10B-107 (3) BP-2022-1659
24 AUDUBON RD COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
10B-107-001 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-2022-1659 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2022 Contractor: License:
Est. Cost: 4900 SDL HOME IMPROVEMENT 103635
Const.Class: Exp.Date: 05/20/2023
Use Group: Owner: A MCCOY, CLARA
Lot Size (sq.ft.)
Zoning: URB/WP Applicant: SDL HOME IMPROVEMENT
Applicant Address Phone: Insurance:
24 CHESTNUT ST (413)247-5739 WC9024456
HATFIELD, MA 01038
ISSUED ON: 12/28/2022
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:
� - 11-01 61 0
Fees Paid: S65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
-,.., Roo
,. / 4."`•r.,>., ' ' • ;.: .
...., . City of Northampto7 '''. .,,:,i'SN.
Building Department
,.,,,
212 Main Street veo Nk.',, ‘,/
Room 100 x c•Northampton, MA <90(2(2
. .
phone 413-587-1240 Fax 4 272
ONL ler
7/r
APPLICATION FOR INSULATION FOR A ONE DR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
i
This section to be completed by office
1.1 Pro arty Address
c=77 --r-t-/J_t_.(, )q-C'
ist,
MaP Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT i
2-1 Own r of Record:
C.-
Name(Print) Current lviailing Address: ii
S —k--- 07 -- LIL—a Telephone I
Signature
2.2 Authorized A ent: Atde....11 rli .,i d-;-4- c3V J
si-
,SI
Namerir , Current Mailing Address:
, ............................._ 4/3 - ;,?V7- 5—/3 1
Sigreture 17i. Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
, completed by permit applicant
1. Building ' c.,C.) (a) Building Permit Fee
19 bp 1 2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
-
4. Mechanical(HVAC) (3 6 aq 1
5. Fire Protection
6, Total (1 4-2+3+4+ 5) I "--/, q 60 --'() Check Number
This Section For Official Use Only
! ,
:
Building Permit Number: 6fi-))))- 11/ .1 ,
Date
1 Issued.
i
Sigitatire. /7Z /1•2f5-7-6ZZ
Building Commissionarilnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Co Isor: L 1.
Not/ Applicable 0
Name of Lice Hok r: lid Y'. nci (L 1 .. " 11).:I D
License Nu ber
24 Chi&I-MI.1' .64-fr Pot-f-he id." PM 0 0. 8""'
Address
E 5- c2 0/07-.5
xpiratio Date
.., ),.,,t,/ize4,,,__________...--'
eik,3-: //9-,„6-7V
gnature Telephone
Not Applicable 0
t - y ,t3°L� li t ? egistrabon Number
> \ .s -1,\L, - i. r / _
Address '' Expiratiort ate
VAtA.k"<�'1'1'C,.... .., ' A Oi O S Teiephondh 13J c)4'7. ' . .i
SECTION-S-FRS'CONIPEINIATICS8S4SURANCE AFFIDAVIT(M.G.L.c.182,§25C(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 bui permit.
Signed Affidavit Attached Yes No 0
Brief Descripdon of Proposed Work NOTE: I S UL_A TION O L Y
.
, Q O -P4 1 13 " / LL }-' i . - �s 71- •/ 11 cz) ,
2 aAr t-u_e_51 1 ,
/,3 s5 .�� / k tI ,. 10,E to `' 0 4k i 0.1' f-*/8'�
hooceti-ci (A-7-e rc-a-c.
1, 'Pti.4 -k-----
I 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.
Rad 5c.....,: ,- 611/4-
Print Name '
.47 t...D't..4-,„ *-k7-1'1kft.,> ' (le,(ZDste„ry-t Rxrk-
is - .a- a�
Signatur t Own Agent Date
1, CA(A) -, Mc- l , as Owner of the subject
property
hereby authorize S 1 --
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
DocuSign Envelope ID:BB727A81-A36A-4523-A9CB-24C7E1443E4A
\Ult
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
clara Mccoy
(Owner's Name)
owner of the property located at:
24 Audubon Road
(Property Address)
Leeds, MA 01053
(Property Address)
hereby authorize
(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.
r— oc uSigned by:
Owngi'VS`f F re
9/24/2022 I 5:54 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
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street *Municipal Building
Northampton. MA 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:
0711 •/(\:*-t---t -D(TiTh
(Please print house number and street name)
Is to be disposed of at:
C -1 44c7k-A-g -L C‘-
(Please print n4me and loco of facility)
Or will be disposed of in a dur]Oer onsite rented or leased frt,m:
0
—
VrcLYNA..e.„
L '4
nij•-•k- \A- J-creA3 fY\ CD
(Company Name and Address)
,;7
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
PT ..
4 Massachusetts 4 .a,- t�
at: )
DEPARfl ENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Budding `
Northampton, MA 01060 i'' "''"'��
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation ("OCABR")regulates the registration of con tr
ctors 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(" IC").
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 LLC, that entity must be registered
Type of Work: I, -}'l bA Est. Cost: ' , CV
Address of Work: a 4 4 ' t.A.Lt.. n 12 d S AA_
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 I42A.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 t of the owner:
t..., x.11rlA —
-r -?- kv - cb,1--0,- .__,-1-t_-- I / 9 9 / 5
ate 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 -
L
DEPARTMENT -I, BUILL'ING INSPECTIONS
.,
212 Mal.r. Street • Hunlcipal Buliding
„ . Nortl'amp.,or MA 0106('
MANDATORLT FOR HOUSES BUIL r BEFORE 1945
Property Address 07 .if_L..0,1,c.„,..3
Contractor
Name t-t-\je_,rs--\drz_rvk--
1
Address ,,9 q c1 , ..,‘„k- k•-•_( ”1
City, State: AA-MA V- ..A (,.. V-Y\t CD\
,
Phone: H t 3- 3 q i - ,45 i 9
Property Owner
Address: ,74 14/A l dc.oKi l4_c-1
City, State:
(contractor) attest and affirm that the building I intend to
insulate coes 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 _____,.."'
Date
The Commonwealth of Massachusetts
►�_*. =ft Department of Industrial Accidents
. =:�1� 1 Congress Street, Suite 100
s. - t i= Boston, MA 02114-2017
.Y =t www mass.gov/dia
'Porkers'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):
LEI lam a employer with 7 employees(full and/or part-time).* 7. D New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. El Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
10 Q 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 are sole 11.0 Electrical repair or additions
proprietors with no employees. 12.Q Plumbing repair or additions
5.1:1 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.D 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#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 indi sting 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
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: 62 4 I�vi, 60,_, ,e- City/State/Zip: I r
Attach a copy of the wor ers'compensation policy declaration 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 fit insurance
coverage verification.
I do hereby certify,unde the ains and penalties of perju that the information provided above is true and correct.
Signature _ Date: ��- `7
Phone#:413-247- 739
I
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#: