12C-115 (3) 88 RICK DR COMMONWEALTH OF MASSACHUSETTS BP-2021-1856
Map:Block:Lot: 12C-115-
001 CITY OF NORTHAMPTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1856 PERMISSION IS HEREBY GRANTED TO:
Project# INSUTION Contractor: License:
Est.Cost: 3932 065992
Const.Class: Exp.Date:03/16/2023
Use Group: Owner: MELLING VINCENT J &LYNN M
Lot Size (sq.ft.)
Zoning: RI/WSP Applicant: GOLD STAR INSULATION &CONSTRUCTION LLC
Applicant Address Phone: Insurance:
1 CONGER RD (774)329-4664 65620B5N23815620
WORCESTER, MA 01062
ISSUED ON:09/13/2021
TO PERFORM TIDE FOLLOWING WORK:
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.
Signature: ( i
cp,
Fees Paid: $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
_) k_
•
iJ
Cry
j _' 14 78 The Commonwealth of Massachusetts
i - Board of Building Regulations and Standards FOR
,- V i J' MUNICIPALITY
I
, c� Massachusetts State Building Code, 780 CMR USE
\ ' ,Th.7, Butt`..:Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
Uv1
This�Section For Official Use Only
I )3uildin �+ : �0'oZ("l g5'' Date Applied:
n.> ` JZ55 / 2 6/1-'-id ZDZ 1
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 rop AAdddre - 1.2 Assessors Map&Parcel Numbers
(tv.t_.
1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qwner'of Record: + �.�
`t‘". ;tnir ►--t2.1\'iA3 ofeANR..C . , mAt 4o10(a2_
Name(Print) City,State,ZIP n
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied ❑ Repairs(s) 0 r Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other IS-Specify: %i.StAfk5.- ..a 1.
Brief Description of Proposed Work2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost3 (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:) r
/ Check No.2-'4 Check Amount: 41• Cash Amount:
6.Total Project Cost: $ Cj ,bk 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ('S- 8�5 (� 6?#
14 h A`\e_f1 License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) l�
4;A 0,f -Q.4-
Type Description
No.and Street
M� bl bS U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Tdwn,State,ZIP M Masonry
b( ( QQS�� � RC Roofing Covering
U v'rAf � �ate.an C d r uC�'.o" WS Window and Siding
�j - 1 SF Solid Fuel Burning Appliances
'T Tff -�i L� lR(,(,N ei 1 C i\ l a(4 ..1• Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 20b (4f_c,;J-
44 SA-N C._0✓ g_Lx HIC Registration Number Expiration Date
HIC lompicy Name or HIC itraistrant Name
No.anti Street Email address
City/Town,State,ZIP Telephone
SECTION 6: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 ice No . ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 2 d. gko.r ,144..lIrN%or. Ciefaca-;
to act on my behalf,in all matters relative to work authorized by this building permit application.
V'kc.e 4 ILc.
Print Owner's Name(Electronic SiteWure) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
V1 C-12-r4 r.-k k\`I ce-xJ - 2
Print Owner's or Authorized Agent's (Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
*= = /, Department of Industrial Accidents
;ipl;:" = 1 Congress Street,Suite 100
e Boston,MA 02114-2017
www.mo s.gov/dia
Workers'Compensation Insurance Affidavit Builders/Contr^actoreIElectrlciansIPlumbers.
TO BE FILED WITH ritE PERMITTING AUTHORITY.
Applicant Information Please Print Ljb (
cue(Business/Organization/ndividtui1): G cal d S't '.yt,�rJlc.4acsl (arl.5-)-(0 n L-LG
dress: . co>1� of
y/StatelZip: (,J art t 2S4ef pet (1- eS/1 Phone#: 7 7 L 3 D ot -y((4
yew an employer?Check the appropriate box: Type of project(required):
em a employer with (Z employees(full and/or part-time).' 7. ❑New construction
I i am a Bole proprietor or partnership and have no employees working for me In g, E3 Remodeling
any capacity.[No workers comp.Insurance required.) f-t
1 am a homeowner doing all work myself.[No workers'comp.insurance require) 9 Q Demolition
10[]Building addition
1 am a homeowner end will be hiring contractors to conduct all work on my property. I will 1 l.[]Electrical repairs or additions
ensure that all contractors either have workers'compensation Insurance or are sole
proprietors with no employees. 12.0 Plumbing repairs or additions
i am a general contractor and i have hired the sub-contractors listed on the attached sheet 13.Q Roof have repaiisc
These sub-contractors ha employees and have wotrnacs'comp.insurance. 14.Et-Other 11 ra�r �G� 4.rcYle-
]We are a corporation and its officers have exercised their right of exemption per MGL o.
152,§1(4),and we have no arnployes [No workers'comp. Insurance required.)
applicant that checks box 41 must also-fi1tout the section below showing their workers'compensation policy information,
slowness who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
motors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
ryees, If the sub-contractors have employees,they must provide their workers'comp.policy number.
I an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
rmation.
ranee Company Name: U f tQi'1 M U-kJ 0.
y#or Self-ins.Lie.#: (o SG k S t1 a 3 S 5 Expiration Date: i(I (( f a !
Site Address: Pr (-4;CA (2'%vC City/State/Zip: Pc, r .)C f r I an,G 7,
rch a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
.u+e to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a flee up to$1,500.00
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
against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
xage verification.
hereby under the pains and penalties of perjury that the information provided above is true and correct
nature: Date: CS-Z 4 Z/
Qe ; 1 Lf 9" 4 f
i,jflcial use only. Do not write in this area,to be completed by city or town official
;ity or Town: Permit/License#
suing Authority(circle one):
.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Other
:ontact Person: Phone#:
City of Northampton
r: ii ti Massachusetts �' `'� =z
3 � DEPARTMENT OF BUILDING INSPECTIONS v
.}r 212 Main Street 40 Municipal Building
e. -a' Northampton, MA 01060 t1'
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number 4' is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: �g cbCe" 6.6-e--/ i ?/ edci A- r4 a/do_c
The debris will be transported by:
Name of Hauler:ti.,0 ,LW Ae.4-1
Signature of Applicant: ��.c �DGtJrJ� Date: pe-Zhu -01
DocuSign Envelope ID:70AF93A5-D8E9-4F3D-BE04-F430C937CF8F
RISE
ENGINEERING-
OWNER AUTHORIZATION FORM
I, Vincent Melling ,
(Owner's Name)
owner of the property located at:
88 Rick Drive
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize ,
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The permit will be secured by the subcontractor, at no additional cost.
It is the homeowner's responsibility to close out this permit by contacting their municipality at
the completion of this work.
DocuSigned by:
10/6/2020 18:03 AM EDT
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com