29-357 (3) lom
mass save
ttsf
PERMIT AUTHORIZATION FORM
, owner of the property located at:
(Owner's Name, printed)
/VC 6rbe'ili
(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.
/ 64 4 63
`CSwner's Signature
3l(-)k '
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:
) 3Aci /:4,o‘3
Participating Contractor Date
Rev. 5/24/2012
License or registration only stration valid for individul use oni _ ✓ �ay�z -�,zar u�a S c�' I 1 , act
Office et` consumer Affair & z i3ir incss xegulanoh
before the expiration date. if found return to: _- HOME IMPROVEMENT CONTRACTOR
Office of Consumer Affairs and Business Regulation >? ��
10 Park Plaza - Suite 5170 Registration. 156686 Type:
Boston, MA 02116 � =? Exp 7/25/2013 Private Corporatio
JI'GEORGE & SON -INC
7°, „:‘ / t - JOSEPH GEORGE
--r,L7'r-t• t ' ° 6 r 4• • 64 HAYW000 ST
! Not valid withottt signature GREENFIELD, MA 01301- Undersecretary
:�3as,ai hu.cita - Del) artMen' ut Pui3! c stilt:‘
BOar(1 of Building Regulations and -t (adards
Restricted to: WS,IC
JOSEPH GEORGE
64 HAYWOOD STREET
GREENFIEI_D, MA 0'301
Expiration: 2/11/204
( ,nnnlisi Tr=: 99372
_�7
t ._,..,-,-
a:., t3 Office of Irrvestzgations
%idr = ' 600 Washington Street
;� r I ,
Boston, MA 0211I
.� 1 -4- WwPittitangOlilditt
Workers' Compensation InsuranceAifidai►zt: Builders /Cootractors&E1ectricin / *lumberr
Applicant Infarmadot2 Please riot IJezibly
" ECG I C SOt tiL-
Name ( BuswesstOrgaeizafionitadividoal ): _ -- t - - 3
Address: `1 kiva ST- .
5, t r .—+
citytstate�l 7 _ -- :�� % � � \ C �. 3u • Phtne#: ( t3 } -7 ' '�
f
Are you an employer? Check he appropriate box: - Type of prtrlee€ required):
1. M.. I am a employer with `A a ❑ 1 am a genexal contactor and 1 6. ❑ New cants =ruction
employees ( 13 azid/or part lime).' have hired to sub- coutractms
2. ❑ I a:m a sole prvimiebor orpariner-
listed an the attached sltet L 7. 0 Rettx)delir
- snip and have no cloy= These subcontractors Dave S D DemoIitio r
working for mixe in any capacity. — workers' Comp. inSL Uaa»Ze- 9 0 Building addition
o workers' comp_ Durance - 5. ❑ We area corporation sad its -
MD Electrical -van' or additions
remised.] officers have exercised tick
3.0 1 Ma a 'homeowner doing all work ` _ *lit Ofeser on ffirlutGI, I .0 pininhing rcpaus or additions
- myself [No workers' cow _ c S 1(4): *Owe no 12.0 Roof repass
insurancerc ui:red.} } ePiliggest [NoW4rkt✓IS" 13_Mi Oder �.n)'1loll!'
cUii i. insmanrc icgtnred.) •
'Any applicant thotahe abo moot also MI out the mctioabelowaiso-+ theirwurkets' compeosEdicro policy id/ma**
1. Fiomeownas who submit this' affidavit indicating-ijtey aie <ioiogeatwaskame ten 1rsr omsids conbuctoismtost sanit anew officio - fit indicating sack
_' Conaathan that cnecicthisboa- moorcovobad 033 additiC 01304411g tht 33333000fthe toib-contreciors andtcirworkers 'ramggalkyit os ton
d int alt errployes^ that isprin i workers' compensation insurancefor my employes,. _Reknit is the policy andjob Set
Informutio>x � = '
baszzrance CompanyNam L \J r ; i S _
Policy n or Self 3u5 is y �i�% ` J _ - l; Zra Date: '7 s
Job SiteAadres: 5_ 1 At' Vt pr . - - • � CitylSthtef 1 C tore , i/0 (31 3`
Attach a copy of the workers' compensation poiiey deciarabioa page (showing the policy* number and eepiraden date).
Faiuze b secure coverage as required trader Section 7-54 .-QfMGL C. 152 MA lead to theiovosifiQn OL'criErtiltal penalties of a
Roe up to $1,500.00 and/or tine year iazprisoumen ; as well as' civapeoalties in the folio of a STOP WORE ORDER and a fine
of up to S25OE00 a day against the violator_ Be advise 1 thatla cagyofthis Stetementreay be foirardei to fie Ofce of
Inver 4g2110323 of he D A tbr hest rauce covczagc verification_ - -- - -
r do hereby rertif t underthe pains and"- . ' r - o fpe t y"thattke itformatioapropiderl alcove is trine a net correct
Sienat e= `sa. 1 t • Date_ / 1111
Official use orb Da not write in thus area, t# be tampleitsd citY et' Mt* official
City or Town: - - - - ks
• Per enie Y -
Issuing AntJior[ty (Circle one}?
L. Board of 3liv th 2_ Building Department 3. City/Town Clerk 4_ Electrical Inspector 5_ Plumbing Inspector .
6 Other
Cont:met1Persea: - ]phone £:
City of Northampton
' Massachusetts 4,7 .,t F.. * x
„„ DEPARTMENT OF BUILDING INSPECTIONS t4411
s 212 Main Street • Muni Building " 7;
F r,
:"q"' Northampton, MA 01060 j �''
Property Address: a "'L kre in 1 U rw Fin r NA
Contractor
Name: Nei* George / a, P. Georg rMdk S,vr, 'Inc
Address: b t Nvywooc S tree}
City, State: GreerNi.leiA , MP oi3Ol
Phone: C1 3604
Property Owner rMv)n . 0 ch.\ 4
Name:
Address: h #D' ( Ur
City, State:
Ftorer4e j M p\ V
I, 30StON Cseort 2 (contractor) attest and affirm that the building I intend to
insulate does 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 c„ / 3
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor :: �i�' Not Applicable 0
Name of License Holder : JbSe (Teal , cJs1 "1-1 ; ` 2- \ NS % T C
License Number
&y H tAywMOc, G reNi z 1 c MA o\3 t' D. 11 -
I5
Address Expiration Date
�► tilt,( ($31 7 ' 7 ' t -1‘04
Signature i Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
() (reor 04c1 1 (3 b
Company Name Registration Number
!ilVfoodk C (sretAtAt tvp 060\ 7/ S /i
Address ` Expiration Date
e ' W4' Telephone (9I3)779
—
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 13i 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 El
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [EJ Siding [D] Other�
- DNA. ntio.r
Brief Description of Proposed 10
, , p � . �� ��
Work: A� c-hCA� 4, c ft ^A v (\GU of ceti � l.rAl GAR.
Alteration of existing bedroom Yes 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 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
! \n R �
kr\l ✓ h , as Owner of the subject
property I
hereby authorize .S & Ivy t.
to act on my behalf, in all matters relative to work authorized by this building permit application.
ee, Ato,�,�e v - 1/2.14 /
Signature of Owner Date
Jo 2 Fh (en{ , 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.
Print Name
■40■1° I / ` 340os 13
Signature of Owner /Ag - nt Date
�E
Department use only
City of Northampton Status of Permit:
APR - a 2013 Building 212 Main Department Street Curb Cut/Driveway Permit
Sewer /Septic Availability
Room 100
� NORTHAMP INSPECTIONS MA01060 Water/VUell Availability
_ Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 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: P7 " I p - t r• 4, b r'of This section to be completed by office
7 Map Lot Unit
Gh(ence 1 MI
yy����� Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
J\ 0 \o 'i Vo�,t, tt ash Rcreta Ur`,ve F�Qrel,t , M� 000
Name (Print) Current Mailing Address:
S AOU� Telephone
Signature
2.2 Authorized Agent:
3-0s - Q\ (3 ,0C t 64 I4E,,,, G
SI' . re er 10, MA 0i3
Name (Pri t Current Maili g Address:
�- ��i1 7�y�36�y
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 V? , by Check Number 5123 y 5 575; ex
This Section For Official Use Only
Date
Building Permit Number: Issued:
-
Signature: /��� /� // / J
Building Commissioner /Inspector of Buildings Date
259 ACREBROOK DR BP- 2013 -0885
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 357 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 -0885
Project # JS- 2013- 001521
Est. Cost: $2188.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 13111.56 Owner: BOMBARD ANTHONY L
Zoning: Applicant: JOSEPH GEORGE
AT: 259 ACREBROOK DR
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774 - 3604 WC
GREENFIELDMA01301 ISSUED ON:4/3/2013 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 4/3/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner