37-116 BP-2022-0425
23 ICE POND DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
37-116-001 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-2022-0425 PERMISSIONIS HEREBY GRANTED TO:
Project# INSULATION Contractor: License:
Est. Cost: 2500 SDL HOME IMPROVEMENT 103635
Const.Class: Exp.Date:05/20/2023
Use Group: Owner: KIMBERLY MAHONEY,
Lot Size (sq.ft.)
Zoning: SR Applicant: SDL HOME IMPROVEMENT
Applicant Address Phone: Insurance:
24 CHESTNUT ST (413)247-5739 WC9024456
HATFIELD, MA 01038
ISSUED ON:04/26/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/W EATH ERIZATI 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:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: 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 , +l
'I •
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fa x:(413)587-1272
Office of the Building Commissioner
City of Northampton g--
Building Department r-_�'
212 Main Street INStJLA` ION
Room 100
Northampton, MA 01060 QPR
v` phone 413-587-1240 Fax 413-587-1272
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DW`Ei 4.i#�i 3 ONLY
SECTION 1 -SITE INFORMATION I �S " LA 1 ION PERMIT
i 1
This section to be completed by office
1.1 Property Address.
,3 Pôr)d `�'� Map 3 7 Lot /1 Cf Unit
O- () Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
"K KOL-k,bri-/UL) c•)? ?) Ponc.),
Name(Print) Current Meiling Address: , /
' Telephone l 1 �a 3
Signe re
.n
4151A/1 (2)24 (-4_.-j) rik4-
Name(- ntrrent Meiling Address: O U
_1\111- 41 - 73 p
Signe ure Telephone
SECTION 3 ESt JE STRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building I5 (a) Building Permit Fee
_.
2. Electrical (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee0/0
c
4. Mechanical(HVAC)
5. Fire Protection
6 Total=(1 +2+3+4+5) i5—aO•t° Check Number
LL This Section For Official Use Only
Building Permit Number. Afi' i- - C38
te
Issued:
Signature, /�//�— LI- 25-2oz
Building Commissioner/inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSIMUCMI W.
8.1 Licensed C r: Not Applicable 0
hiliDLALigesisitilidder: i.ti 60-IVX- d- 1— C., - /DN,d3S-
License Nu ber
dress1-1 C ili Ctriatk £+, 4401.4-\e[di nlil go, s--' ,3.--- c;20/a3
A ---- Expiratio Date
2i/3- 1/12-•,-5-?,3,
eattire Telephone
Not Applicable 0
, I 5--
compir 3 ,1,.., - -cal-r‘fL.. '1 ,-1 ,
egistradon Number,
C.6.s4-- 0- , --t- rliz.0 /3
Address Expirstio ate
Telephond4 13- z)4K15-#7.39
SECTION 5-WORKERS'Ced0PEPASAIMINSURANCE AFFIOAVT(M.O.L.c,.182,i 25C(6))
Workers Compensation Insurance aft!ylt must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the bui permit.
Signed Affidavit Attached Yes....... W No 0
Brief Description of Proposed Work NOTE: INSULATION ONLY
foRbff , -P-4, 1 Di I il)L\ e - 57 ic-icU c_21,
Li , Ic., -(j. _ _40,
J 1
1 C:
a IA. i ‘...•'' '\ieNtOX.1 '.''''/k.*''' .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.
PriLd. 3c;.. ,. 6._--1/4-- d' ---4---' 4c---1-Nosi, 'Tr-ti-ef-t-vefylk,n4-- 02,1444does, -17,-,
Print
SignaturgDwXnt Date
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
DocuSign Envelope ID:73E07855-6338-4F87-AD86-0179D3F0F47A
RISES
ENGINEERING-
OWNER AUTHORIZATION FORM
Kimberly Mahoney
(Owner's Name)
owner of the property located at:
23 Ice Pond Drive
(Property Address)
Florence, MA 01062
(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.
e.—DocuSigned by:
�ls kalatn.. II
•.--.s��a,r7ss� ��c�
Owners ignature
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com
City of Northampton
, s s
Massachusetts f.
'7..0.• . ;,./
DEPARTMENT OF BUILDING INSPECTIONS k 4
212 Matz: Street • Municipal Bulldlng
Northampton, MA 01060 4.44
AFFIDAVIT
Home Improvement+Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation COCABR") 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 he registered as a Home Improvement Contractor("HIC").
M.G.L. 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- he
done by registered contractors,
Note:If the homeowner has contracted with a corporation or LLC, that entity must be registered.
o u
Type of CV"— Est. Cost.. `51)
Address of Work:
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law (explain):
Job under SI,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 pewit as the gent of the,owncr:
(-14,u0
Date Contractor 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
zu
e( ,
DEPARTMENT OF BUILDING INSPECTIONS
', % 1
212 Ma In Street 4,14unlci_pal BuIldang ,':, • "V
Northampton, MA 01060
4 ,
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 ei being performed at.
------ .
Cld
(Please print print house number and street name)
Is to be disposed of at:
U.,4 -i-A- -12\9 CL-1 0.Ait-\ c (A.:,1Q„c -i.
(Please print print n4rne and loca n of facility)
. 1.---
Or will be disposed of in a dumps r onsite rented or leased fr9km, , t, <,
.s
>(*--,t,-, \ )
n..
CD i c) --)
4 c ‘iv ,(--A----r\k-k-k.. 5 Ak- .-..\--VCO' 'tcr. -- 17Y\ '14
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If. 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
Massachus ettas * 'r
g ,. W
, ,, -
: DEPARTMENT OF BUILDING INSPECTIONS x
, ' 212 Main Straot • Municipal Building ',, ti�
Northampton, MA 01061' 4 ,4
MANDATORIF R H USES BUIL T BEFORE 1945
Property Address: oZ 3 d ) t U'-L
Contractor
Name. c.. C" \\r:..>"Y -, {)t"N P i-NA e\-- --
Address: )L,C fi `�ras 15
City, State: r -.,.1. c.. 01- CDC 1) .3 e
Phone: ,`t���tt�
I ,5- ; LI 1 .. a5-- 't 9
Property Owner
Name. i ' 4 ma, v
Address: rp-�c(,
City, State: -}— l (V\ 0 1 U C° �-
I, ea, ' ni- 8"""' (contractor) attest and affirm that the� building I intend to
insulate does not have any open air(knob and tube) wiring spaces the s aces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
'1: 4etL ,_,
Date4 ()"- ; _�
40,
The Commonwealth of Massachusetts
Department of`Industrial Accidents
I
.r Congress Street, Suite 100
Boston, MA 02114-20.1 7
y v www.mass.gov/dia
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):
I.p✓ I am a employer with 7 employees(full and/or part-time).* 7. ❑New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
any capacity.{No workers'comp.insurance required.]
9. ❑ Demolition
3.0 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]
4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will
10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions
proprietors with no employees. 12.Q Plumbing repairs or additions
5.0 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.:
6.0 We arc a corporation and its officers have exercised their right of exemption per MGL c.
14.1OtherInsulation
152,§I(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#I 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 f jor my employees. Below is the policy and job site
information.
Insurance Company Name:Selective Insurance Company
Policy#or Self-ins.Lic.#: C9024456 Expiration Date:0212312023
Job Site Address: o?3 I - 1 can d v--)Z-- City/State/Zip: --\----LQJ\-L-t`\�
Attach a copy of the workers' compensation policy declara ton page(showing the policy number and expiration date).
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 grins and penalties of perfu that the information provided above is true and correct.
Signature:.f Date: � d 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#: