17A-123 (13) BP-2023-1027
330 BRIDGE RD COMMONWEALTH OF M SSACHUSETTS
Map:Block:Lot:
17A-123-001 CITY OF NORTHA PTON
Permit: Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGI TERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARA TY FUND (MGL c.142A)
BUILDING P .RMIT
Permit # BP-2023-1027 PERMISSIO IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
GOLD STAR INSUL•TION &
Est. Cost: 4001 CONSTRUCTION L C 065992
Const.Class: Exp.Date: 03/16/202.
Use Group: Owner: KOES I R TUCKER JONATHAN &JEAN M
Lot Size (sq.ft.)
Zoning: RI/URA Applicant: GOLD ',TAR INSULATION &CONSTRUCTION LLC
Applicant Address Phone: Insurance:
1 CONGER RD (774)329-4664 65620B5N23815620
WORCESTER, MA 01602
ISSUED ON: 08/01/2023
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATH ERI ZATI 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 Drh el‘a) Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NO HAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
>d . CP1 •
f I �
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax (413)587-1272
Office of the Building Commissi.ner
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I.,1„Propert),Athirs: . 1.2 tNsessors NIA),it..Parcel Number*
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1.3 Zoning Information. 1.4 Properly Dimessioas:
iontng Onn to Proposed Use . Lot Area tmt if) fromagt:tft ,
— —
I.' Building Setback*(ft)
Front Yard Srtle Yards Rear lard
Reqz.mcd Providi:d Required ' Praroded , Reaturred ' Proaelud 1
1.6 Water Supply:i NI( I.c 40.§541 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Putiht:0 Pnvate 0 Lone ..,.., Ordarde Flood/one"e0 mumop,1 0 on snc.divoial,,,km 0
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SECTION 2: PROPERTY OWNERSHIP'
2.1 fc 1127'ofu&mll:
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Prin0 (lay,State.ZIP
Name t
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li`k and Street Telephone rinail Addle,
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Constnicnon 0 Existing Building 0 Owner-Occupied 0 Repaircist 0 Alteratiom si 0 Adkittion 0
Demolition 0 Accessory Ill&0 Number of Units . Other Er<lareily, :::),.)(4160
Brief Description of Pripised WarCAC,_./jAl.)__.(k.... „(.L.C. fPC.Le
SECTION 4:ESTIMATED CONSTRICTION COSTS
Estimated Costs:
hem Official Use Only
(Labor and Materials)
1.Building $ tfigoo 1, Building Permit Fee:S Indicate how frets deterinined:0 Standard Citylown Application Fee
2,Electrical S
0 Total Project Cost (hem 6)x multiplier x
3.Plumbing S dr 2. Other Fees: S
-: 4.Meebankol t IIVAC1 S 0 List:
5-Mechanical (I irc
. p:.. Suppression i S 0 Total All ieseit_. ti ag6'
Check NJAW r Cheek Amount: ....Cash Amount:
L....
6.Total Project Cost: S 611)
C.3 PAid in full CI Outstanding Balance Due:
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SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT 1St G.L.c.152.II 25C110)
Workers Compensautin Insurance affidavit must be comply and submitted with OM application tailure to provide
ti this affidatii Will result in the dental of the Issuance of inkling permit.
' Signed Allidava Mocha! Yes„„ -.„, No , 0
SECTION 7a;OWNER AUTHORIZATION TO BE COMPLETED WREN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
C 2eatt,,r(. 11
1.as ownet of the subject property,hereby authorize_„,,,,, L,e4\
to act on my behalf,in all matters relative to, Ak autte'ed by this budding permit applIcation.
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Pratt Ow 's same(Electronic Signature) I tie
SECTION lb:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
.... _....... __,......... .,..._:11/4 3,..._
Print Ovine , Authorized gent's Name tElecimnic Signature) a
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an iissner who hires an unregisteredcontrac
tor
(not registered in the Home Improvement Contractor(IIIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HI( Program can be found at
www,mass,aostoca Information on the Construction Supervisor License can be found at www,mass„govidgs.
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementattics,decks or porch)
_
Gross living area(sq.II) Habitable room count
Number of fireplaces
Number of bedrooms
Number of bathrooms —
Number of halt7baths
Type of heating system Number°Ideas/porches
Type of cooling system
Enclosed Open -
,.. ..,-...
3. "Total Project Square footage"may be substituted for"Total Project Cost-
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https://mail.google.com/mail/u/0/?shva=1#inbox/FMfcgzGtwVxjPwjtBJNgLgcWZmdZWSC?projector=l&messagePartld=0.1 1/2
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The( ommonwerthlt of Alassachaisetts
Department of lntluorial.4eridInts
Office of Invesligations
--4
1 Congress Street,Suite 100
Boston,414 02114-2017
stww.masslovidia
Workers' Compensation Insurance Affidavit: Builderstontractors,'Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Businns'Organiza;lo•linaNidu0; ' 1 2 Address: Cc-Al
_ctate'ziJjjQ d•J.Phone
Are you employer,Check the appropriate Ina: 1
Type of project(required):
I a employer with Cr 4 1.1 I am a f:encral contractor and I
have hired the suh.contraelors 6 1---; COr c7'ic•6'"
einplo,sets(full and/or part--.in.c).•
2.0 !an a sole proprietor or partner. listed on the attached shecl. 7. Rem:xi:I:lid
ship and have no employees Thrse sah-cntaracinrs have 8, 0 Dvnollion
working for me in any capacity, employees and have workers
9, 0 Building addition
[No workers*comp.insurance comp.insurance.t
required.' 5. [] We arc a corporation and its 10.0 Elecuical repair or additions
3,El I am a homeowner doing all work officers have exercised their 114_j Plumbing repairs or additions
mysaif.[No workers'comp. right of exemption per MOL 2.0 Roof repairs
insurance required.]* c. 152.§1(4),and we have tic
D-Orh 11 •
empioyets.[No workers' 3.
comp.insurance required.]
'Any applicant that cheeks So'#1=It airo till out the ateetion hc.ktw shorting them oorters.compersation rtu,ic.).information
Hornirowners st.ho submit t htrkievit indteat int the:,are Jong an wort and thmtvre autstrte cnntnnor,must uirenit hes,effidovit itrit=intl,such.
kontractors that dwelt this hos must mtatthed ar arAtiortal ci-ee stuns tnE tise namc of the sub-contradors ant state whether ty not tilosht eTt :I a.,
emplitywes, If lite sub-honsrareors,have cripioyers they must provide their when..comp polio)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,
Policy#or Self-ins.Lic.P: 4, IS-7 Expiration DateTri:
Job Site Address: 3 3O City/StatetZip: clo eot
Attach a copy of the workers compensation policy declaration page(shoving the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of s
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 tine
of up to$250.(49 a day against the violator. Be advised that a copy of this statement may be forwarded to the OfT:ce of
Investigations of the DIA for insurance coverage verification.
I do hereby certi yir er he pal and penalties o perjury that the Mfornuaion provided above is true and correct.
Sitmature: _ Dste: Z3 1
/
(,° 6,•
Phone p:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: PermitfLicense
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 3.Plumbing Inspector
6.Other
Contact Person: Phone#:
_J
6
Cite of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste 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 defin d by MGL c '11, S 150A.
Address of the work: i 366 �} . --/-) ( e._
V 1.0 --
The debris will be transported by: 1 -S � JC' PlierA--
The debris will be received by: W , fl"C' l Cv /'r`
�J
Building permit number:
Name of Permit Applicant ( ( ( (6- ---e--,I
Date Signature of Permit Applicant
4