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38C-078
BP-2022-0243 174GROVE ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 38C-078-001 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-2022-0243 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: Est. Cost: 3000 SDL HOME IMPROVEMENT 103635 Const.Class: Exp. Date:05/20/2023 Use Group: Owner: L DUGAL ELLEN Lot Size (sq.ft.) Zoning: URB Applicant: SDL HOME IMPROVEMENT • Applicant Address Phone: Insurance: 24 CHESTNUT ST (413)247-5739 WC9024456 HATFIELD, MA 01038 ISSUED ON:03/15/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERI ZATI ON 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: Gas: Final: Final: Rough Frame: Rough: Fire Department Driveway Final: Fireplace/Chimney: Final: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: I f • 1' . Fees Paid: $65.00 212 Main Street, Phone(413) 587-1240,Fax:(413)587-1272 Office of the Building Commissioner ' 1-7:r.-.:-.7-,....,--- ; '''' ' _ -___ ,.; City of Northampton j"-� ,:.i Building Department ( I�. . 212 Main Street 1dAR i I LI P Room 100 II Northampton, MA 01060 -- fi r r.'-'` phone 413-587-1240 Fax 413-58'7 .1'' ' 2rn,v, f Y 1n , II, APPUCATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property AddressgqTis section to be completed by office Map (JZ,,,.� Lot 0 71 Unit / 7',/ 6),,,,_ (1(1 4Zone Overlay District v`o 0 Elm St.District CB District SECTION 2 PROPERTY OWNERSHIPIAUThORIZED AGENT 2.1 Owner of Record: i. E/ eA/ 5\L4 i / 7V Name(Print) Current Mailing Address / p- �_<T[� Ug 9 c( —e—A- GtTI—�� LJ—... 4 Telephone Signature 2.2 Authorized Agent; L2( Jkrv�Cd_--1-- - .. .iy-)eir-L_V--E_Tr\-Q....A.--1-- / --7-,7( 6---;,--Lxi-c- -,4-- Name{Pri Current Mailing Address: S' nature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee C�=X'> 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) P6Iv 5. Fire Protection 1 +2+3+4+5 �iu c� 6. Total = Nu__ 3, .01 { ) �C�C� � Check rrbe� f�, 22 This Section For Official Use Only Date Building Permit Number. V" A—I"�`�/ Issued. Signature: //7 ' 3- ZZZ g Building Commissioner/inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4- .. '-.-"; f:it', n .j +,: : 8.1 Licensrld C ,__ ;- ,Aw. _ . leer: (Jj��yy� /^/j Not Applicable 0 ,/)� ii .:At, • x.:f.; a ";L. :, AK/ �"_�Pi//c d � ' i 0, 1d�✓3 License Nu ber ,24 Ch n l- s-1, -40r---g Cd., ni 4 O)v,8' 3 (© 3 ' { j� r7 Expiratio Date - 23 gnature Telephone '' Not Applicable t�ffiW 11 Z C L.. e irLk,f �restrtion umber 67 /R Address �."r' '� / ExpiratiorVDate V �t.A.k",-'t'1'rA 8 l'Y -,‘ 0 U" t8 Telephoneek/13- 4'2— '239 SECTIONS-Wes'COMPENSATMINSURANCE AFFIDAVIT(M.G.L.C.152,125C(6)) Workers Compensation Insurance affida must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the build" g permit. Signed Affidavit Attached Yes No Brief Description of Propos.d Work NOTE: INSULATION ONLY kir( I -c_, Lr cl aLA r �S I, '1 t c � � C��-� .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. 1 Patki3�, a S �r , .1Ertyt vC, Print Name Signatur f Agent Date i l Il I .t�1� 14 , as Owner of the subject propetly hereby authorize •. to act on my behalf, in all matters relat ve to work authorized by this building permit application. c.,-e A �Sl- -vIS�.� Q3� ? "oZ a-- Signatureof Owner Date City of Northampton Massachusetts rr (14 - DZPARIIIIINT OF BUILDING INSPECTIONS 212 Main Stratet •Municipal Nu,:icia.ng •-4421?',•' Northampton, MX 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A, The debris from construction work being performed at: f7q (-)J KO---Y4-140-41 (Please print house number and street name) Is to be disposed of at: -1v rA C 4- -cc-Vg-k._ YY\ (Please print name and locan of facility) Or will be disposed of in a dunjiii)s ar onsite rented or leased frnA • CD t c„) (Company Name and Address) 3/ Signature of Permit Applicant or Owner Date f, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. City of Northampton . Massachusetts ' DEPARTMENT OF BUILDING INSPECTIONS , 212 Main Street 0 Municipal Building , Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation ("OCABR") regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes, a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.I. Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units_or to structures which are adjacent to such residence or building" be done by registered contractors. ,Vote: If the homeowner has contracted with a corporation or LLC, that entity must be registered. Type of Work: I a Est. Cost: C.)0CD Address of Work: pp/ p Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law (explain): Job under$1,000.00 Owner obtaining own permit (explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building petactit as the gent of the p rAtAA Nry‘j ck—k -d` 1-"‘ / ST-- Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature ... City. of Northampton Massachusetts it v' / 1 V ./...; , ,•-••• x DEPARTMENT OF BUILDING INSPECTIONS ......, 212 Ma= Street e Municipal Butids.nq Northamptdt, MA 0106(' MANDATORY FOR HOUSES BUlL T BEFORE 1945 Property Address: cSi- ,\ _ Contractor Name: ,,:3ts..) ,,-,. 44--;-'4CY\-0-, 'M )ii\je.-11-\,- (\141— 1 Address: ‘ 214 cilL.LcA-r-vL,L.A.- City, State: A-ket-A V-t_t,. cLk. YYN.Or C--,NN C3 ?)e Phone: 3 )4 t 5-- q 1 - 5 'Tr?) Property Owner Di Name: Address: / City, State:State: Ni L)')-4-4--)et--i--N--,pkr_-_-)k.D 'MA CD) b(4 0 dal ,<)cnrva,ici-f- (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 ,/6=--------' Date Permit Authorization mass save Form Seams Von*stnionr, z Site ID: 4419446 Customer: ELLEN L DUGAL ellen dugal , owner of the property located at: (Owner's Name,printed) 174 Grove St Northampton, MA 01060 (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. ��, ez( ,014# Owner's Signature: �/ Date: 03 / 04 / 2022 FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Name: CLEAResult Phone: 800-480-7472 Email: Page 1 of 1 F r C i e Use Orly _ The Commonwealth of Massachusetts ►1!=MD i!t Department of Industrial Accidents +' =I. 1 Congress Street, Suite 100 _?.ji= Boston, MA 02114-2017 ,,- www.mass.gov/dia 41 10. Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):SDL Home Improvement Contractors, Inc Address:24 Chestnust Street City/State/Zip:Hatfield, MA 01038 Phone#:413-247-5739 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 7 employees(full and/or part-time).* 7. DNew construction ' 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling any capacity.[No workers'comp.insurance required.] 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑ Demolition 10 Q Building addition 40 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.12 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 50 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 14.DOtherInsulation 6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c. 152.111(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire 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:Selective Insurance Company Policy#or Self-ins.Lic.#:WC9024456 c I Expiration Date:02/23/2023 Job Site Address: / (/' 4//)%f-e—, City/State/Zip: Nj��r cter\(7 ti cpensation policydeclaration page(showingthe policynumber and expiration iration date). Attach a copy of the workers' p g p ) Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable 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 certify,unde the sins and penalties of perju that the information provided above is true and correct. Signature: / _ Date: J' R-a Phone#:413-247- 739 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#: