32A-209 BP 022-1550
16 BUTLER PL COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-209-001 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-2022-1550 PERMISSION IS HEREBY GRANT D TO:
Project# INSULATION Contractor: License:
Est. Cost: 4500 SDL HOME IMPROVEMENT 103635
Const.Class: Exp.Date: 05/20/2023
Use Group: Owner: RUTH MAHONEY, KELLYANNE
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: 12/05/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHERIZATI 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 VIO ATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: 97-)
tI
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
RECEIVED ity of Northampton RE zr:p I krii-:,
ri 1 ,
ilding Department
212 Main Street
IC*1
DEr N ,
Room 100
INISPEC'TIONSNo hampton, MA 01060
NPR-riii- ' ' .'; ,--,' - '
DEPT OF UM rAN:r lt,' PCTICPq`3.
L.
t iN•Mtfritre 4.13, 87-1240 Fax 413-587,1272 ,,,, '
.
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
. ..
This section to be completed by office
1.1 Property Address
• Map /4 Lot Rog ,i, .
Zone Overlay District —
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Rectl:
Ki0</Zy i4--/-i cl-L, rqa-h Ortf hi /Go Qact/1. ' )04 eA
Name(Print) --
Current tytalLingikret,
c:L;J-71-z-z-c-ke---`1' Telephone
Signature
2.2 Authorized Ad,,nt: 4_,,,, cS i-u-k(--i ,t---k
Name Current ya117rerk ,5.-I- .74,24/7_L
C-217/
a-e-I
ature 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
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3 Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
-,.
6, Total=(1 +2+3+4+5)
1/ s.)--- _.)0 Check Number ti 5
This Section For Official Use Only
Budding Permit Number 6a- AA-156-0 , Date
issued.
Signature, /.-- _ /2- '- ZZ
Building Commissioner/inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION-4-CONSINUCTM
8,1 LICArnied il,Kfr: Not Applicable 0
4/ 0Jji i'C t- - 1 to p .-
license Nu ber
Andres' CA/cr-#u1J` } )Lc ((If �4 qq o 6?
Expirati Date
,�
Aiorv.,....04„...........
1/13- 1./9- 573, ,
i�natur Telephone
Not Applicable 0
C•it..;..n ., Lip .. ,, - I'Y"�„a--. egistration Number
r7S e .S4-miet- & _..
Z_e? /0?'
Address Expiration ate
V—Vet k-gC.._l thNfzt 010 S' Teiepnond4 l3- )4'7 s739
SECTION 6-FRS'CENOPEISSATICSIIINABRAME AFFIDAVIT(M A L c.152,3 6))
Workers Compensation Insurance affda * 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 No a
Brief Description of Proposed Work NOTE: INSULATION ONL Y
is/4/k/ 6 9 tfi' ?'I �-, (�4 c�. Cie l 10 n 2y c v�+�( l l�- lc-ND 2
c,I__.-t .A.A.1_0. . f_, Fi ci. , 1-11_,,, a " (7_ t.5 , ci louq,czi (-g-g,,,,_ __.)
(, 5_1 6 .rh lc(' 10,101,_ ie _ Loy 71-ii-)c- ---pc. _)g_, of--,--- lo,
I, Pil It I ""' '\ '"' . as OwnerlAuthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best o`my knowledge
and belief.
Signed under the pains and penalties of perjury.
1 _
Rid 3c .k_" a'` � Y -.m�., , `" .,0„,( cCb,s, . ....,
Print Name
---
Signaturg—Ovegent Date
I, Kp,\LeJ Alq ri-L (1 Cit.k,02—'-/ , as Owner of the subject
property
hereby authorize S is l—
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
-„:
City of Northampton
Massachusetts 4>�' .w.
' ` `` DEPARTMENT OF BUILDING INSPECTIONS ;-y
212 Main street •Municipal Suilthng
Northampton, MA 01060 1�
`yh...e�,
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:
IlQ C��tl� r
(Please print house number and street name)
Is to be disposed of at:
e n ' �-- 1,�. g. t� - 4- k- A
(Please print n me and loca'n of facility)
Or will be disposed of in a dumps r onsite rented or leased frArm
LX f\ �
(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
� Massachusetts Affi. ,
DEPARTMENT OF BUILDING INSPECTIONS
212 Ma,n Street • Municipal 8uiiding
Northampton, MA 01060 t. "4,.
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.
.Note:If the homeowner has contracted with a corporation or LLt;, that entity must be registered
Type of Work: 04-1 t—VA Est. Cost:
2 �
Address of Work: / LQ
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 ,ierebv apply for a building pettmit as the gent,of the owner:
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:
Data Owner Name and Signature
4„T� . City. of Northampton
:x ,
'� s>= Massachusetts h/ 46.
:g
'frr. 212 Main Straat a Municipal Suildinq
Northampton, MA O10V 4
MANDATORY FOR HOUSES BUlL r BEFORE 1945
Property Address: I LC t-L c. 01 oc c1
Contractor
Name: * 1Q-.= �. () -"' ''c-
Address: rs9 Li ( 11.G h...L..k- �`
City, State: ?..)e
--\---\--etA VL. � `� 1 �'
� i
Phone: )4 t 3 (4-1 " .,``) 1. 1
Property Owner 1 ^ _,,_ i
Name. ''l--I 1 L(-At\ru� si- rnckf--k m,h v n.--,e.
Address: ) Co ee1 U-FL-K. Pi
City, State: 11‘
n-+cc.rn p A -, pc)' pi a
I, tt f rv\ d"t- (contractor) attest and affirm that the building I intend to
insulatedoes 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. 1
Contractor signature jziet ________
iy-
Date
Permit Authorization
ris SaVet Form
Site ID: 4285489 Customer: KELLYANNE MAHONEY
Kellyanne Mahoney , owner of the property located at:
(Owner's Name,printed)
16 Butler PI Northampton, MA 01060
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor fitted
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
Owner's Signature: Kellyatafe Hahiozcey
Date: 11 / 06 / 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 For Office f_ .,
Document Ref:A37EU-AOR3M-XZMCN-QKGE9 Page 7 of 17
The Commonwealth of Massachusetts
t
r:--1(A Department of Industrial Accidents
.1 Congress Street, Suite 100
= ti
Boston, MA 02114-2017
s�.'<,; 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):
1.0 I am a employer with 7 employees(full andfor part-time).* 7. ❑New construction
2,0 I am a sole proprietor or partnership and have no employees working forme in $. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
3.0I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
10❑ Building additio
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.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 1 3.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
14.0 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'camp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t 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 enti ics 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 Expiration Date:02/23/2023
Job Site Address: /( c L LQ r Pi Q Liz_ City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expi ion date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up o$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA fo insurance
coverage verification.
s
I do hereby certify.unde the ains and penalties of perjug that the information provided above is true and correct.
Signatures Date: //- d 0 rc71-
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
b.Other
Contact Person: Phone#: