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16A-006 (3)
mass saver C11111 FOR S•AWu•o.q0*nW!affi @rCV now, PERMIT AUTHORIZATION FORM I, Phillip Kelley ,owner of the property located at; (owner's Name,printed) 110 Bridge Rd Northampton (Property Street address) (City) 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. X I owners signature ' ; Date FOR CSG OFFICE USE ONLY Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Q�rO a. For Office Use Only Rev.12132011 %-T 11r1r, L-iprovement ConLrxior LaxN S,,Jlpfcmcnt to Permit Application /kfridwii U(j, Home Impmement Cormacclor Permit A ppliCM1011 Nnine of Cit-. Note, 142 A, requiM that the reCorUtj-u(:,,iorj,adt4 ra6cn, renovation,r1mir, model �.IKU. 001r�"") Unprtmemeni,removal,Or demolition,or the coasawdon of an addition to any pre-e,-a S . t_ng over OCCUPit-0 NW(hng containing at IeW one but not more than fatty dwelling ttnit(s).or to sb-ucmrrs which am adj-xtnt to such rt%zidence or building' be ck)nc by registered connjr-wm with oerWa vcceptims,along with OkT requimments, Type of Work-,- Est Cast AAdrcss of Work- 0\ Ovmer's 'qarne. Date or Pc trait i Ap9iiC-9Fjnn I hereby crrtiA, that - Registrari(-v is net r,!;ji red f,)r tl�e following rcasor(i) Work j-,e\ClUded b% 13V, lob Un&-T S I(m 00 P aildi ng not owner-occupied 0"TWT PUPIP. 0"'I'l Permit Other (Specifi). Nori-e is her-,bv giv en that: OWNIRS PULUN6,THER OWN, PEWH ()P,UEALUqG W11-ij U?,MEGIS1-ERFr) COK -,kTP (-Top ,S FOR A-PPLICAPLE HOME MROVEMEN-q WORK Do NOT RAVE ACCESS TO TITF AP-PITPAlItW PROGJRAM OR(,,(!A-PAN-ry FLNtT)UNDER Nf(-�L C 1-1? A Signeii under the penalitcs Of p,-rjur. I hemb-% apply for a cf1l"it aS the agent 0[the 0%meM 0(or-actor R4slrafin Q� 0R t7of w hstandi ag the at')`e notice, h-,r,h-, Apr,Iv Fri- a r-rmll as the otvner of the atKWr PTOfXTC;' Date fs7Fr City of Northampton Massachusetts »r Saa r OF BMLJ r= ras�c�roxs '' 212 lion Street • Municipal Building Northampton, Wi 01060 Property Address: Contractor Nam `J c`1Y`C'1. 4. JJ ". Address: 1 ' (1 S�- City, State: Phone: J Property Owner ) Name: Address: ^' City, State: Lit (contractor) attest and affirm that the building I intend to insulate does not have any open air(knob and tube)wiring in the spa s to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date The Commonwealth of Masvachusetts Department of Industrial Ae dents O flee of_1nvestig4ti0ns 600 Washington Street Boston,MA 42111 www.mass gov/dia Workers'Compensation Insurance Affidavit: Builders/ContractorsTiectricians/Plumbers Applicant Information f_ t Please Print Legibly Name(BusinessKNgmizationllndividual): �T► &) tQ4t o h Address: city/state/zip: 1y b K e_ p& 010q0 Phone#: qi 3° 5 3$_ GPao D.. Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with. -1 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 E]New construction 2.❑ i am a sole proprietor or partner- listed on the attached sheet. T ❑ Remodeling ship and have no employees Tie sub-contracum have g_ ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.instranr ce. required_] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L[]Phmnbing repairs or additions myself. [No workers'camp. right Mexemption per MGL 12Q Roof repairs insurance uied,)t c. 152,§1(4),and we have no t en�iloyces.[No workers' 13.®Other cTN S 1�1 I o rJ comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showirng their workers'compensation policy information. t Homooumers who submit this affidavit indicating theyan doing W work and then hire amide con mrAoa nsmmAnii a new affidavit indicating such. lContracton that shack this box nna!attached in additional shat sbowing the name of the wb-eoApactom and mate whotb r or am those cartitits have employees. IF the sub,-conaactors have tmtployces,they must provide than wodwrr'comp.policy number. lam an employes that IsproviOng workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Narne:_ �'(� 44 WS U 944Q.2_ Policy#or Self-ins. Lic.#: W e, Q a 7'1 Expiration Date: �! /a C) Job Site Address: City/State/Zip: 7 r -e J,AC 3 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 irnposibou of criminal penalties of a fine up to 31,500.00 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 Investieations of the DIA for insurance coverage verification. 1 do hereby certify under thepains and waftiff of peryury that the information provided above is true and correct Sign ture: Date: `° ____ P X13 - S3�- (oDv- hone#._ ._ Official use only. Do not write in this area, to be completed by city or town officiat City or Town: Permit/Ucense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3. City/'Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: f1 - Not Applicable ❑/ Name of License Hader: �1 ( LI (� `C ` t_ ( ;C) i � (� License Number Add Expiration Date G Signs ure Telephone Not Applicable ❑ Company Name Registration Number Address —�— Expiration Date N/\A1 � \ U Telephone —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 permit. Signed Affidavit Attached Yes......: No...... ❑ 11. - Home Owner_Eum flon 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 buildine 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 Addition Replacement Windows Alterations) ❑ Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [M Siding[0] Other Brief Description of Proposed q r Work: ?4;2•k-!` G_�l_�' C� toa- 1, 4(t t. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. If New house and or addition to existing housing Comalete 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 as Owner of the subject property hereby authorize ('k- � to act on my behalf, in all matters relktive to work authorized by this building permit application. Signature of Owner Date 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. Q / Pri me C Signature of Owner/Agent Date Section 4. ZONING Atl 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 Q DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q 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 0 DONT KNOW © YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: 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 ® 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. City of Northampton et"0 . Building Department 212 Main Street Room 100 Northampton, MA 01060 sim I or _ 2 2 2 ph 13-587-1240 Fax 413-587-1272 n ions Oft( Electric.Ft TRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be campietad by df1w 1 1jC +p Lot Unit Zone Overt"Di VWI Ehn SL t CS INS SECTION 2-PROPERTY OWNERSMP/AUTHORIZED AGENT 2.1 Owner of Record: C� CA Name(Print) Current Sz \ Telephone s 22 Authorized Agent: , Name(Print) Current Mating Address: Signature TeWmne SECT10N3&jM7W2QWMjMl0H CASTS 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 ConOuchon 6 3. Plumbing Building Permit Fee 4. Mwd 10 ieata(HVAC) n - 5. Fire Protection 6. Total=0 +2+3+4+5) c7. 5_0x_3 Check Number d This ioebon For OMcial Use Orft Building Permit Number: Date Issued: Signature: Buildirg Of Buklirvs Date File#BP-2015-1008 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002 PROPERTY LOCATION 110 BRIDGE RD MAP 16B PARCEL 006 001 ZONE RIO 00)/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 Tyueof 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 INFORMATION PRESENTED: pproved 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 De 1' ' ay Sign of it mg cial 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. 110 BRIDGE RD BP-2015-1008 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16B-006 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-2015-1008 Project# JS-2015-001929 Est.Cost: $2500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin DONALD PELLETIER 101876 Lot Size(sq. ft.): 12980.88 Owner: KELLEY PHILLIP R&ALICE M Zoning: RI(100)/URA(100)/ Applicant: DONALD PELLETIER AT. 110 BRIDGE RD Applicant Address: Phone: Insurance: P O BOX 5020 (413) 538-6002 WC HOLYOKEMA01041 ISSUED ON:412312015 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 4/23/2015 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner