29-519 (2) AFi'A')A%7
La"
Suppfcn-icnr to Permit Applicatio a
SO4v�rsfcd Affl(l;i%it forTlorne Improvement Corirri�:tor Permit A ppiw-36(irl
F
it N;
Note, 142 A, requires dwt the" recorutiu(.:ion,ahci-ation, renovation, repair, rnodCI`nizRbICLi, 03
improvement,renxraL Or demolition,or the construction of an addition to Any pre-e'-sting owner occvpitA
building containing at least One but not more than four dwelling unit(s).or to stKturrs which-vc adjacent
to such residence or building* be done by registered contractors,with certain c ris.along Vrith Other
requirements.
Type of Wark� Est Cost
Mdxcys of Work'
Owner's Varne:
Date of Permit Appiical'Otl
T herrbF cerfiR than
Registf-ation is ncr for the following rcascri(5)
Work is excluded b% 1:1%1
job under S IM0.00
Building cot ouner-occupied
(.),A-Ti,-r pLflbng oA-,i permit
ci C_ V�t 2-
---Other (Specih),
Noti-e is her--bv given that'.LL
0 WPI%4TRS?ULLjN-(-,Ta[K OWN, OR DEAUG W,-I-,j UNREGISTERED
Co�rp _T WOP v F A (ASS
.% *_ACTopS FOR APPLICABLE HOME LNQRMTMEN, K DO NOT H-k
TO T9F A PPITPATION PROGRAM OP GVAPLA_N_n_ FLND UNDER
NIGL (7, 142 A.
Sipned tinier the perialitt's Of Pw--dlir.
I heteb-, apply for a crTnit as the agent of the ow lets
stra(i
Date--, —Contractor m
OR.
t:ot willht,-,anding the anti e notice, f ;tnpi% f(-,: a r,-rmii m the owner of the above PT0f'X_TTi-
n,r
tow"
•M,5,.00;
3
mass save �c o"R
SwAry tit=O attt w Milldam r.. ,
PERMIT AUTHORIZATION FORM
I, TRACI BOROWSKI ,owner of the property located at:
(Owner's Name,printed)
8 Tara Cir FLorence
(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.
Owner's Signature
1 a\ l 5
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:
<;r
Participating Contractor Date
01 s�
For Office Use Only
Rev. 12132011
City of Northampton
Massachusetts {,
M1 aEiARnMCi QE BMZJ)ZNG XNSP CXXO J
212 Bain Street • Municipal Building
F" Northampton, Mh 01060
Property Address: r4 C�(�. C\
Contractor i
Name:
Address:
City, State:
Phone: tii z 3? 6
Property Owner
Name: Cl-
Address:
C C
City, State: - 13.1 (- V Pw r_ 2
/ J
I, -X-'a C¢�' /l'�►�'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
Date
The COAMMO WOZ&h Of JlifaSSUchstsetts
.aejprrilwW of 1xAKTfti 1. cddm&
Office of I"esfigsll w
600 Washhwn S~
Boston,MA 02111
rvww.ma Lgott/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/E1ectridaas/Ptumbers
AppUcaut Informgdou Please Print 1 ibl
Name(l3 tdividira!): QT► i 0 A� _ -
Address: i► 0-7 �a} _
City/State/Zip: -�o ly u K e p& oEOqo Ph,,,,, q,3" " O_�'0 �_.
Are you an employe?Clock the apprrspriate box: Type of project(required):
1.9 I am a employer with 14 4. ❑ I am a general contractor and 1
employees(fldl and/or part-time)-* have hired the sub-contractors 6 E]New construction
2.❑ I am a sole ptoprieloir or partner- listed on the attached sheet 7. Q R,eawdeling
slap and have no employees These sub•carttts w s have 8. Q Demolition
working fin'=in alb►cglactty. m4k1Ym and have wmrl m
[No workers'comp.insurance comp.invxance.t 9. []Building addition
r l 5. [] We are a roapotatiou and its 10.0 Elecuicai repairs o"additions
3.E1 I am a homeowner doing all work officers bare exermaed lb ea 11.0 Phanbmg repairs or additions
myself (No wrkers'comp. H&Mex°mptyO°per UGL 12.[Q Roof"Pairs
inansrancc .)t c. 152,11(4),and we have no 13.®Other aN S
employees.[No wartess'
insnnmce TOined
;Any appliew dntebedcs boot 01 moat abo fw oat dw seafta badserabowigs emir worbaes' p�1'k(n=has.
t Hoomaw M who A&Mh 1Mis tdllAroit iadiatiag tliay are Ooitg sll abut and t ea hiss auldiia aDaaactors m ariasit a sear ai;idwit iniieatieea each.
tConawctmr*me check This bar,uric.ee.eti- on addManal sheet dw*4a#da umu are*aabowwckm and awe.umber or.a ftee tare
wnpk*vm if be arboaaaat*=bans aniployoeu,fty nwt pasrih dleir in **oM peft arwebr
1 am sn iasrployer tJrasr Is 'cesrpan%p&ear Assureacefor rty wupfeesx BTlow k tke paloicJr and job site
information.
Insurance Company Name: S C QS u AQ.K-CR.
Policy#or Self-ma. Lice# W w C_�D(6`5 071 Fxpuation Date: *_Y o-6 /c�0
Job Site Address: C 11
Attach a copy of the wrrftrs'compensation pMq dedaratios page(showing the policy number and expiration date).
Failure to secm-c coverage as required Hader Section 25A of MGL t~ 152 can iwd to the uquitim of uiminal penalty of a
fine up to S 1.500.()0 and/or one-year nnprisonment,as well as civil pcoahica in the form of a STOP WORK ORDER and a fine
of ups to 5250.00 a day against d*viotator. Be advised that a copy of this statement ruay be forwiuded to the Office of
hives ti
I do hereby certify ynder W pakrs andavurkin efpd yrtry did die enfenwai*m proWdod above is true and come.
5ienaturc: Ai-m"— 4-
phone
offi-V-1ase only not write in Ais area, to a usrrys y e ty or fnwtr Offk eL
City or Town: Perrultlucenst tf _
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 ar;
r
+ 1
1 SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: JC�)'{`�Q�`�!L l� �`l 1 P j l] R—
G
License Number
Addr j,ss Expiration Date
Signature Telephone
9.Re istered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
V\6-) !�!� <J 3— 2;�— 1 -6
Address Expiration Date
' i
Sk'0/�o e--� �� J 5- Telephone
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 `it.
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 C] Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors []
Accessory Bldg. ❑ Demolition ❑ New Signs [ol Decks [M Siding[C]] Other[1:[
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea.if New house and or addition to existing housina complete the followina:
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
1 C•lL� 20 as Owner of the subject
property
hereby authorize
to act on my behalf, in all matter3-relative to work authodzed-by this building permit application.
Signature of Owner Date
I, L I�C°dl �C'! l► ) -y ' ! { 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 penes of peg
Print Name
Signature of Owner/Agent Date
Department use only
CityCrt N rtharn on Status of Permit:
Building i partment Curb Cw0dvomw Permit
AW 1 ,2 2015 212ji in Street 5ewer1Se$c AAvailai bility
100 Watermell Availability
-
Electric, Plumbing&c n, MA 01060 Two:Sets of blUCUW Plans
North ton,t A s _ Fax 413-587-1272 PiotfSibe Plan&
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be canpleted by office
1.1 Property Address:
Map Lot Unit
Zone Overlay District
Elm St District Co District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
TIC
Name(Print) Current Mailing Addre :
Telephone
Signature
2.2 Authorized Agent:
Name(Print) `, -� Current Mailing Address:
Signature Telephone
SECTION 3-ESTIiMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit 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)
5.Fire Protection
6. Total=(1 +2+3+4+5) ��' Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building CommissionerAnspector of Buildings Date
File#BP-2016-0177
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002
PROPERTY LOCATION 8 TARA CIR
MAP 29 PARCEL 519 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ,//`/_�„ 1 Z741 ,
Building Permit Filled out
Fee Fee Paid
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
INFORNATION 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
WffFicial
t 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.
8 TARA CIR BP-2016-0177
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 519 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-2016-0177
Project# JS-2016-000299
Est. Cost: $2800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 5880.60 Owner., BOROWSKI TRACI L
Zoning: Applicant: DONALD PELLETIER
AT. 8 TARA CIR
Applicant Address: Phone: Insurance:
P O BOX 5020 (413) 538-6002 WC
HOLYOKEMA01041 ISSUED ON.811312015 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 8/13/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner