24C-182 (3) ENERGY CONSERVATION APPLICATION FORM FOR
LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS
780 CMR Appendix J
Applicant Name: 0(\ \A\s Site Address: 2.12 Cl 5C.PAV
Applicant Address: City/Town: ^ 1 v' M ' 'It it
il Use Group: e.. 1 W 1
Date of Application. _11
Applicant Phone: 111 S " S'2-8� Applicant Signature:
Compliance Path (check one):
❑ Prescriptive Package (Limited to 1- or 2- family wood frame buildings heated with fossil fuels only)
Package (A through KK from Table J5.2.1b): • Heating Degree Days (HDD,„) from Table J5.2.1a:
(For items d. through i., fill in all values that apply from Table J5.2.1 b:)
a. Gross Wall Area sq.ft f. Wall R -value R-
b. Glazing Area' sq.ft. g. Floor R -value R-
c. Glazing % (100 x b + a) % h. Basement wall R-
d. Glazing U -value U- i. Slab Perimeter R-
e. Ceiling R -value R- j. Heating AFUE
❑ Component Performance: "Manual Trade-Off" (Limited to wood or metal framed buildings only)
Climate Zone (from Figure 16.2.2) ❑ Zone 12 ❑ Zone 13 ❑ Zone 14
Attach Trade-Off Worksheet from Appendix J, [and HVAC Trade-Off Worksheet, if applicable]
❑ MAScheck Software
Attach Compliance Report and Inspection Checklist printouts
❑ Home Energy Rating System Evaluation
Attach Home Energy Rating Certificate (HERS rating score must be 83 or higher)
❑ Systems Analysis OR ❑ Renewable Energy Sources
Attach Mass Registered Architect or Engineer Analysis
ALTERNATIVE FOR ADDITIONS ONLY:
a. Gross Wall + Ceiling Area 11 sq.ft. b. Glazing Area 7 sq.ft. c. Glazing % (100 x b _ a) 3.
/ ADDITION with Glazing % (c.) up to 40% may use 780 CMR Table J1.1.2.3.1 below:
MAJ{IMUM U -Value MINIMUM R- Values
Fenestration 2 Ceiling ' I Wall Floor Basement Wall Slab Perimeter, Depth
0,30 R -38 R -20 R -30 R -10 Continuous R -10, 2 ft P
1 Glazing Area may be either Rough Opening or Unit dimensions.
2 Based on NFRC listing. Applies either to every unit, or to area weighted average of all units.
3 R -30 ceiling insulation may be used in place of R -37 if the insulation achieves the full R -value over the entire ceiling area
(i.e.- not compressed over exterior walls, and including any access openings.)
❑ "SUNROOM" addition (greater than 40% glazing- to-wall and ceiling gross area)
Attach "Consumer Information Form" from 780 CMR Appendix B.
Official's Name: Official's Signature:
Application Approved ❑ Denied ❑ • Date of Approval/Denial:
Reason(s) for Denial: (provide additional details as needed on back side)
GitU ai Wartipampinit
4 11311 Ad-Hurt:1
t"'"4-.-1,t- • - Z. ----
d'agOe EP:V. TM ENT OF 3 UILDING INS? ECTIC N.S
\
212 Main Strett. Municipal Building
INSP.C..CTOR
...-
Northamaton, Mass. 01060
Square Footage Azr.ount
ti
Easement
15t FlOor
?
2nd Floor @ 11
1/2 Floors, Attic, Garage .a..0
Dec.':, Porches •e?-
TTAL
/ a 1 ›- et\tt-t Sr
•
Ni'M (- e-1241 OV
meei, 4 cti Ic (4 10'06 t 114(171
• •
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : (Al 1 01r 1.41! (VGI ---� P go
License Number
A P Ai Sw" ./ N o P1)114 /144 O l 6 6 p g/ 0 l i3
Expiration Dat
'4101111111■-_ of
Signature Telephone
9. Registered. Home Improvement Contra or:'` Not Applicable ❑
Wi4e -404 11A-Ags I 6 053,6
Company Name Registration Numbey
( f - Q igi' ST . N e -, VOW MA' 0/010-D (0A (›-
A. - ! 1 y8
{�Q Expiration Date
��(>•�S>� Telephone J O r- '
SECTION 10- 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 permit.
Signed Affidavit Attached Yes No ❑
11. Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780. Sixth Edition Section 108.3.5.1.
Definition of 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.
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.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition 14 Replacement Windows Alteration(s) n Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [0]
Brief Description of Proposed Q 6fM A-1).0110 N ` � g 4'C t. re n
Work: Y �.""' rG 1"' �/ U"�'
Alteration of existing bedroom Yes X No Adding new bedroom _ Yes x No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family X Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms 0 " I° 1
N } 1o' > , Nag B w /s'+&
II' -
c. Is there a garage attached? 1
/
St-.'" ` $ x 5 -6y '
Di me nsi on s q
d. Proposed Square footage of new construction.
e. Number of stories? 4,-k, P N M '� ' ( S'f�1f�/►° I Q x v. V , . t� 1 S N /' I) I � f. Method of heating? tV - t Ar t Fire a odstoves Number of each
tt
g. Energy Conservation Compliance. "( Masscheck Energy Compliance form attached? V
h. Type of construction 5g
i. Is construction within 100 ft. of wetlands? Yes k No. Is construction within within 100 yr. floodplain Yes >( No
j. Depth of basement or cellar floor below finished grade willow- 'i` o t� ��/T"G - Mf N I. (f( t:4
k. Will building conform to the Building and Zoning regulations? Xs Yes No
I. Septic Tank City Sewer X Private well City water Supply X
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
it " (/p ( Q" I "
I, _ as Owner of the subject
property ' ^r ((( j J �w �Q
hereby authorize V `r "' t up " r �
to act on my behalf, in all matters relative to work authorized by this building permit application.
V1 t..) /4".....4
Signature of Owner Date
I, (4 41111-4)615 , as Owne Authorized)
gent ereby declare that the statements and information on the foregoing application are true and accurate, to the best omy Knowledge
a elief.
Signed u er the pains and penalties of perjury.
114 ' f"a-[
Pri ame
_.-Ill A.....114)._ — ....■ \ \ k % \ ‘2.---
Signature of %A� Date
eGeft'A s/er hot-e4A-Tp lAirptivtl) et-e-mt'r. V
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled iy
Building Departme
Lot Size
Frontage
Setbacks Front
Side L: R: L: R: _
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking • aces
Fi .
•olurne & Location)
A. Has a Special Permit/Variance/Findin• ever been issued for/on the site?
NO 0 4P,„,
DONT KNOW tap YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 41. DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained
, Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
04
D. Are there any proposed changes to or additions of signs intended for the property ? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex .vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
RECEIVED Department use only
I ity of Northampton Status of Permit;
:' ilding Department Curb Cut/Driveway Permlt
J>�N 2 212 Main Street
Room 100
Sewer /Septic Availability
Water/Well Availability .
"o .NsPE lort ampton, MA 01060 Two Sets of Structural Plans
• e - 3- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
0.1. 1 q er 1ar s-r • Map Lot Unit
Not ritN( m i t - Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
NA-isle/GI 2.1> e e, r Si-7 No RI,r
Name (Print) Sly_ Current Mailing Address: c (
NI \ f ""�'r y Telephone �O 7 1p jS
Signature
2.2 Authorized Anentt: ,, ,�( l A n
V � el) /.�e��I`� UM ' ¥4 , D A' sr. MP).1— ,mitaTv!`i
Name (P Current Mailing Address:
Signature Telephone
SECTION 3 ES TED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building # d 7 / (f X. (a) Building Permit Fee
T Off
2. Electrical . T goo — (b) Estimated Total Cost of
Construction from (6)
3. Plumbing 3 t' f C - Building Per Fee
4. Mechanical (HVAC) i $0
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) # 1,, 795,— 45-! !7
Check Number 1 5 Sg_3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0660
APPLICANT /CONTACT PERSON WRIGHT BUILDERS
ADDRESS/PHONE 48 Bates St NORTHAMPTON (413) 586 -8287 (116)
PROPERTY LOCATION 212 CRESCENT ST
MAP 24C PARCEL 182 001 ZONE URA /URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 3 7
S ��
Fee Paid 7
Tvpeof Construction: BATHROOM ADDITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 80376
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
" Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
- • o�D�ly
S _ r e of Buil g icial Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
212 CRESCENT ST BP- 2012 -0660
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 182 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit # BP- 2012 -0660
Project # JS- 2012- 001076
Est. Cost:
Fee: $83.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WRIGHT BUILDERS 80376
Lot Size(sq. ft.): 13503.60 Owner: LOWRY NANCY N REVOCABEL TRUST
Zoning: URA/URB(100)/ Applicant: WRIGHT BUILDERS
AT: 212 CRESCENT ST
Applicant Address: Phone: Insurance:
48 Bates St (413) 586 - 8287 (116) Workers Compensation
NORTHAMPTONMAO1060 ISSUED ON :1/19/2012 0 :00 :00
TO PERFORM THE FOLLOWING WORK :BATHROOM ADDITION
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:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 1/19/2012 0:00:00 $83.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner