32C-121 (23) BP 2022-1443
20 FRUIT ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32C-121-001 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-2022-1443 PERMISSION IS HEREBY GRANTED TO:
Project# insulation Contractor: License:
Est. Cost: 4000 SDL HOME IMPROVEMENT 103635
Const.Class: Exp.Date: 05/20/2023
Use Group: Owner: ELIA DAN JEFFREY A& TALA R
Lot Size (sq.ft.)
Zoning: URC Applicant: SDL HOME IMPROVEMENT
Applicant Address Phone: Insurance:
24 CHESTNUT ST (413)247-5739 WC9024456
HATFIELD, MA 01038
ISSUED ON: 11/03/2022
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:
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:
• y .
II
Fees Paid: $65.00
212 Main Street Phone4 3 58 -1240 Fax: 413 587-1272
( 1 ) 7 ( )
Office of the Building Commissioner
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City of Northarnpto i °"-', -d l ;
Building Department
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- 212 Main Street NOV - 3
- Room 100 ' ��22
Northampton; MA ' 1
phone 413-587-1240 Fax 41 « L1
J`PFcr. r • - . - Y
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APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION 1 INSULATION PERMIT
1.1 Property Address This section to be completed by office
a----- Map 3d C_ Lot_,?-/ Unit
�_, + Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Ci re—y CrL,0 ijb •+- S-4 _
Name(Print) Current Mailing Address: ,J, 75 _7 3 a
9 f (1-1 �0 A Telephone / /z J /
Sigra[ure
2,2 Authorized Agent; T , -(rlrvj.c± aq Ices- � q
Sl + C irl fret C rR.S, __Lr Q --IA-CL`-i '-C.
Namei) Current Mailing Address:
4( (94/7-.595
,Sigr:ture Telephone
SECTION 3 -ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by permit applicant
1. Building Li/DOD u) (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 4 0 c
5. Fire Protection
/1 J +
6. Total=(1 +2+3+4+5) 1OOt) G Check Number 3y , -1-_
y 2,This Section For Official Use Only
Building Permit Number. 12,i9
° 2 2 c/(1 / Date
Issued
_—i
Signature: /7. 1/- 3-zazz
-
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
1
8.1 Licensed Constructio upervisor: Not Applicable 0
Name of License Holder: qI &_. L/ J a *- n- 1 v•1 03 5J
'�'� Ci /_ r -/ License Nu ber
Adress' hi
`l na T. .s-/ ��011--�"f e, (G.L, ni A 0 u.Jr c_ /(275
Ex iratio Date
«�� /-/j,3- y�-.5? p
gnature Telephone
&R Contractor Not Applicable 0 _
/`� 'I/ 5
Compan Name
�... �YL.Q. J'Y1.�l1 egistration Number
7 �') l
AdeAdress S--n + &I.. ,--, l v / a�_3
Expiratioi�ate
1 k4eL V �L C1 /Thr\44 cif U3� Telephon 13- U'7-S-739
-
SECTION 5-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affida t 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 Proposed Work NOTE: INSULATION ONLY
/IWO S? 8 " /e( -1,eA. , , ,,_30 Acid-La. ./ A-1-/- -- 16.t)/e.
1^
1 Pa 4 I a\-\" ..): &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.
6.:k--- k......) -4--- .\64-- 'VI Ye yplei-Y1 k_nA-- (042(cicKS, c
Print Name
Signatur f Own r Agent Date
I. , `� . as Owner of the subject
property
hereby authorize >L
to act on my behalf, in all matters relative to work authorized by this building permit application.
.� CL\,( 6tC--I-,mac //—l--- c2°aa-
Signature of Owner Date
City of Northampton
I° n ti 5�y� .'"' sip
J� Mas sac1111S�tts qv .._ Cam.
G
91
. -'•' DEPARTIWNT OF BUILDING INSPECTIONS -t'
y } 212 Main Street •Municipal Building �4 cs
Northampton, MA 01060 s.:A •• j4
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
k (i....(. -t ,� -i )Q ;n14hQ>-,,p-1-- N)
(Please print house number and street name)
Is to be disposed of at:
(Please print n me and loca n of facility)
Or will be disposed of in a dumps r onsite rented or leased fr ` c G
---,21--1 C \INi2.-4-INLA-k— 5k- , ''\A-CX,k-g-e-- a fY\ PC C)1C). ''S1—
(Company Name and Address)
Lei
Signature,,,Z. -------
/ / `�
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
Massachusetts ._ '�
c.
Or
- DEPARTMENT OF BUILDING INSPECTIONS 7' '
212 Mair. Street • Municipal Building Z& a
• Northampton, MA 01060 5: 0,
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.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"be
done by registered contractors.
:Vote:If the homeowner has contracted with a corporation or LLC,that entity must be registered
aU
Type of Work:— +_e.1 a o't., Est. Cost: 5L/< C EO
Address of Work: <7/3i�1 u i-f— S
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 LNTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME LMPROVEMENT 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 agent of the owner:
I I I-- .�-2-- '`� \\\.-- tk- oc`n ...- rNil rb.-e-+Y.iz-il+-- 119 41 "_
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 .
,f Massachusetts
+. z
il r DEPARTMENT OF BUILDING INSPECTIONS -'1Ili
212 Main Street • Municipal Building �, ..,, `
_ Northampton MA 3:GS'
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address C 1 ►-c,cA f" St
Contractor
Name: ]�I✓ k-V-- CYS¢ 1 p fL-,(P j-rvtA~L
Address: ,9 Li _`A uk
,k--.
City. State: 'k -1n'eA. 'PcA" c_D\ V e
Phone: H t& a q 1 " _47 I I
Property Owner Name: \ef---r-e-1
Address: C) 4 ; --It- _`3 f
City, State: /V c- '1ca.v , rn\ 01 dC c C)
l i1 I • .. ('�m .t ci ) (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 _�
:/7/
Date //-- (— a
DocuSign Envelope ID:8E5A5157-B2BE-446F-814E-2C6923CE9A89
RISES8
ENGINEERING-
OWNER AUTHORIZATION FORM
I, Jeffrey Dan
(Owner's Name)
owner of the property located at:
20 Fruit Street
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize b 1.---
(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.
DocuSigned by:
E
erFrfq Oaf
own 61'?g 'dire
10/26/2022 11:57 PM 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERIVi1TTING 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. ❑New construction
2.0 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.]
3,0I am a homeowner doing all work myself.[No workers'comp.insurance required.]
9. ❑Demolition
10[]Building addition
4.0 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 arc sole 11.El 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.
These sub-contractors have employees and have workers'comp.insurance.:
13.❑Roof repairs
4.[]✓ Other Insulation
6.0 We arc 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 box ii 1 must also fill out the section below showing their workers'compensation policy information.
,Homeowners who submit this affidavit indicating they arc 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 luh sits'
information.
Insurance Company Name:Selective Insurance Company Policy#or Self-ins.Lic.#:WC9024456 Expiration Date:02/23/2023
Job Site Address: ,o U + City/State/Zip: r tr),
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirati n 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.
1
I do hereby certify uncle the 'ns and penalties of perju that the information provided above is true and correct
Signature: Date: /( (
Phone 4:413-247 739
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
b.Other
Contact Person: Phone#: