29-466 BP-2023-0598
15 CRESTVIEW DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
29-466-001 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-2023-0598 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
GOLD STAR INSULATION &
Est. Cost: 3790 CONSTRUCTION LLC 065992
Const.Class: Exp.Date: 03/16/2025
Use Group: Owner: ANGELA CHEEK RICHARD J&
Lot Size (sq.ft.)
Zoning: WSP Applicant: GOLD SITAR INSULATION &CONSTRUCTION LLC
Applicant Address Phone: Insurance:
1 CONGER RD (774)329-4664 65620B5N23815620
WORCESTER, MA 01602
ISSUED ON: 05/09/2023
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: i
V •' ) ► . 1 •
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
1978
Depp014
City of Northampton--C 11
Building Departr ient�---- 1--J
212 Main Street INS ULA TI ON
Room 1001 MAY — 8 2023
Northampton, MA 01060
phone 413-587-1240 Fak 4 3-SR7-1272 0!'!!.. Y
Oc BUILDING INSPECTi N$
R7NAMPTON P.1A ni990
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:
I CJ Cfe_S‘- Le\e. , /- Map Lot Unit
t' Zone Overlay District
A er e�•^'N ( v\, VVI flr kOC .)•
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
v\ 5.e C -e z 1 C r e S j- w Or
Name(Print) Current_Mls iligg�dre,� c
1 -1 ?
1(� / GI S
�\ 1, L•. e-. bi Telephone
Signature
2.2 Authorized Agent:
Lei\ 1/C7 i1 (Cc Z - �--�A �. �—r'C s-f—e_,'
Name.. rint) Current Mailing`XCddress:
.� Lt CSC it
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 1 l 616 (a) Building Permit Fee
1
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing 0 Building Permit Fee
41)
4. Mechanical(HVAC)
5. Fire Protection C'
6. Total= (1 +2+3+4+5) 3 -1 G( c' Check Number /5 q
/� 2 �/� This Section For Official Use Only
Building Permit Number: �I 01✓.✓"/f Date
Issued:
Signature: J//17 55 q-ZOZ3
Building 6 Commissioner/Inspector of Buildings Date-112 ii PRelef"
lJ
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: e>ti/ l '1 � �� \ l- () g /
License Nu qer
C) V1P‘ 5)--- y( p lq
Address Expiratio Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
Company Name Registration Number
Addre Expiration Date
16,1/1 ( � Telephone `1"10-cgt'CC9
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building ermit.
Signed Affidavit Attached Yes No ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
A41LC1 (e ) 6 ( cf(CutoS.C,
I, , as Owner/Authorized
Agent h eby 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.
&71 yG_ u
Print Name
Signature of Owner/Agent Date /
l n ' C � , as Owner of the subject
property
hereby authorize a(4.1 J r✓� r ti �l 0-+-11 1
to act on my behalf, in allm ers relative to work authorized by this building permit application.
IA - ( e S / � 1 � 3
Signature of Owner Date l
City of Northampton
f Massachusetts ' . 'cf
Ati .c
ga= w
DEPARTMENT OF BUILDING INSPECTIONS S;
212 Main Street • Municipal Building ; ��
" Northampton, MA 01060 ';�b j�.�
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 on6 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 LLC,that entity must be registered.
Type of Work: $In (._,- CJ�I a^ }-\1 Est.Cost: 5(1 96
Address of Work: r0 ( c CrC- S 1 4 c--, tin ( PI w
Date of Permit Application: V f/ ? 3
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 SPONSIBILITES 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 permit as the agent of the owner:
S/ U l J Cn (c,� ( ( I �cC%)'d
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
Y A.
•
Massachusettsals
"
' DEPARTMENT OF BUILDING INSPECTIONS ?S
212 Main Street • Municipal Building �yk�
._.- Northampton, MA 01060
Massachusetts Residential Building Code
Section 110.R5.1.2
Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside,
on which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section 110.R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she shall be responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to
time, during and upon completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153
(Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts
General Laws Annotated, you may be liable for person(s) you hire to perform work for you
under this permit.
„,,,„..r.„:„
City of Northampton
„...„„„„1., ‘,.. Massachusetts C.
-* DEPARTMENT OF BUILDING INSPECTIONS '
`F 212 Main Street •Municipal Building
Northampton, MA 01060 rruj. ��”
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:
(Please print house number and street name)
Is to be disposed of at:
? C6 L.,,J-e) Ski S ,/- r 0,(C S 1--V 1/7--1 r-4
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
,�d t d S l-c-,/ 4--1„ ( 1c� (---
t G�/
Com an Name and Address
( ompany )
..A--''Ll S7 Xi ; 3
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.
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
cc��
Name(Business/Organization/Individual): j/ .S u 1 '— n Cl [C%�; c4/'
Address: CO'Vl (( r c'/1
City/State/Zip: W 11 Phone#: 1 - (1 3 )"C1 Lt Cc l.!
Are you an employer?Check the appropriate box: Type of project(required):
rr
1. a mployer with 1 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.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
9. El Demolition
10 ❑Building addition
4.❑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.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑ P
ROOF repairs
These sub-contractors have employees and have workers'comp.insurance.: —'— v"1
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[.}PJfher �-1
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.
t 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: v ' 4 .4/•. � \
Policy#or Self-ins.Lic.#: C � 3 l� Expiration Date: rJ l � I l t�
Job Site Address: l C ( S�- L i City/State/Zip: �t. "'' t' 1.. (/w� 11^-0-
Attach a copy of the workers' 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 for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true nd correct
Si nature: Date: d- 3
Phone#: -3)- (kw Cc
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#:
r 1
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants 1
Please fill out the workers'compensation affidavit completely,by checking Ithe boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number()along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license i8 being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a re erence number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massaclusetts
Department of Industrial Accidents
1 Congress Street, Suite 1
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
City of Northampton
. •
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A( , %�� Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building
.y .. Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address:
Contractor
Name:
Address:
City, State:
Phone:
Property Owner
Name:
Address:
City, State:
I, (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
Date