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43-049 (2)
Permit Authorization 4 .o- mass save Form 1'ARTl1f°AiIN{'s Site ID: 50129021 Customer: RON GALLAGHER I, RON GALLAGHER ,owner of the property located at: (Owner's Name,printed) 40 Fairway 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: v' 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 a Conservation Services Group • 50 Washington Street,Suite 3000 • Westborough,MA 01581 • 1800-480-7472 Rev.062015 OY Office () Consutncr Affairs and Business Reguiatil�i� 0 park Plaza - Suite 5 170 Boston, NA assachusetts 02116 Home 1111 rovement Contractor Registration Rea 150319 TVVe- inrli Alum Fxp 312412616 Tr* 748926 L)ONALD PELLETIER DONALD PELLE` IER 1 107 MAIN ST - HOLYOKE, MA 01040 - Updats Addl- i ad+rotaM dtd.Mark for tM - r�dress r 'gosuaal '71 FAU*Wyawnt I.trs1 Card srr,, Massachusetts -Departmern of Public Safety Board of Building Regulations arcj Sianaara C omtruction Supen-i,wr Speciuiri _:tense- CSS2:101M DONALD W PUj 1167 KAU4 5t'RIST HOLWAM MA #I I C�rnntsssione* iQJ0il212a16 Affi&wk kw Ham hw C4aftwWPc=itApOicafim For ethos Um ONO Dak 1�1E�r�s�mrwwrroesrt C i.trw Std to Pasit Awe 144GL c-142A rrrgtwrae dw tie 2* MOL or be dow by loh,+rd wa eessmsie esospM�im�wse,sk"wriib odhw�e*riea� Hype ofw=iL c JU(-)b - a L)Ln-A z Y-- 1&cm: AddmouatWast: � P-Q I r Owsw Neese I hweby oertity erst 1s gi is eot ngrrined for ere fbaowimg ,eirop(sr _.,_Wank embubd by bw Jab w dw il.m ad awaerw wNpied Nobm is b weby men*At awNfls Pv1 LJm 7HM OwN rmuff ost umLmo wrrH ma Apvtrrr.AKE HOw sesovgmmwr wwK Do mr HAve A(XEss To na ARtwmATvm PROGRAM OR GUARANTY FUND vNM MUL c.142& S*iwdumlwVm, l bweby qVly for a p mk es dw a mt ofsw owm Doe Mrrsre •No_ c>R: Netwirmw.dios dw sbwo eosick I MwmbY forly tier a pumbft ere o ns of the above propwq': D.t�a omm N�Fwft i City of Northampton Massachusetts ` `�{c D$PIR22MM OF BUZZDZXG ZALO 'CTTaNS a air 212 Main Street a Municipal Building Northampton, Wh 01060 Property Address: (-4 C_ Contractor Name: Address: ` ( ) City, , State: + G.. c�- Phone: Property Owner Name: C� Address: f'Ch C City, State: I,7 U'>rt,\:tj Ij T :I I l f i R 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 �— rttt+t rvtn+ The Commonwealth of Massachusetts Department of Industriral Accidents Office of Investigations t Congress Street Suite 100 Boston, MA 02114-2017 ` ww w.mass.go v✓dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information please Print Legibly 7 Rustrtess/Organization Name: -�1e tart N5V �c,'� ttir.1 Address. H3 3v4orL K j Ci /State/zi - ra Of Qy0 3 - S- bra 00 Are you an employer' Check the appropriate fox Business Type(required): l I am a employer with employees(full andf 7. F] Retail i or part-time).* 6 [ Restaurant/Bar/Eating Establishment I atn a sole proprietor or partnership and have no 7 Office and/or Sales(incl. real estate, auto, etc errmployees Avorking for tyre ire any capacity [No workers' comp insurances required] S Non-profit i,[_,_� We are a corporation and its officers have exercised ❑ Entertainment their right of exemption per L. 152, §1(4), and the have 10.0 Manufacturing, no employees, [No workers' comp, insurance required]' I !-�] Health Care 3. We are anon-profit vrgani7tion_staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.[ Other I'll S ` ' i — l Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted therrrsetves,but the corporation has other employees,a workers compensation policy is regmred and such an organizations should check box Ni t arm an employer that is providing workers'compensation insurance for my employees. ,Below is the policy information. insurance Company Natrre 11 Q 4,0 Insurer's Address: <�3 b0 110'12 l,� AV e- Li> - a 1 At City/State/Lip. e 1 i t N �' ]I _ Policy H or Self-ins- I.ic. # (Ad C, 3 1 I;k �'f 7 5 Expiration I)ate:— -7 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 M(+I c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or erne-year imprisonment, as well as civil penalties in the farm 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 tine Office of investigations of the DiA for insurance coverage verification. do hereby certify, under thepains and penalties ofperjury that the information provided above is true and correct. ( * )ate: kjj ' OQ_ F)fT cial use only. Do not write in this area, to be completed by city or town official City or /'own: Perm it/l,icense# Issuing Authority (circle`one): I. Board of Health 2. Building I)epartnlent 3. Cityff'own Clerk 4, Licensing Board 5. Selectmen's Office 6. Other L ntact Person: Phone#: __—_----------- „.v.v mac,gt»lA+a � —_. �_._ l 8EM ION 8-CONSTRUCTION SERVICES 8.1.1 LLlwsed Construction Supervisor: Not Applicable ❑ Name of Licerme Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ Company Nam Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152,1 25C46)) 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...... ❑ 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.CNIR 780, Sixth FAition 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 res,�n�ii,3,,le for&H such work performed render the budding USrmit. 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,Vogl 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 S , SECTION 9-RMW-TM2E MeNED WM(chec&J!apsolkable► New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bidg. ❑ Demolition ❑ New signs to Decks IQ siding I[31 other Brief Description of Proposed 'r le � � J Work: ti��.�l.( 1� �`C� L)e- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roil -Sheet f.tf NOW# m Wd of BOOM-to 9XIStIng boushm cm.t9eft,ft I—oilowlim: 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 APKJES FOR'81JIL ING PERWT 6 C1.1 ` 1^. (� ( as Omer of the subject pretty hereby authorize to act on my tsehalf, in all matters relative to work authorized by this building permit application. Signature of Omw �T Date l v ( p 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 ury. Print N Signature of OwnedAgent 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 ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 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 0 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 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 O NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Blllit�!`�ll7Qtit " Room 100 $ 201 MA 01060 1 7-1240 Fax 413-587-1272 DEFT. x ,� TiON TO TRUCT,ALTER,REPApt,RENOVATE OR DEMOLtSFi A�Oi't TWO FA�.Y OWEWNG SECTm 1 -SITE IATK)N 1.1 ftgoOft Addrm: iw 10 be bbd by Lot LkA 1 zom . WCTMDN 3-PROPOM OWNERSONAUTWXUMD AGOff Ll Ownw at&Kwd: Name r v Ad : "ama(om) CuNVWd MOM AdareW T T94hoM + E*rAftd Cost(DoMOms)bD be Oil Use(ktly 9 (a)Bunking Permit Fee 2. E ' TOW Gust of cw4kuc l hm 6 3. Ping SuNdkV Pandl Pee 4. Ajachanical(HVAC) 5.Fire Protection 6. Totat=_(1 +2+3+4+5) Check Number i TAio Fier OMold Use Buiid"Pon*Nun+ber [fie auwft �s�ect: 6+gndEuro: Cwmftw&w&spodw of B d&w i File#BP-2016-0880 APPLICANT/CONTACT PERSON DONALD PELLETIER ADDRESS/PHONE P O BOX 5020 HOLYOKE01041 (413)538-6002 PROPERTY LOCATION 40 FAIRWAY DR MAP 43 PARCEL 049 001 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 Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildins Plans Included: Owner/Statement or License 101876 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOR,XATION 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 elay ature ON tng O ial 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. 40 FAIRWAY DR BP-2016-0880 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:43 -049 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-0880 Project# JS-2016-001495 Est. Cost: $4000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DONALD PELLETIER 101876 Lot Size(sq. 111 24088.68 Owner: GALLAGHER RONALD Zoning: Applicant: DONALD PELLETIER AT. 40 FAIRWAY DR Applicant Address: Phone: Insurance: P O BOX 5020 (413) 538-6002 WC H O LYO KEMA01041 ISSUED ON.111112016 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