38B-154 Customer IA91073 Customer Name A 4 _ Address • 11 4t
•
KNOB & T E WIRING
During the Energy Survey of your home, indications of "knob and tube" wiring were found. This old style of wiring
involves individual wires that are run through walls and ceilings in a house, with ceramic "knobs" and "tubes" to
prevent contact with wood framing. The knob and tube wiring that has been noted may or may not appear to be active.
Even if the observed wiring appears to be inactive, there may still be active knob and tube circuits hidden inside walls
or other inaccessible areas of the house.
MassSAVE Program requirements require that you have the home checked by a licensed electrician and certified as
being free of all active knob & tube wiring where needed, before insulation and/or air sealing work can be done. Your
electrician should fill out and submit a copy of this document to the Center for Ecological Technology (CET) in order to
verify the absence or inactivity of the knob and tube wiring in the areas of your home where we are proposing insulation
to be installed. Due to the liability involved in signing such a form, we suggest you show or describe this form to
your electrician before hiring him to inspect your home to be sure he/she is willing to sign it. The Center for
Ecological Technology (CET) and MassSAVE program will rely on the electrician determination and certification
below and will not be liable if inaccurate.
Your home could benefit from insulation and/or air sealing in the:
T Jill Open Attic i Exterior ❑ Basement Attic Floor ❑ Knee Wall Floor
Walls
** Only after this certification is received by CET can a Contract be issued for
energy saving insulation and/or air sealing work. **
Electrician's Certification
(This form is invalid when any qualifications or alterations are added.)
ll
Company Name & Address GI. 14 trt..) fvt k kit CkAC
�j Z ez' S* 6 S* . 6`.sf -` 7 9 , 04 , - c ioA7
Electrician's Name Avt Olt 1 k License # 477 75_
I have performed an inspection of the wiring at the home of:
flu V' 14i0 (-c at / 74 SO d-Pk- S4 in PO
(Owner's Name) (Street Address) _ (City)
Upon completion of my inspection I have found that there is no active knob and tube wiring in the area(s) noted
below.
143 Open Attic A Exterior pil Basement p Attic Floor ❑ Knee Wall Floor
alts
Electrician's Signature - 4 1 Dater /j/ Z.
Please mail this certification letter to: Center for Ecological Technology
241A W. Housatonic Street l
Pittsfield, MA 01201 1 Z - .Z ( 4 5 "l''-
Or fax to: 413- 443 -8123
Rev. 12/15/09
Please call 800 - 238 -1221 with any questions or concerns.
A ._ata. _ r
Customer (mail -in when comnletedl - Whits. ( ietgmar C'nav __ V.ni1 .
• City of Northampton
Massachusetts
kr
DEPARTMENT OF BUILDING INSPECTIONS
' 212 Main Street • Municipal Building
- �b may°
s *��
Nort hampton, MA 0106
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her
construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which
he /she resides or intends 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 home owner."
The building department for the City of Northampton wants any person(s) who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection
(before work is concealed), insulation inspection (if required) and a final building inspection.
The building department requires these inspections before the work is concealed, failure to secure
these inspections can result in failure to obtain a certificate of occupancy until the work can be
inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be
responsible to make sure that the trades hired secure their proper permits in conjunction to the building
permit issued, and that they get their required inspections. Failure of the individual trades to secure
the permits and inspections as required can DELAY the project until such time as the proper permits
and inspections are made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
•
. The Commonwealth of Massachusetts
Department of Industrial Accidents
" Office of Investigations J '
-, - ra
0- -xi ` 600 Washington Street T ,
4114, '� o ,
9 Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): p. c wti kL- o `- " Cs
Address: 1 0k4 b .
City /State /Zip:' ke-kk M 0\-- C&J ( Phone #: - 1 - 7 6 0
Are you an employer? Check the appro box: Type of project (required):
1. It I am a employer with L 4. ❑ I am a general contractor and I
employees and/or part- time).* have hired the sub - contractors 6. ❑ New construction
�11
listed on the attached sheet. 7. El Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. [.Other �tS ��
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. C �� Insurance Company Name:
Policy # or Self -ins. Lic. #: (2-16/ 5 Expiration Date: t it -act —ao c
Job Site Address: 1 7 C So J( (A C ` City/State /Zip:C1 v 0 (A d "- - Y le d 10 t 0
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiratio date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereb certify under the pains and penalties of perjury that the information provided above is true and correct.
k t , . - Date: -c t ( — I
Signature: ` � `- 1( 6 i
Phone #: (`-\' T Li '3 k_;G`(
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 #:
SECTION `8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �(� 0 Not Applicable EJ
Name of License Holder : V UU `'� 1 J Is ` 1
License Number
Cyi e-e :'L C\ M b sacs O (�
A ess Expiration Date
Signat re Telephone / % r 1 `-
:_ ,� . - , m��- 1 N ot '9 Registered -�Iome.Improvement.Contr ctor , , . , gmozmi e ' . Applicable ❑
l ( / s'6
Company Nape i Registration Number
te\ t t, L{c30vb Sri ( tA8 o 7 - -c4 cO ( 3
Addr Expiration Date
Telephon 7 3 �, l
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVrr (M G L c 152,
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 lt. No ❑
1.,,.iomeeowner : xemp:hon
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 ❑ Replacement Windows Alteration(s) ❑ Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other PIA
, J W.. 'el a
Brief Description of Propos d . C
C4- Ce-, \bSe- Vi — ®O(` IA a- CC 5 <
Work: -Vtf C" . � Ce-kL)(o c,‘ 1/4.,s eTs s µd 1.4s -1cj 0v∎ \u e ` -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sax ,st rsz,: �.,; : >
saxlf�New, louser:an or addition to ex,sting hous the�foliowmg:
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each '
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN . ;
OWNERS AGENT OR CONTR APPLIES FOR BUILDING PERMIT
1, I e.- `'\C.k ✓"\ (,�., o\f eltn , as Owner of the subject
property \l
hereby authorize ` cs f Se'
to act • •ehalf, in all matters re tive � work authorized by this building permit application.
i f
_ -s (r - r a-
Signa ure of Owne. Date
C � ���— , as Owner /Authorized
Agent hereby declare tha 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.
' \A °.f
Print Name _
• ■ i �, S "-[ k (
Signature of Owner / Agent Date
4
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
b
Existing Proposed Required by'Zoning
This column to be filled in by
Building Department . 0j,A4 L {
i
Lot Size ' '
Frontage -
Setbacks Front , i'
ront j
Side L: R: L: i R:
Rear F-----y
Building Height
Bldg. Square Footage i % r
Open Space Footage % e — i
(Lot area minus bldg & paved 1 i i
parking)
p 1 t i t
# of Parking Spaces
Fill: ____ _ _ ._. .______ ; .___.___., �_
(volume & Location) I: ----•
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
I i
IF YES: enter Book 1 Page I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: 1 I
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: '
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
� � , � De p art eat se orijg K 43 .i z
_ R . �c i
+,,.. C ity of Northampton �Sitiatu o r�.7� H
Building Department C'r�yet r
a � a 4 ' , ye s'` ,e �€ t y 7
212 Main Street 5e� u er S� ICAVa f , r .. �� �f,
' 14 I 4 Room 100 ; �N #er el i� it bo � -:*-41,10.41102,4..1---,`,0,-
orthampton, MA 01060 ` '' 41 o fttru'c u 3Pian � . �
Fe u,�oN "sp.`s ne s- 587 -1240 Fax 413 587 -1272 P i a She ans �` � ` ,
�Ep t ukL i ON -1r l r z's, r`f ` �*, i,.. -f e � . & t¢
No i the r Speci ' ; ` . = , '
APPLICATION TO CONSTRUCT, ALTER, R EPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be__ completed by office
.. ;n
��� /t N l a p `Lo M ' U ,
1.1 Property Address:
Zone Overlay Dtstrlct
n
Elm`St. "District CB Di
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ittQAAA,frj) vi
k u,_�� Al u{ � � o 4' � 1 � �
Na Tint) Current Mai' dress: u b 0
r 7j
L . 4r ' _ R I £ Telephone
0 ,,,,,, Gt_etkv,
Signature i
2.2 Autho Agent
Na (Print) Current Mailing Address: cir
• illiD ffi.,, (tk‘i fl y 0` I
Signature ! Telephone
SECTION = ESTIMATED C COSTS
Item
completed by permit app
1. Building
Estimated Cost (Dollars) to be Offi cial Use Only
licant
(a) Btaildmg PermitE e
2. Electrical (b) Estimated Total Cost of
Construction from` (6)
3. Plumbing Bui Permit Fee:
4. Mechanical (HVAC)
5. Fire Protection r , .-7��
6. Total = (1 + 2 + 3 + 4 + 5) .575�JC1" ° Check Number 2
This; Section 'For - Official Use Only
Buddingg Permit Numb- ' IDssuetl:
Signature:
Building 'C'
ommissioner /Inspector of Buildings Date
176 SOUTH ST BP- 2012 -0988
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 154 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0988
Project # JS- 2012- 001712
Est. Cost: $3850.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 20386.08 Owner: WOLF ALAN C & MEGAN L MURPHY
Zoning: URB(100)/ Applicant: JOSEPH GEORGE
AT: 176 SOUTH ST
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774 -3604 WC
GREENFI ELDMA01301 ISSUED ON:5/14/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION & AIR SEAL
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 5/14/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner