The URL can be used to link to this page

42-035 (3) AFFAD A VIT 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: '`1,0cL'.vC-._ SY • 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. Type of Work: �,[) \o Est. Cost 0600 Address of Work: y!1 Owner's Name: J 0(• " (0,.. &\ Date of Permit/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 X Other (Specify): ad 4�j t\ ‘, r .e 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 MGh C. 142 A. Signed under the penalites of perjury: I hereby apply for a rormit as the agent of the owners: 1! Date: / Contract � �� i atJUtiol.stratio1 6331q OR: Not withstanding the above notice, I hereby apply for a permit as the owner of the above property: Date: Owner: 1 , ir. ti riorneranm mass save -111-F Sav+reRt rough*nee,'"Oft danr ��. PERMIT AUTHORIZATION FORM -.. Occ (") r '-N \. 0 . --sC COaUc < ,___:3 , I � J� , owner of the property located at: (Owner's Name, printed) _ `> _�'.. I A__113L)- \ N"--; qr'C .-1 ce to /AO (6-62 (Property Street Addr s) (City/Town) hereby authorize the Mass Save Home Energy Services Program - igned Participating Contractor listed below to act on my behalf and obtain a build' • permi to perform insulation and/or weatherization work on my property. li ■ \Ad Owner's Signatur - - 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: , l /D 2 Participating Contractor Date Rev. 12132011 • —ter""1 PELLE-4 OP ID:LL AIk�°.—'�°i CERTIFICATE OF LIABILITY INSURANCE DATE 02/2 tYYYY} a7ro2/2a13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(Ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Phone:413-538-7862 cONTACr FieldEddy insurance E Linda Landry 79 Lyman Street Fax:413-538-7179 P, .413-538-7862 I t/1M.,No):413-538-6010 South Hadley,MA 01076 ADDRESS:Iindalandryefieldeddy.com � Remillard Ins.Agcy.,Inc. -- -- °-- -INSURERJS)AFFORDING COVERAGE NM* _ _ _ INSURER A:Hanover Insurance Company _ 22292 INSURED Donald&Patricia Pelletier INSURER a:Wesco Insurance Co dba Pelletier Insulation - - __.-- -` 1107 Main St INSURER c: ----__ __. Holyoke, MA 01040 INSURER D: -__._- INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR'- ' -ATIDL SUN( POLICY XP -�'��----- LTR TYPE OF INSURANCE MSR IWO POLICY NUMBER tMM/ODNYYYYL IIMINDEVYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 MIS A X COMMERCIAL GENERAL LIABILITY ZBN9082391 05/05/2013 05/05/2014 DAM/CtaE TO R RPE6 100000 PREES(Ea occutr�)--- s----- s `_ I CLAIMS-MADE (X,occuR MED EXP(Any one person) 5 5,000 ____ ,_ _ PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 G_ERI.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 1 POLICY 1 I to PI 1 j LOC I - _ $ AUTOMOBILE LIAeILrrY COMEIN&SINGLE LIMIT 1,000,000 (Ea accident) $A ANY AUTO _ AWN9160781 07/10/2013 07/10/2014 BODILY INJURY(Per person) $ AUTOS OWNED XOSD BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS {Per accident} $ $ X UMBRELLA UAB I X OCCUR EACH OCCURRENCE $ 1,000,00( A EXESS LIAR J CLAMS-MADE UHN9221421 07/22/2013 07122/2014 AGGREGATE $ 1,000,000 DEC-11 X RETENTION$ 10,000 $ A_ WORKERS COMPENSATION I�T_Wn-CC_-S-T•A-TU- 0TH- AND EMPLOYERS'LIABILITY Y/N X�N U1KT1.1�$� IZ B ANY PROPRIETORPARTNER/EXECUTIVE WWC3063074 07/25/2013 07/25/2014 E.L.EACH ACCIDENT $ 500,000 /M OFFICEREMBER EXCLUDED? N/A --.__ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,0001 It yyeas desc ibe under - DESLtRIPTtON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT_$ 500,000 A Property Section ZBN9082391 05/05/2013 05/05/2014 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more space Is raryulred) Installation of insulation CERTIFICATE HOLDER CANCELLATION DONALPE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Donald&Patricia Pelletier THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1107 Main St. Holyoke,MA 01040 AUTHORIZED REPRESENTATIVE Gam` Gs, ©rkn.., I ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:'C10..� (� \\ t�c \o \ZT) 6 License Number ‘\ 1 S-T O.-\ -k • v...eke Ntyrk , \O- . t(4 ,ss I.C.J Qa-17-,4_, Exp iration Date Signature Telephone 9.Reciistered Improvement Contractor; Not Applicable ❑ � ." >,. J -e W- \CO Qom. Company Name _ Registration Number C-Sk Address !1 Expiration Date O l ; J � � \ .a D lephone S %� 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 • . 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 (D Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs ED] Decks [Cj Siding[CI] Other[Cr Brief Description of Proposed � � A (1 Work: �� tO;r �tiN`J 'L t`\O � 1� y 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 I, —375 C\-.Y'\ S d ,L\'v ,as Owner of the subject property -- �]hereby authorize authorize J�J 1(`� w R��1�„) L `. to act on my behalf, in all matters relative to work authorized by this buil ing permit application. Signature of Owner Date re -\`"Z-N v e � 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. reAd c%S.d- r Print Na ,e au I,1 , I9/iari 1_40 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 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW ® YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained i Obtained ® , 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 0 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit r g I j , ---, "ding Department Curb Cut/Driveway I rnit I� 11`_I .- _ ' 12 Main Street Sewer/Septic Availability I doom 100 Water/Well Availability il 1{ }� 7 2013 Nort ampton, MA 01060 Two Sets of Structural Plans I phone 413f :7-1240 Fax 413-587-1272 Plot/Site Plans Electric, Plumbing&Gds inspections Other Specify Nortnampton, MA 01060 r • ' • • . - ,, T,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 5--" Map Lot Unit /'� Zone Overlay District WRak�V■`l(� i )� �ei • Elm St District CB District SECTION 2-PROPERTY OWNERt HIPIAUTHORIZED AGENT 2.1 Owner of Record: T codkk ��1,J R� . Name(Print) Current Mailing Address:\?.., t��'. � LQ r�� Telephone Signature La Authurii Arent; Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS I Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee CO 2. Electrical (b)Estimated Total Cost of 0 c�6cC) Construction from(6) I 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) -- vs.,50 ktki-l7> -�- 5.Fire Protection y� Az5-5-'6. Total=(1 +2+3+4+5) ° o6 , C5 Check Number (5 j 9 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Budding Commissioner/Inspector of Buildings Date File#BP-2014-0482 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE 1107 MAN ST HOLYOKE (413)538-6002 PROPERTY LOCATION 735 WESTHAMPTON RD MAP 42 PARCEL 035 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin• Permit Filled out —/ .iir- Fee Paid t.. r Typeof Construction: INSTALL 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 N PRESENTED: roved 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 Ale o;io 'elay II# i / y1VY Sie o B tiding 0 ficial 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. 735 WESTHAMPTON RD BP-2014-0482 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 42-035 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-2014-0482 Project# JS-2014-000827 Est. Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq.ft.): 30361.32 Owner: FRADKIN DAVID L&JOAN ROBB Zoning: Applicant: DONALD PELLETIER AT: 735 WESTHAMPTON RD Applicant Address: Phone: Insurance: 1107 MAIN ST (413) 538-6002 WC HOLYOKEMA01040 ISSUED ON:10/21/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 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 10/21/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner