07-005 (3) 480 NORTH FARMS RD BP-2017-1312
GIS el: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 07-005 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-2017-1312
Project JS-2017-002177
Est.Cost:$4000.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq.ft.): 25221.24 Owner: ATKINS SUZANNE E
Zoning: RR(100)/WSP(l00)/WP(16)1 Applicant: DONALD PELLETIER
AT: 480 NORTH FARMS RD
Applicant Address: Phone: Insurance:
P O BOX 5020 (413) 538-6002 WC
H O LY O K E M A 010 41 ISSUED ON:5/12/2 01 7 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION EXT ALUM WALLS
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: OI: 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 5/12/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1312
APPLICANT/CONTACT PERSON DONALD PELLETIER
ADDRESS/PHONE P O BOX 5020 HOLYOKE (413)538-6002
PROPERTY LOCATION 480 NORTH FARMS RD
MAP 07 PARCEL 005 001 ZONE RR(1001/WSP(1001/WP(16)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tvpeof Construction: INSULATION EXT ALUM WALLS
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
INFO3MATION PRESENTED:
Approved 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
Demolition Delay
Si_- f Buil gO 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.
Building Department ICS CuvDriveway Permit
r'212 Main Street l Sewer/Septic Availability
Room 100 1 Waterlwe;l Availability
I Northampton. MA 01060 IT.vo Sets of Structural Plans
phone 413-587-1240 Fax 413-567-1272 IPlousrte Pians
I Other Sceafy
APPLICATION TO CONSTRUCT.ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION I
1.1 PnQroce��llAAdddress. This section to be compile
Y/Jad by office
LASO`x ` .QCST\S Map Oil Lot 00 Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
-
2,1 Owner of Record:
SOZOLrxmQ. F*kvn Cit n 'taccnS RA -
-
vvCurrent Mailing?Adri,p 3 D
\ t S Ky\�U6 Teleph
one
1 S:E-r..e
22 Authorized Agent: •
�nkNi l0�\M, ec 1107 (N14om
Current Mailing Address
t
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Items I Estimated Cost(Dollars)to be Ofioal Use On:y
completed by permit applicant
I Bui dnc I (a)Building Permit Fee
2 Eecr2 ( (b)Estimated Total Cost of c �
1 Constmdionfrom 16) 700-
li 3 P.r-o-_ Building Permit Fee
4. Mer^ to : .Ar
.^. reE 2 g #0V/J
a Tea - "_ e 1NS.f r6-lam prrj OA
Check Number 6706 j
This S_ tdc ion For Official Use Only
Date
Bu:idtc Per"- 'vz-c_ ____ I Issued
Signatcre
Bundmo Commissiooerllnslxxuor of ECQt r s Date
F— -
.
MAV
SECTION 8-CONSTRUCTION SERVICES
' 8.1 Licensed Construction Supervisor:
\�\'(� Not Ap livable ❑
{
Name of License Helder: y )(� },1C.V t. t C,.�ij1CT(ty-t€ r
License Number
• k . . . Y ... IRO 1r) _ ry4r 'Ick- r6- /g
-... _
ExpirationDate
C3FADon....
Telephone
9. Registered Home Imdrovetment,Co 1ntr(accttoo-r?' Not Applicable 0
(
Companvigarne Registration Num r
aC/- tom
,;; ':ss Ate, SI nTelephon¢ J � t--} Expiration Date
_ 1 ✓`lam t ]J ,l�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152, §25C(6))
N
Workers Compensation Insurance affidavit mu e completed and submitted with this application. Failure to provide this affidavit will result
in!ice demai of The issuance of the building mit.
Signed Affidavit Attached Yes No O
11. - Home Owner Exemption
The current exemption for"homeowners'was extended to include Owner-occupied Dwellinzs of one(I) or bw(2) families
and to allow such homeowner to en_aec an individual for hire who does not possess a license,provided that the owner acts
as supervisor. (:MR 788. Sink Edition Section 108.341.
Definition of Homeowner: Person tsl 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 geriod 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 alt such work performed under the building permit.
As acting Construction Supen'isor s our presence on the job site will be required from time to time,during and upon
completion of the wrork for which this permit is issued.
n iso be advised that with reference to Chapter 1521 Workers' Compensation) and Chapter 153(Liability of Employers uy
Employees for injuries pot resunine in Deaths of the Massachusetts General Laws Annotated,you mow be liable Tor person
e to perform work tor)ou under this permit.
The undersigned'hommwner certifies and assumes responsibility for compliance with the State Building Code.City of
\orthampmn Ordinances.State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-.DESCRIPTION OF PROPQSEO WORN check all applicable)
New House ah
Addition ) Replacement Windows i Alterationisj L I I Roofing {'"-'
Or Doors
Accessory Bldg in % Demolitio ❑ I New Signs (0) Decks ni Siding ILi Other r
i
Des !on c.`Pro sec w '•. ...... .
erotic^C'ex!stino bedroom Yes No Addino new bedroom Yes No
'e_hed Na'fa'_ive Renovating unfinished basement Yes No
P ars Aranned Roil -Sheet
6a. If New housea d •r add' -.n oexistin• ousin• om•lete tilt followi e.
a Use of binding-. One Family Two Family Other
: ri_mee cd rooms m eacfi family hob Hunner of Bathrooms ...
here a garage attached9___
'socsed 8ovare footage of new construction._„ Dimensions__ —
Nanoer or stones^
Method of heating" Fireman-es or WnOdstOVes Numberr of each
? Energy Conservation Comphance MasscheCa Energy Compliance form attached?
Type of construction
!s antsmi con wino `h it of wet train Merv` No is construction anion 100 yr floodplain Yes
Benin 01 r aleaZai pf Malar floor bolo?finished made
- .. ,Cotttoor ;ft tne o mdin t and whiny regulatchsh Yes No
Seciiic TtInc..__ CI, Sewer Pr. a:e 4iEii _..._ CO, water Supply ._
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN I
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,
Suz tnr\q FvnS ,_ as Gamer o!tnesub.ci
act(...,. "I\` OZ.\AQj t-C? c
C' c-3�' !
(r‘ tens relat,y to work euthorixed by this building permit agplicaboa
fate
6 SC w r'Sk_\ -Rkie
- s:e that the statements and infcrmabon on the foregoing abdication are toe aec atobtrate rn^-e hes-- ?nabob
'. --- e car, a o oenanes , perlu
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05/04/2016 11:40 14135871272 NIGH BLD DEPT PAGE 01/01
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DEPARTMENT SOF PDT LIMN INSPECTIONS V $.
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Northampton, M 01(06�D�.f ° :.
Property Address: "I a-0 f C Q«S `` '
Contractor
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Address: Ak �� ( 0.L0 �
City, State: l-k k G .
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Phone: si ( 3 l h WO �---
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Property Owner n `may 1�
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Address: 1',TI�CX )� \-- cO(r&S S4 . /'
City, Slate: '�l 1T K)(f''V `--`{i I'-t � I d l00�
I, 75' GA-4 i,\LU i 2( (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 he insulated and that I have
provided the property owner with a copy of this affidavit
contractor signature t5 r� ,. ! eta 4 W
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CERTIFICATE OF UABILIT)( INSURANCE ;,�. WS
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ABOVE FOS THE POLICY PER/00 NCAOLITB3 NO'/YNTl6TMONB AM'RECAME EMT, TEM OR Ctl%O%HOn OF ANY
COMPACT OR MIER OCKONE HT WM RESPECT TO YRSCHI THIS C9ITENCATE MAY SE MEMO OR MAY PEtTAN 1 .€
INSURANCE REFORM() BY THE POLICES OEICRMED HERM B TRs.EcT TO ALL THE MINS. EXCLUSIONS AND
CONE/MONS OF sun POLICES-I.IYES MOM MAY HAVE BEM REDUCES BY PNC IAAS®.
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PCOM El OnESER The AWN)Awa sed Imp as r.SSNeY mots of
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
t;- 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name lBusinessiOrganixatmnnndividuat): )Q\\et( eC1
cr GJ`0.'1v e' c
Address:!._... vLl Soccb
11.0k �j \ ^.....�N 9� ^�
City/State/Zip: 0k L { w S3 6 bb
. -, a Phone#: (
Are you so employer?Cheek appropriate box: Type of project(required):
I.bib am a em 1 er with_ 4. 0 I am a general contractor and 1
P 6. ❑New construction
employees(fill and/or part-time).' have hired the sub-contractors
2,0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
workingfor me in anycapacity. employees and have workers'
P R 0 Building addition
(No workers comp.insurance comp,insurance.:
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
( ffi
officers have exercised ❑Plumbing their 11. repairs(] l am a homeowner doing all wort: or additions
myself. [No workers comp. right of exemption per MOL I'D 12.grpairs
insurance required.]' c. 152.§1(4),and we have no
employees.(No workers' 1' _. . —__...
comp_insurance required.)
•An}applicant that checks but a I must also till out the notion below showing their workers'contamination policy information.
•ilumeownen who submit the affidavit indicating they arc doing all work and then hire outside twnuacvrts MUST submit a new aatlavu Skating such.
-CtminMnsthat check this ben must attached an additional sheet showing rhe name of the sub-stratraciort and Veit whether or bol thou entities have
employees. If the subccontlaclora have empkoyees,they must provide their workers comp policy monitor.
I am an employer that Is providing workers'commentating insumncefor my employees. Below Is the policy and job site
information. /� �/�
Insurance Company Name:_.. IR C t: f�f'tfft€ACS{a,C
Policy#or Self-ins.Lie. : 1ov W � yu U f qc{l3gq r 9/ Expiration Date: r/-7�/ d O i 7
Job Site Address: Sie Ls C44 - tonic Pc Citv/State/Zip:_ /-i- d-e?
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 MGI..e. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby eerrufy under eekeepains
/anti penalties of pedwy that the information provided above is trite and cornet
Signature!
'S-/1 Cfl(CSK)�iC11f�.6 Y�18}.�s.1�-!\ pate: J��....1 7
Rippe#.(_9 43 > S S�/O6Cte)
Official use only. Do not write in this area,to be completed by city or town o ciat _ _
City or Town: _ Permit/Licensea
Issuing Authority: Building Department
Contact Person:
I
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
_— ReplSalbn: 150319
Not krasiabta
•j.- Emi'appn: 32412018 Ira Slam
DONALD PELLETIER +
DONALD PELLETIER M = -- I - --
1107 MAIN ST `•Z
HOLYOKE, MA 01040
W A=1
Update Maras sad'Sr.rad Mark roma ter cbage
n Addresss..d❑ Rp ..w.,..ai 0 Lw1 Card
SCA i a Mail'
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CBBL-101/176
ConstructionnSpecialty
Specialty
DOMKD W PELLETIER
110 MAN STREET
HOLYOKE MA „ase
N,nn l/L— Expiration:
Cdnmissioner taM0A1a
•
en
•
Permit Authorization 'rN�
MASS saw: Form emegaNMIN
S6d•v6nlmq� Sy- a.,.ac,sn
Site ID: 502259846 Customer: Suzanne Atkins
Suzanne Atkins ,owner of the property located at:
(Owner's Name.prMtedl
480 N Farms Rd Fllorence
(PropertyStreetAddress) (City)
hereby authorize the Mat 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: M'///a /./b FFF
FOR CLEAResult OFFICE USE ONLY
CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
•
Participating Contractor Date
•
123'D
CIFAResult • SO Washington Street,Suite 3000 • Westborough,MA 01581 • 1800.480-702 D
For pace UseOnly
Rev.102015