46-028 Aft
1
mass save WSW
PERMIT AUTHORIZATION FORM
1 , 5 Ld , owner of the property located at:
( er's Name, printed)
F&r(v AV! Qt1r
( Pro 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.
j
Ow,Ser's Sign
0c21/ 446VS
Date
FOR CET OFFICE USE ONLY
Center for EcoTechnology has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
V Rev. 5/24/2012
•
E, v CENTER FOR CONTRACTOR WORK ORDER
EcoTechnology
., make green make sense"
Printed: 314/2013
\ 43 I f440 work order Id: 519812P23786C136
Contractor Information Customer/Site Details
Fontaine Enterprises Inc Stanley Pelts • Phone (Eve): 413. 684.8314
•
PO Box 251 11 Ferry Ave Phone (Day):
Sturbridge, MA 01566 Northampton, MA 01060-4233 Site ID: 600002119812
Total Installed Measures • I
Location Description Quantity Unit $ Total $
Damming 16 $1.85 $29.60
Living Space Hatch: Thermal Barrier Polyiso 2 inch (Attic) 1 $38.09 $38.09
Living Space Insulate Vaulted Roof From Interior With 5" De 108 $2.20 $237.60
Living Space Whole House Fan Box: Thermal Barrier Polyiso 1 $154.32 $154.32
Living Space Attic Floor Open Blow Cellulose 8" 468 51.48 $683.28
Living Space Perform Air Sealing at Estimated 62.5 CFM50 6 577.00 $482.00
installed Measures Total *1604.89
WorkOnlsr Notes
Attic slope has voids as noted on diagram.
{ Payments
Incentive Payments
Air Sealing Incentive 5616.32
Weatherization Incentive $741.43
Total Incentive Payments 51,357.75
n
Customer Share
Total Customer Share $247.14
Less Deposit Of 582.38
Customer Share Balance (Due Contractor) 5164.76
a
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Center for EcoTechnology, Inc. 112 Elm Street - Pittsfield, MA 01201 .
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0
Construction Debris Affidavit
(For all renovation work)
In accordance with the provisions of MOL c 40, S 54, a condition of Building permit Number
Is that the debris resulting from this work shall be disposed of in a properly licensed disposal facility as defined
byMGLc111,S
The debris will be transported by:
L�E�3 Riij33ish
(Name of the hauler) •
The debris will be disposed of in:
'' SLIVM �t
(Location of the facility)
"4,4
Signature of permit appli t
7 70V3
Date
U
The Commonwealth of Ma&sachusetts
11�� Department of Industrial Accidents
!
- ._.7-4 Q,f'rce of Investigations
!% t 600 Washington Street
=' �= Boston, MA 02111
" `
www.marEgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Bnsinesdorganr1 .ationflndividual): Fon MLLJC E4 TYR.P Rri- 6 - 7 C_
Address:p() Box / (5 Q) 1? y3 -0-99e CELL
City/S : U2j�t2 i 5 ') m _�} - Phone #• (g ?) 7L 5 -S d �O C E �
Are you an employer? Check the appropriate brit; Type of project (required):
1. am a employer (fir with 4. ❑ have hired the sub contructnas 6. ❑ New construction
employees s (frill and/or part-time).*
2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remy d"ling
ship and have no employees These sub - contracts have 8 ❑ Demorition
working for me in any capacity. anployees and have workers'
s' 9. ❑Building addition ,
[No wot leers' comp. insurance °P. insurance.:
.
required" 5. ❑ We area corporation and its 1 Electrical ors or additions
3.0 l am a homeowner doing all work officers have exercised their 11 Phmtbing 1epairs or additions
n¢yseit [No workers' comp. right of mtemption per MGL 120 Roof repairs
insurance required.] t c_ I52, ¢1(4), and we have no
employees. [No waiters' 13.0 Other
comp. insurance re4thcd.)
*Any appiipnt that aheeJk box 01 mast *boa nut the seeing below showing task walker? azimensasico poioy infonmh1on.
t Homonyms who submit this at5davitiakoatbag they are do an contractors work and then hire outside contracto mast submit a new affidavit iadiar®ng sack
rCant actots that cheek this box mod atdchod as edditiaaal sheet slowing the name of the sub- contracasa and state whether or not those cotifies havo
employee:. If the sub- oontrntas have employees„ they mast provide their 'worbsts' comp. policy number. .
I am an employer slut is provider:" workers' compensation insurarteefor my employes. Below lL the portcy and job site
information.
Insurance Company Name: C H A Rr3
Policy # or Self- -ins. Lic. # I J(. ?d 7 y4/ / ?OS Expiration Dale: j a/ 0q/ r
Job Site Address: I t f'2 U &✓ C y/StateiZip
Attach a copy of the workers' compensation policy declaration
p p cY page (showing the policy number and expiration date).
Failurs 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 imprisorantmt, 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 certiig under , fairy _ ,
Indd ,r;r.;�
. o f perjury that the information provided above is true and comet
Sign : / ? � / / Date: 3 7
Plane #•/S ) 7243 ` a i/ [ ¢ (5 7 4 , j O s�? 0 Cf/-F.2
I Official use ont}c Do not write is this area, to be cleted by dry or town official
i city or Town: Permit/License if
j Issuing Authority (circle one):
1 1. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
I Contact Person: Phone #: 1
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
i C' 1
Name of License Holder : i „m(,!, 2 I } 1 -A ) E 3A,
L 6
Nu ber
5 N iS b‘ }on R r) vy/ 80
Address Expir on Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
1 h- E Lu a /
Company Name Registration Number
CC, ic - asi Sv nran,c� .. , /1 6 I za�3
A dress Expir t ion to
Telephone $ W3 2yy
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 ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [p] Other [0]
Brief Description of Proposed �L -t ,
Work: fi/() /� A l l� ►� see etied pie} -pC4A fig
Alteration of existing bedroom Yes A./...._„No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. 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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, - F fl 1{3.x.1 Pe l 1 , as Owner of the subject
property / �1
hereby authorize f l t. i urnd 1 `-r-oy) T L
Ab kC
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, td C)i 'rem. M J Cr j fL--- , as Owner /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 under the pains and penalties of perjury.
n- � mac) i 1. Fov f -t) L= J
Print Name
Signature of Owner/Agent Date -57-7/
ff
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 Q DONT KNOW ',f YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained Lf , Date Issued:
C. Do any signs exist on the property? YES O NO fit
W YES, describe size, type and location:
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, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northa pton — status f Perrrrit: fr .
Building Depa me REC'Et � - = rb •rivewaypermit
212 Main St et S wer/ eptic Availability
Room 10 III Nis 1 1 2013 W ter ell Availability
Northampton, M 01 160 T S of Structural Plans
phone 413 - 587 -1240 Fa 41; R B - B USit Plans
r ' I v i.?
NORTHAMPTON. ii ',A 010. f, , fy
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
Map Lot Unit
r Rlzy AL'
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
£7 n /E y Peas /1 rr
Name (Print) Current Mailing Addr s:
• 1 ii3 5589 - g3ly
1 Telephone
Signature
2.2 Authorized Agent:
R1611 rind (' Foal
an Alit/ TS P6 ii / ,S 'Ul2/3i`'li'd ../A
Name (Print) Current Mailing Address: ; CISC
5r67 iv 3 -- ,y 9
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) I / 61/, 8' 7 Check Number 5 - 7 31
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0814
APPLICANT /CONTACT PERSON RICHARD R FONTAINE JR
ADDRESS /PHONE P 0 BOX 251 STURBRIDGE (508) 843 -2498
PROPERTY LOCATION 11 FERRY AVE
MAP 46 PARCEL 028 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT {r . tif(
Fee Paid V 1
Buildinl Permit Filled out •
Tir
Fee Paid
Tvpeof Construction: INSULATE ATTIC
New Construction
Non Structural interior renovations Amy
Addition to Existing G
Accessory Structure 7 cif
Building Plans Included:
Owner/ Statement or License 99490
3 sets of Plans / Plot Plan
THE FO ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
i ��•
4 . 1 . 11 ! — e of Building Official 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.
11 FERRY AVE BP- 2013 -0814
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 46 - 028 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 -0814
Project # JS- 2013- 001394
Est. Cost: $1605.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD R FONTAINE JR 99490
Lot Size(sq. ft.): 7405.20 Owner: PELIS STANLEY
Zoning: Applicant: RICHARD R FONTAINE JR
AT: 11 FERRY AVE
Applicant Address: Phone: Insurance:
P 0 BOX 251 (508) 843 -2498 WC
STURBRIDGEMA01566 ISSUED ON:3/12/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: INSULATE ATTIC - COPY OF FINAL UTILITY
INSPECTION REPORT REQUIRED
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 3/12/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner