Address: e \/• k .
Contractor
6 .k 6 (.,v � \ -ks-
Address: \ a' �/ - (j L
City, State: \w ��"r2 ) VC� a \) 4 4L-)
Phone: -Ex-
Property Owner -
Name: 'C C 'l " Vc
Address: \ `
City, State: t. E'_ Q d .
(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
A rim. VVIIM/WisnmasKrs Vf l►IYaatsurasszcasa
` mamma. r Department of Industrial Accidents
M = " Office of Investigations
:z ip= _ 600 Washington Street
Boston, MA 02111
`' :.''' ►t�►t: mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business / Organization /Individual): 1 rrr,,,. `C L ? n � `\. \ k'
Address: 1 10'1 C'- l `t" . 0 1 6
City /State/Z i : d c) k \ Phone # :c ! . S) C
Are yo employer? Check the propriate box: Type of project (required):
1. M 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. ❑ I am a sole pmprietor or partner- listed on the attached sheet. I 7 . ❑ Remodeling
ship and have no employees These sub - contractors have 8. Q Demolition
working for me in any capacity. workers' comp. insurance. 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. ❑ 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' t l dal ts,/`
comp. insurance required.]
`Any applicant that checks box N1 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: T. 1 "1/4 S C(D
Policy # or Self -ins. Lic. j3. f. .40 S Expiration Date: 1 _ DO.
Job Site Address: 1 G. kAC City/State/Zip: L (d \J''`A \
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 certify under the pains and penalties of perjury that the information provided above is true and correct
Si:nature:
61"12.4.Q__ ' t�-t Date: .. -
Phone fl: (c,41 )
Official use only. Do 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. Other — Contact Person: Phone #:
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all amicable)
New House [J Addition Replacement Windows Alteration(s) 0 Roofing t l
Or Doors 0
Accessory Bldg. ❑ Demolition E] New Signs [0] Decks [C7 Siding [0] Other [El
Brief Description of Pr
Work: b{J Q� G "L�j - �a. � e. («o k'TN
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 S J \c. \ b, -
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 BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, O - L ' , as Owner of the subject
property
hereby authorize Jd LL ) X\QA■'
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, '4 o \cj j � \'� E' r , 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.
Print Name
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
Ibis 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 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Oopswtotoot use only
ity of Northampton o€pentit
R : Tiding Department Curb Cut/[ � Permit
12 Main Street SeweriSepticAvtOlability
_ Room 100 Abi
ort - mpton, MA 01060 Two Sets of Structira Plane
r w -1240 Fax 413 -587 -1272 Plot/Site Plans
o. f B P o f Mp,
D other om'•
(CATION 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
. EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
1,NCVC .� + Mc� � — c� 5 \ c� d e•r� v a Rct *
Name (Print) Current Maiti Addre s:
phone
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
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)y.����a "�_
5. Fire Protection
6. Total = (1 +2 +3 +4 +5) 31 aa; J0 Check Number c4‘6
This Section For Official Use Only
Date
Building Permit Number; Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0907
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION 124 HAYDENVILLE RD
MAP 11A PARCEL 058 001 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 �--�
Fee Paid 357V ,d
ea
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 FO WING 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
( 1) 0 ------ # 1
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.
124 HAYDENVILLE RD BP- 2013 -0907
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11A - 058 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 -0907
Project # JS- 2013- 001552
Est. Cost: $3700.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 616374.00 Owner: BRISSON PIERRE R & SUSAN H
Zoning: URA(100)/ Applicant: DONALD PELLETIER
AT: 124 HAYDENVILLE RD
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
Annemmenummow