31A-304 (.b - 2-
` Customer ID Lstomer Name € ( \` l l"r-, Address 6c4 t'\
KNOB & TUBE 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.
The Mass Save 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 EcoTechnology (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
EcoTechnology (CET) and the Mass Save program will rely on the electrician determination and certification below and
will not be liable if inaccurate.
Your home could benefit from ' ulation and/or air sealing in the:
❑ Attic Slope Exterior ❑ Basement Attic Floor ❑ Kneewall Floor
a
** 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.)
Company Name & Address
/1'lfld 1e7
Electrician's Name/CO f'/ Z-(747 License # Ek.5
1 have performed an inspection of the wiring at the home of:
76 e/lt e / Ve. _ at 2 41.02. i ?"'WLce rr oTZ ' tl'-)LL7 t
(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.
❑ Attic Slope Exterior ❑ Basement Attic Floor O Kneewall Floor
Walls
f
Electrician's Signature Z , �-/ .. Date /-7
Please mail this certification letter to: enter for. coTechnology
320 Riverside Drive 1 -A
Florence, MA 01062
Or fax to: 413-586-7351
Rev. 5/24/2012
Please call 800- 238 -1221 with any questions or concerns.
Customer (mail -in when completed) - White Customer Copy - Yellow Auditor - Pink
..er,"
PARTICIPATING '
mass save CONTRACTOR
Savings t !Inman 1011110Y Of filSWCY
PERMIT AUTHORIZATION FORM
4 -- frey/ , fJ
I, , owner of the property located at:
(Ow 's Name, printed)
•
10A1U,4 A-14.
(Property Street Address) (City/Town)
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property.
.C./4 , 1‘2-
Owner's Signature
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
Rev. 12132011
The Commonwealth of Massachusetts I PrititfOttn
Department of Industrial Accidents
= Office of Investigations
1 1 Congress Street, Suite 100
Boston, MA 02114 -2017
4 �'w
' * www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): � �ov
Address: / :
City /State /Zip: _ Phone #:
Are yo n employer? Che .1 the appropriate box: Type of project (required):
1, am a employer with 4. ❑ I am a general contractor and 1
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in capacity. employees and have workers'
g any P ty 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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.] t c. 152, §I(4), and we have no 12 �, R re p �
employees. [No workers' 13 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1 Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state w hether 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.
Insurance Company Name:
Policy # or Self -ins. Lic. #: 6 4C / - - � � c� t I Expiration Date: 03 3
Job Site Address: City/State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing 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 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.
I do hereby certi the pa' - d penalties of perjury that the information provided above is true and correct.
Signatures Aar _ = — - - -_:__ Date
j 7
Phone #: / y/3 + � - 7 /C
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: /� / J Not Applicable ❑
Name of License Holder : 1 �„ T ar, / Sha ( A.) L S ' 3 c r ( 73z1
License Number
n l '
1 u 1Iv�C � �ZIy ch (cc J4 /0 (3
Address Expiration Date
..t+r '115 Ef Z 5
1
Signature Telephone
S. Regittered'.HOme.improvement Contractor Not Applicable ❑
14 f a (er�%1 "t SCE Lt. C f �P (,, 0
Company Name Registration Number
P6 6 X 2 3 - 42 Y - Z./ — �y
Address Expiration Date
2 6 A ° f - e- /l 0 /02 t Telephone ` Lj - (
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 ip No ❑
116 - 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 6- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs D] ppcIts [Q Siding [D] Other [iE
Brief Description of Proposed - ) t� ('
Work: ii/ /a �+ 415kkfrit.*� /1 G 1 4ti Jetitt5i 6(
Alteration of existing bedroom Yes No Adding new bedroom Yes N o S'64(3 Attached Narrative Renovating unfinished basement Yes No 4-,/e
Plans Attached Roll - Sheet
sa. if New house and or addition to existing housing, complete the following:
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 CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject
property j;
hereby authorize J �� , /C C^L k ! L`"'
act on my behalf, in all matters relative to work authorized by this building permit application.
S ignature of Owner Date
I, � .(S �� "--/' , as #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 u .: r the . ns and •e - ties of perjury.
& 1 thi►.a -' An.
Print Name i►
Antliir: ,-.'
( "
Signature oFAwRer /Agent Date
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 in by
Building Department
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 Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES
IF YES: enter Book Page and /or Document #''
B. Does the site contain a brook, body of water or wetlands? NO (J DONT KNOW Q YES
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 NO
IF YES, describe size, type and location: '!
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
�P C-----ii-7-r\117 - Department use only City of Northampton Status of Permit:
4 2013 \ BwIthnDePartment Curb Cut/Driveway Fermat
1 212 Main Street
�rlSeptic Availability a Room 100 Watr/Well Availability I __ _ _
uE , rthampton, MA 01060 Twcr Sets of Structural Plans
_ ___ �' - =.' — phone 413 587 - 1240 Fax 413 587 - 1272 Plot/Site Plane`
Other Specify,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: n This section to be completed by office
( 9(40 ;etail�S A Ve, Map Lot Unit
NO r i GI mp k n M A 01000 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: /� 010 1 -- 1
1 60x /b CiliCa ee /n
Name (Print) Current Mailing Address: ic;-1:::___N..........,,..._____ t13 2 --
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 1 +2 +3 +4 +5 Check Number 1167
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0796
APPLICANT /CONTACT PERSON JEFFREY BRADSHAW
ADDRESS/PHONE P 0 BOX 1276 CHICOPEE (413) 427 -5481
PROPERTY LOCATION 26 JAMES AVE
MAP 31A PARCEL 304 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out l /�
Fee Paid
Tvpeof Construction: INSULATE ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 094734
3 sets of Plans / Plot Ply
THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved 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
- olition De • .
e p, 3
Si... - s B " ding Officia 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.
26 JAMES AVE BP- 2013 -0796
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 304 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- 2013 -0796
Project # JS- 2013- 001361
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BRADSHAW 094734
Lot Size(sq. ft.): 13939.20 Owner: BOND FLORENCE R & HOWARD BOND & JUDITH POGANY
Zoning: URA(1001/ Applicant: JEFFREY BRADSHAW
AT: 26 JAMES AVE
Applicant Address: Phone: Insurance:
P 0 BOX 1276 (413) 427 - 5481
CHICOPEEMA01201 ISSUED ON:3/6/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: I NSULATE ATTIC
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 3/6/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner