24A-021 (2) Y�� - City of Northampton
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Massachusetts A'° "' {'
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#, DEPARTh NT OF BUILDING INSPECTIONS S. ,a.
212 Main Street • NOnicipal Building 1-ini f���►.�+11�lti
Northampton, M 01060 4 ` -4"7C
Property Address: y S- \G' ` e cc 1 )1,--XN
c_L. poi i ''')-C 0-fi- 14
Contractor r CA CA k, K )c'`1 -k `k C
Name: \ \ hi-��• /-C°3 (°f 3- -I- 14..
Address: t \ � ) \'`C\0,-\ C,--
City, State: \--AO '_ (. \ �{(
Phone: C2 1 r ---) S. D 600D
Property Owner ,�^ac i `
Name: � '` \ \..
Address: cm (---710 (-1--L-- )--N,(-
City, State: N c \ -Gwa \ c ''\ • O\C C U
I, rc,\N (._J 1'C+ .e 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 ^c) fyY1i. 6.j.p�=�C.�
Date
A1TAD A VIT
llotne hi:provemeat Contractor Law
Supplement to Permit Application
Suggestzd Affidavit for Home Improvement Contractor Permit Application
For Office Use Only Naive of City/Town
Permit No: Y11;5('k hen
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_ t
Type of Work: , i)ka i° Est Cost a6 0
Address of Work: tom," be_
Owner's Name: .M-1/ (.4gal
Date of Permit r Application: -->'
I hereby certify that:
Registration is not r rjuired for the following reason(s):
Work is excluded by law
Job under$1000.00
Building not owner-occupied
Owner pulling own permit ll r
X( Other (Specify): cxdd c e `l kt�s'J
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED -
CONTRACTORS FOR APPLICABLE HOME IMPROVE.{ENT 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,crrnit as the agent of the owners:
Date: �n-/ Contract /011- s J. 4stratioi I S)3\
OR:
Not withstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date: Owner:
LiMa*4""14)
mass save "MilIntor"
.1lvd!P3 t7* $'d`SW r JJfK:6:{.y
PERMIT AUTHORIZATION FORM
1, rAAcv , owner of the property located at:
(Owner's Name, printed)
(Property Street Addres- (City/Town)
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property.
W
Owner's Signature
lazy I a_013
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
,) 6 (L) ' \— KM- 03
Participating Contractor Date
Rev. 12132011
.N24.2 sc wetas,W,$riEUtara of IruUAAUI.rIi& t iw
1= Department of Industrial Accidents
• t
t Office of Investi g ations
UV= 600 Washington Street
', ;qt.— Boston, MA 02111
-Tr ' ►i�nnv.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual) Ors" .
Address: 1 10.1 . \ 6
City/State/Z p: c, c) �. e CX Phone it:CV )_) ss 6
Are yo employer?Check the appropriate box: Type of project(required):
1. M: am a employer with ) 4. ❑ I am 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 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 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 g
insurance required.]t employees. [No workers'
13 er !A j C)iCk ZS V'
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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: t e_. - VD S CO
Policy#or Self-ins. Lie. Expiration Date: `DC)13
Job Site Address:
(l \O \S e« L n • City/State/Zip:
copy V'\
Attach a co of the workers'compensation policy(leclaration 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.
Signature: kNle-Q-eQ---(13 Date:
Phone#: 11-4 1
Official use only. 1)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.Other
Contact Person: Phone#:
8 'd 176171 '0N A O ouyaal 033 ao} aaiva3 Opg/ : I l BLOZ
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors i]
Accessory Bldg. El Demolition ❑ New Signs [D] Decks (Q Siding[DI Other RE(
Brief Description of Proposed
Work: ek L e t $C de\A 2 k_.
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
l •C`f -L( bbloAl , as Owner of the subject
property 1 \\ -
hereby authorize � � ' ,LJJ t`\C.[� u l/
to act on my behalf, in all matters,elative to work authorized by this building permit application.
tfqw*e 61 C)--\/ — 1
Signature of Owner Date
a v A0 bi1 e\l‘e v Q C ,as Owner/Authorized
Agent hereby declare that the statements and informs ion on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
c \(N,,C0\ci
Pri Name
6_ )6/64_,tt__SL ) /-
Signature of wner/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 cyo
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Findin ver been issued for/on the site?
NO ® DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T KNOW 0 YES t
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES o 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 Q 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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
A=
r-1�1C0" Department use only
ity of Northampton Status of Permit:
ilding Department Curb Cut/Driveway Permit
,, 103 212 Main Street Sewer/Septic Availability
1 Room 100 Water/Well Availability
`,'NG NsPEEI�ON ort'l ampton, MA 01060 Two Sets of Structural Plans
c µ°iKa�+-ko .•- • - 87-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
Zone Overlay District
1r1aC\z om(-SI Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\CKC t,] X10■\\ 4.4 S %\oxc4<_bec-c j
Name(Print) Current fyl5ing Address:
wN1/4 O` lq�,Nr 6 -y l 3� 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
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) Sv�sv\p � b V�
5. Fire Protection /�
6. Total=(1 +2+3+4+5) bc) 0 �
Check Number V
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0076
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE 1107 MAIN ST HOLYOKE (413)538-6002
PROPERTY LOCATION 45 BLACKBERRY LN
MAP 24A PARCEL 021 001 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 ?/ 'U 46--3
-"
Fee Paid �J(,..7
Typeof Construction: INSTALL WALL 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 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
depos
De•• /00.„. •,:-. 11,- a
-:]"/3
Signature of Bui •mg 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.
45 BLACKBERRY LN BP-2014-0076
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-021 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-2014-0076
Project# JS-2014-000155
Est.Cost: $2600.00
Fee:$55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq.ft.): 10018.80 Owner: HALL MARY F
Zoning:URB(100)/ Applicant: DONALD PELLETIER
AT: 45 BLACKBERRY LN
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538-6002 WC
HOLYOKEMA01040 ISSUED ON:7/26/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WALL 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 7/26/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner