17C-044 (3) BP-2023-0701
19 HILLCREST DR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
17C-044-001 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-2023-0701 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
GOLD STAR INSUL TION &
Est. Cost: 5000 CONSTRUCTION L C 065992
Const.Class: Exp.Date: 03/16/202
Use Group: Owner: BR T WILLIAM R&MARTHA S BORAWSKI
Lot Size (sq.ft.)
Zoning: URA Applicant: GOLD STAR INSULATION &CONSTRUCTION LLC
Applicant Address Phone: Insurance:
1 CONGER RD (774)329-4664 65620B5N23815620
WORCESTER, MA 01602
ISSUED ON: 05/30/2023
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:
X2 , '1 •
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissi ner
13-FcL,1 ; Dep ,:n- 'rL zoo
'r City of Northampton
r , Building Departrr y
212 Main Street 3
c.: Room 100 INS l.,�LA TIN
Northampton, MA "16i,lr,ia�aPrct�ora
phone 413-587-1240 Fax 411= $7 1'2'q,8oso ONL Y
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 Lot Unit
q11,4- -a c-r -cs7-- ,,V Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\\V L4N Oa r •ft,i- IT li c. r Name(Print) Curren Mai ing Add re s:
'� - i Telephone{\ 3 3c-L(0
Signature
2.2 Authorized Agent:
C� IAA IQ& — Li 1 ilt) t..)ar -c/C ► n 0
Name(Print) Current Mailing ddress: (,/
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 363° (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Q Construction from (6)
3. Plumbing 6 Building Permit Fee
iko
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 +2+3+4+5) SO3'0 Check Number V`(J`.C1�
I
n
/� This Section For Official Use Only
Building Permit Number. (170-��' -701 Date
+�� Issued
Signature: ////<-7
5"30- zyz3
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
Fl.
8.1 Licensed Construction 1Suupervisor::/► rn 7/��I p 1 ' Not Applicable ❑n
Name of License Holder: 1`�r�jV{'1 11 1-'r 4��Y 1 b { 0
License Number
/off s) 3� �' � �a �IS 31 a
Address Expiration ate
t\L , AM1,-e4N W -0 ek € y
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
5 )( ace agr
Comr tW Name Registration Numtfer
CC- 6-ems w �r Ces a 3Li
Address Expiration pate )13
CIAALLC%le-Phone V‘ )
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 buildi permit.
Signed Affidavit Attached Yes 1 No ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
c 2-e-r) C1,( 01
I. Ut) • C7- c -fl J , 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 p alties of perju
Print Name /.3o/a3
Signature of Owner/Agent Date
I, `'t \1\\4 % . as Owner of the subject
property
hereby authorize ,� 15211 fe_
to act on my behalf, in all matt relative to work authorized by this building permit appli ton.
a- 3
Signature of Owner Date
City of Northampton
Massachusetts
a
DEPARTMENT OF BUILDING INSPECTIONS S' fit
212 Main Street *Municipal Building r ?'
Northampton, MA 01060 ray- 5 )51r
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 streetname)
Is to be disposed of at:
(P ease print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and A ress)
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
alMONSIZ "WWI! Department of Industrial Accidents
=t 4 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
Name(Business!Organization/lndividual): 6-70
Address: 1 C- -i
City/State/Zip: t,,}O1(5 ' — Phone#: 13
azi
Are you an employer?Check the appropriate box: /
Type of project(required):
I a employer with_........c__employees(full and%or part-time).'
7. New construction
2 El I am a sole proprietor or partnership and have no employees working for me in
any capacity.[No workers'comp.insurance required.) 8. Remodeling
30 I am a homeowner doing all work myself:[No workers'comp.insurance required.]4. 9. El Demolition
4❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
5.0 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 13.1:Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑we are a corporation and its officers have exercised their tight of exemption per MGL c. 1 "E91' -==9� } i-f—
152,§1(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.
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
nidogre lithe sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing ra'orkers'compensation insurance for m}'employees. Below is the policy and job site
• information.
Insurance Company Name: J `' ' yvviJ f 1
Policy#or Self-ins.Lic.#: 61K, 1 U 3 L Expiration Date: a3
Job Site Address: 1 °) t-1 \l c1Csa-- 'J f City/State/Zip:_f 1c r c•OCC.
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
covcra2e verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: ec) 3O/ 9L
Phone#: -)14 3a-97 Li C. .17
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#:
City of Northampton
�,,' r �r�X'>, r'
f ,K` Massachusetts
i
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DEPARTMENT OF BUILDING INSPECTIONS
'4 ''Z'4',k' 212 Main Street • Municipal Building
" 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