32C-243 (8) BP-2023-1542
116 HAWLEY ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32C-243-001 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-2023-1542 PERMISSION IS HEREBY GRANTED TO:
Project# INSULATION 2023 Contractor: License:
GOLD STAR INSULATION &
Est. Cost: 10000 CONSTRUCTION LLC 065992
Const.Class: Exp.Date: 03/16/2025
DECHANUPONG CHAOWALIT &SAOWANEE
Use Group: Owner: DECHANUPONG
Lot Size (sq.ft.)
Zoning: URC Applicant: GOLD STAR INSULATION &CONSTRUCTION LLC
Applicant Address Phone: Insurance:
1 CONGER RD (774)329-4664 65620B5N23815620
WORCESTER, MA 01602
ISSUED ON: 11/01/2023
TO PERFORM THE FOLLOWING WORK:
INSULATION/W EATHERI 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 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 1 f
I I
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
#4 , ig
Derp
City of North mot() kal
.
Building Depa tmett \
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.' VLATION
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, . Room 10 0- cp, u wv-ko •
, . DE .r,B-n-ok
Northampton, MA $1060 1‘1-
, -
‘- - phone 413-587-1240 Fax • -587-1272 ONLY
., _..
_„........
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
_ ...
1.1 Property Address This section to be completed by office
Htuity_tiLk.,( '.1-i Map Lot Ur,t
I1 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(\\A CA C e LJ t-C-0)i rtA,.---ril 0 1 (C 1-C.,L.,/ I ey ,...,:\1.-• ,tiuri,c,imete,,,e,
Name(Print) Current Mailing Address Li 6 S 3
P . ...._,--..i.) (--- ry-. ../.1 i\ Telephone
Signature
2.2 Authorized Agent:
7-::Th Ely\ '-)cf7 c...?...-,C,1 t I Ciai ;eci t._)c.r c a S4-te-•- M,A
Name(Print) Current hirlailulAddress.
. 04
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building I Di (300 (a)Building Permit Fee
2 Electrical (b)Estimated Total Cost of
0 Construction from(6)
3, Plumbing
C.) Building Permit Fee
4. Mechanical(HVAC)
C)
5.Fire Protection
6 Total=(1+2+3+4+5) 1 Cri CO Check Number
This Section For Official Use Only
Building Permit Number w-6)-3 -o-i a- Date
Issued
Signature 777/ it/-ZOZ,
Building Commissionertinspedor of Buildings Date
•
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
161•••••••=1111.111111MINIIIII. 4
. .
'
SECTION 4-CONSTRUCTION SERVICES ;
k . — —
ell Licensed Construction Supervisor Not Applicato not,
Namc of lfcvnsc Holdit{ V---kierN rk C)1 i e•r1
t'cense ,
:)<- j
'-10 "7 IY \-12,1 \ ,-F- C ,..„,ci,_ ( C ri I A
Aairess Expos, Dolts
f—.• \t ZIN n -)Li 1 .9 ei ti4. cli
Signature Tot.phx*
R !lei A. • H- ..A,........i.—.11 .....a• ci-r No!Applicable 0
R
Co •a- m I ,
( 0 Qr K c. 1
i egistrati , um et,
0 -5 Id CI
Address Expiratio Date
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T0eDnone '
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SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
WorIcerS COrnPensat:.' 1-.-a-ice afhdavit 7ncst be completed and submitted with this appl ca-lon Failure to provide this affidavit will result
in the delta!of the iss..ai,oe a'the bsildin rmt
Signed Javit Attached Yes No 0
Brief Description of Proposed Work NOTE: INSULATION ONLY
17/
I. OY\ I 'e Lt) t -----
.as Owner/Authorized
Agent hereby declare'..--al—,.s!aternents and information on the foregoing application are true and accurate,to the best of my knowledge
and belief,
Signed under the pai, ye and penalties 2 nury
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Prot Name
I t/ i 1 a 3
Signature of Owner,Agerl Date
1
i/\ ,/ r
Nr-\)\,_ bi ,....._
I, ' as Owner of the subject
ProPerlY
hereby authonze (1 (4\ f
to ac on my behat in all matters relative to w0 authortzed by this building permit aPPIlcatl 'okn 1 ) 1 )
;.\(..)
Signature of Owner Date
City of Northampton
City of Northampton _
Massachusetts
IC Ar
nEmARyMmWr OF mnzxnzwG znomnczzmNS '
o� m��m m,r°a* °^w"=ri�l o"`ldi"o
� w°,u~=W*=, u* omov
Debris
�� Disposal
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����������"� ����"� �� ���� .�.����� �� ��
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� In accordance of the provisions of IVIGL c 40, S54, I acknowledge that as a condition of the building
| permit all debris resulting from the construction activity governed by thisBuilding Permit shall bmdisposed
of in a properly licensed solid waste disposal facility,as defined by MGL c 111, S I SOX
The debris from construction work being performed at:
\'
\ \ r�
(Please print house number and street name)
|otoba disposed ofat:
(Please print name and location o{ta64) '
Or will be disposed ofinadumpsteronsda rented or leased from:
(Chmpeny 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 not4 the
Building Department aebo the location where the debris will bmdisposed.
°
0 -,x,,, City of Northampton
Massachusetts
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Sec DEPARTMENT OF BUILDING INSPECTIONS
212 Mein Street • Municxpel Building
Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: k 1c k
Contractor
Name j0 104 c\
Address: I (ark ( cz(i
City, State: W Or cc .s+-(_T (y p
Phone: � L{ j .`t
Property Owner
Name: A y1 oi r t.o �-
Address: I I 1/(c Fto‘t,J 1C (
City, State: _Nor C/✓ti'\ y ` 1,A
t, d6) l % `Z-''€ 1 I (contractor)attest and affirm that the building I intend to
insulate es 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 `3
— 1
The Commonwealth of Massachusetts
,i.VS.•OP,
...,..--„...---
Department of Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston,MA 02111-1750
www.mnass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
.kpplicant Information Please Print 1,e2iblv
Name(Business Organization.Individual):GOLD STAR 1NSULATION
.„.„ ______
Address:1 CONGER ROAD
_ ...._ _ _____ ..„....__.............._............_
City/State/Zip:WORCESTER MA 01602 Phone#:7743294664
Are you an employer? Chcel, the appropriate hos,: )pe of project(required).
I.% I am a employer with 6 4. Li I am a general contractor and 1
6.
employees(full andlor part-time).* have hired the sub-contractors 0 New construction
2,0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
9. 0 Building addition
[No workers comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per IVIGL
12.0 Roof repairs
insurance required.] t c. 152,*1(4),and we have no
1311 otherINSULATION
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 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
ttployees. If the sub-contractors have employees,they must provide their t,rkers'comp,policy number.
I am an employer that is providing workers'compensation insurance for nty employees. Below is the polity and job site
nfOrmation.
nsurance Company Name:Ace American
'olicy#or Self-ins. Lic.it:6R57139622 Expiration Date:8/31/2024
ob Site Address: 112-116 Harley street City/State/Zip:Northampton, ma
\Unit a copy of the workers' compensation policy declaration page(showing the policy number and expiration date)
:allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
inc 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
)fup to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
nvestigations of the DIA for insurance coverage verification.
'do hereby certif i id r the pains and penalties ofperjuty that the information provided above is true and correct.
; nature: ik---4-1"1/(----- Date: 11/1/2023 _ ._ _. ...... ;
'hone#: 7743294664
Official use only. Do not write in this area,to he completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
I Dlloard of I lealth 20 Building Department 31:1Cit)f Foss n Clerk 413 Electrical Inspector Salunthing
Inspector 61:Other _
Contact Person: „.... Phone#:
16 1—r_. _._,_."".73"Tml""Trf Int A..! 4
ID
Commonwealth of Massachusetts
0 . ,
Division of Occupational Licensure
Board of Building Regulations and Standards
Constc.. - , rt S . • - rvisor
CS-065992 leT6)..iires: 0311612025
KEVIN R ALLN ,....
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45 707 MAIN STREET
a. BOYLSTON ANA 01505
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