36-333 (3) 122CARDINAL WAY COMMONWEALTH OF MASSACHUSETTS BP-2021-1916
Map:Block:Lot:36-333-001
Permit: Alts Renovations CITY OF NORTHAMPTON
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1916 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
GOLD STAR INSULATION &
Est. Cost: 4000 CONSTRUCTION LLC 065992
Const.Class: Exp.Date:03/16/2023
Use Group: Owner: DUROCHER ANDREW J&LINGQIAN KONG
Lot Size (sq.ft.)
Zoning: WSP Applicant: GOLD STAR INSULATION &CONSTRUCTION LLC
Applicant Address Phone: Insurance:
1 CONGER RD (774)329-4664 65620B5N23815620
WORCESTER, MA 01602
ISSUED ON:09/22/2021
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATION
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: (41)17),
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
The Commonwealth of Massachusetts
'(til
Board of Building Regulations and Standards FOR
,
Massachusetts State Building Code, 780 CMR FOR
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
�, One-or Two-Family Dwelling
`n This Section For Official Use Only
Building-I?gnnit Number:Jp' I r l al/Q Date Applied:
_ — — E'ul►J �7 � �f-2Z ZtSz
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property A4dress: 1.2 Assessors Map&Parcel Numbers
12 2 d i n.,1 (Ala.),
1.la Is this an accepted street?yes ��no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private❑ Zone: — Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1Ow er'of Record:
t offcw vurOctier vtio 44,14ni i4tv, wi A, o(c
Name(Print) City,State,ZIP
14. ( 4 d r, ( (.Je%Y n1ti-1)/1-Yall 9Gw Itskec e2 Cam,...
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition ❑
Demolition 0 Accessory Bldg. 0 Number of Units Other C$pecify: T r1 Sulo4..g4s.,,
Brief Description of Proposed Work2: it 4r`a� () '-A (5/04,- [e ((c/(O S-L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
0 Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount; ( Cash Amount:
6.Total Project Cost: $ q 0 Uv. 0 I'aid in Full El Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) / 5-a 6.41 c 7 3//C/..2
KGv;r 1l- " License Number Expira Date
Name of CSL Holder
List CSL Type(see below) U
101 rna1, n
No.and Street Type Description
o a Unrestricted(Buildings up to 35,000 cu.ft.)
1ST �� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofmg Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7 7 Li 3l5 �{CC ,�f(tiri 1'e 5k- I GlOcc4, I Insulation
Telephone v Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 00 G a
C�dl� Si ' T./•• SC/ I G i, cr CUn LG C HIC Registration Number E irat of n Date
HI Company Name or HIC Registrant Name /
No.and Street � j/M 'a J 'l& (c
(„�arGeSl-v- rhI3 01404 3't1 iTciCCy
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 C3� 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 .jb(d g4 A rkSc t CAA ebn01.6y pir)
to act on my behalf,in all matters relative to work authorized by this building permit application.
Pei rldrC.tJ - LtrodeNt f r�/ol� a(
Print Owner's Name(Electronic Signature) l gate
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.
Print Owner's or Authorized Agent's Name(Electronic Signature) ate
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 ro 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
l` y=_ I Department of Industrial Accidents
'=', 1 Congress Street, Suite 100
-.14 ��- Boston, MA 02114-2017
— 4., wwx.mass.gov/dia
Afoot
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH liii,PERMITTING AUTHORITY.
Annlicant Information Please Print Legibly
Name (Business/Organization/Individual): 63 did 5 2..c t ►,.a j CYl (0Y1, 4-4, .Gh L LC
Address: 4 co A.,e'-(- ik of
City/State/Zip: LA/af(,&5 (l1 A- c 1(c.2 Phone#: -7 7 tf - 3)ot -,6( (t`
Are you an employer?Check the appropriate box: Type of project(required):
1. am a employer with C employees(full and/or part-time):" 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in g. El Remodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.Insurance require) 9. 0 Demolition
10 0 Building addition
4.0 I am a homeowner and wilt be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation Insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.0 Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.0 Roof repairs
These sub-contractors have employees and have workers'comp. Insurance. 14.EaOther /I iric‘4-,jell 4Jcf(C-
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c.
152,§1(4),and we have no employees.[No workers'comp. insurance required.)
*Any applicant that checks lox ill must also out the section below showing their workers'compensation policy uttonnatron,
t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: I.)fl 10(-1 i U-kl e --
Policy#or Self-ins.Lie.#: co 5(,.3 4,6 6 S A J 3 ? i S cz7 o Expiration Date: i t( it 14
Job Site Address: 7 Z•2- C i f or R n al C.A.)A l/ City/State/Zip:no( -t c.s t 0}o,t �►44 d t>S.-b
Attach a copy of the workers'compensation policy declaraOon page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation pmishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c •' under the pains and penalties of perjury that the information provided above is true and correct
.,
Signature; , 1 (Ct-Gc,�'�' Date; to J 3( r V
Phone#: 774— .)9— L1W G1 '
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
(-7-
,.,.frj, .- rJ ti. 4s!�+
Massachusetts - !tr
C.
YA', yp F�
4 DEPARTMENT OF BUILDING INSPECTIONS 7.,. '
F 212 Main Street • Municipal Building y. ✓€fib
•!1 Northampton, MA 01060 s' �`‘�
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 ( 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: 7 (03E_JOC- 2-/ cc_ - 4Dc. ( /`-k n-
e,l,o�
The debris will be transported by:
Name of Hauler: ` .. ► . \(\n R'ed1
Signature of Applicant: 1 04-0�`� Date: -7- ,.--?
DocuSign Envelope ID:663105E4-4C12-4D4F-82EC-A54821C7B8EA
RISE
ENGINEERING`
OWNER AUTHORIZATION FORM
I Andrew Durocher
(Owner's Name)
owner of the property located at:
122 Cardinal Way
(Property Address)
Northampton, MA 01060
,
(Property Address)
hereby authorize ,
Subcontractor(to be filled in by office)
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;
LQ tA,1X1,W OtAr'b�
O 6iveS Wee
5/8/2021 ► 10:20 AM EDT
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RISEengineering.com