29-247 (4) uan
Permit Authorization
mass save Form ►, ►,tea
s.rr�pa 0+ 110 �+avir•N+d«Kr Coffffa n
,f111111111111W
Site ID: 500002301149 Customer: Laura Sabin
I, Laura Sabin ,owner of the property located at:
(Owner's Name,printed)
102 Overlook Dr 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:
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
af•o
o� �r
For of lice use only
Conservation Services Group • s0 Washington street,Suite 3000 • Westborough,MA 01581 • 1800-480-7472
Rev.062015
Affidavit for form COB&UCW Panit Appfication
Far O iat un 0017
PIN
Daft
SuPpkmmt b PDX Appfictliaa
tom.c.142A dw the—g ammmd6.
WHO
S1Lh~be doge by wa,wftb aerbepv owm6 moan writs eeaerder
Type of Waric Bat.GArt S-_
wa*wt,,rrw.rt:
Owsor
Daft*( A.M-A .- l _
i bereft cwft thic
co in mW eequired for the SAknotios mnalKsy
wank a�odnded by brew
,, —ieb�dat SI,OtlO
ad ovum � d
Nome is hereby SOM diut
OWNS B PULt.tlyt3 THM Cy'IVN P'iPalar out DeALn io wrrH umetsownsuBD comxAcTms Ka
AMU CANE HOW BAPRovemawr wom oo mor HAvs Ac cws To nw AR9n tATm r'ROGRAm
ox GUARANff FUND UNM MM c;.142&
[braby apply for a peearit ae the arum at tie e"aar:
Daft It Si-in el, N,.
Mm"idwam dke the oh, 0 as kk I booby„#ply it a PN=k ar dw arwarr erdw OWNS p vpmty
nee oetets Nuns Fwaft Aensit
City of Northampton
Massachusestts }.• `'` ~c
w X.
DWAR2WIW OF BUILD.ZNG 2NSPSCSZQNS
titer 212 tarn Street • Nkmicipal Banding t, Cab
Northampton, NX 01060
Property Address: UQ�
Contractor
Name:
Address:
City, State: C
Phone:
Property Owner
Name:
Address:
City, State:
� (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 u 1 0 A
Date _ '
1-lie CominonlVealth of Massachusetts rrtnt rUrtn
Department aflndurtrial Accidents
Office of Investigations
I Congress Street, Suite 100
y` Boston, MA 02114-2017
www.mttss.goMdia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Li.( " ,
Business/Organization Name: i C he_+, ,C.,t- h)5V J,U,
Address:_ H3 _,Sv-FfoL K
City/State/Zip: Lj t? {°'� e— a 0{Vq0 Phone #t: 13 - 635" (c00 3-
Are you an employer? Check the appropriate box: Business Type(required):
l. I am a empioyer with employees(full anti/ 5- ❑ Retail �
or part-tune).* (� ❑ Restaurantll3ar/Eating Establishment
' ❑ I am a sole proprietor of parincrship and have no ❑ ,-
t"ice and/or Sales (incl. teal estate, M
7. Ofute, etc
employees working for me in any capacity.
[No workers' comp. insurance required) 8 [] Non-profit
3.❑ We are a corporation and its officers have exercised Sr. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have l 0 ❑ Manutacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization, staffed by volunteers, I I-[j Health Care i
with no employees- [No workers' comp. insurance req.j 12. Other
'Any applicant that checks bnx q1 must also fill out the section below showing their workers'compensation policy information
"If the corporate officers have exempted themselves,but the corporation has ocher employees,a workers'Compensation policy is required and such an
organization should check box#I
t am an employer that is providing workers'compensation insurance for my employees. Below is the policy infonmtioit.
Insurance Company Narrie:___
Insurer's Address: �8 00 t1 'P_r , AV e, �2I
City/State/Zip- __.01,�, e, 1 q, C) fj
Policy # or Self-ins. l.ic.# L10 d `> !�T 7 51 Lxprration I)ate:— t_
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as rewired tinder Section 25A of MGL c- 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.44 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 cif
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.
T '
tgnaturer✓��-WC Date:
Phone k - t'�- `� -' !._0.C_
Official use only. Do not ►trite in this area, to be completed by city or town official
(pity or i'owit:
Issuing Authority (circic'one):
I. Board of Health 2. Building Department 3. Cityffown Clerk 4. Licensing Board -S. Selectmen's Office
6. Other
Contact Person: Phone 1#:
Wwss mass goy ldia
�SEt'TION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of Ltcertse Voider: ��`�Y3.�C'f 1 S --
License Number
tom• n �`F . ��� �,� r� _ _ 1 -6
Address Expiration Date
Signature Telephone
\ Not Applicable ❑
�J ::R� \\ (—� �� I !?�
Company Name
Registration Number
� e9
A ess � Expiration Date
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 wits result
in the denial of the issuance of the building p®nrtit.
Signed Affidavit Attached Yes...... No...... ❑
11�... o n-er Eatery
The current exemption for"homeowners"was extended to include Owner-occupied Dweliin¢s 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 10843.5.1.
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 ptMn who constructs more than one home in a two-year period hall not eo n r.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be
Irespo1Wble&r aL sueb work performed under the budding Dermit.
As acting Construction Supervi your presence on the job site will he 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
Main�
Room 100 t
NwhunptDn MA 01080
pon
he 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAW.RENOVATE OR OEYOUSH A ONE OR TWO FAMR.Y DIMELLiNG
SECTION 1-31TE EFOIISMTION
1.1 Thb asaftn to be 009%k ed by offte
LAt Lk*
tom
we SL _ cs
SECTION 2-PROPEM OWNERSHWAUTHOROMD AGENT
Ll Owner Q(Bawd:
r
" { I�°
Z2 Avemytod Aunt—TIN Yr
HL
Nwft(PrW) (AxvW*M&UV Ar dMM- I
Signettp+e Telephone
Item Eftmated Cost( S)to be Use OrtY
1. Rui dWV (a)atAdwq Peru*Fee
2. EkbiCai {b)
tt"I PkunNng �Par m
4. MadWOCM(HVAC) ,
5.Fire ProtKbw
6. Toned= 1 +2+3+4+5) c� C'� Check Number
Tt" For OMdW Use Oft
8uiki+rig Permit Nun w- Date
-- W&V Curm0wWwAnspedw°i&*Ar Date
File#BP-2016-0879
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002
PROPERTY LOCATION 102 OVERLOOK DR
MAP 29 PARCEL 247 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ---
Fee Paid
Building Permit Filled out
Fee Paid
Ty_peof 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:
proved 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
Demoli ' Delay /
Signa ure of Building Officia 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.
102 OVERLOOK DR BP-2016-0879
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-247 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa: INSULATION BUILDING PERMIT
Permit# BP-2016-0879
Project# JS-2016-001494
Est. Cost: $2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Sizes . ft. : 15028.20 Owner: SABIN-KIMBALL LAURA&CHARLES KIMBALL&LORRAINE BRUNO
Zonine: Applicant: DONALD PELLETIER
AT: 102 OVERLOOK DR
Applicant Address: Phone: Insurance:
P O BOX 5020 (413) 538-6002 WC
HOLYOKEMA01041 ISSUED ON:1/11/2016 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 1/11/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
-SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [l Addition Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg_ ❑ Demolition ❑ New Signs [01 Decks [Q Siding[p] Other�
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
sa.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.
1. 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
to act on my behalf, in all matters relatLe to work authorized by this building permit application.
CID-1'
ignature of Owner Date
1 \ � ��` � � ��" t ,j 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.
CAA
Print N e /)
L & Ijoi f y I -�
Signature of Owner/Agent Date