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25-069 Arigk iff°""111 mass save PERMIT AUTHORIZATION FORM i, , owner of the property located at: (Owner's Name, pri ) 5 P,;rter a. P t om` wL r 1 - o to(, (Property Street Address) (City own) 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. • Ow ih 7 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: t".t, kly).^,`e-5 VX) p Patin 9 Contractor ( Date p Rev. 12132011 , 1= • CI = V1 4.4 ..C to 40 ,_ r., r. 01 0 01 ‘.. 0 6/ ... i—• 0 = 4) 0 1.. 5 .... .. 0 r•- CV Ti t.4 0 tt, c) -- t. >., •-• N. CO 0 `.." ' 0 --" 1; = 44 0 K4e 0 = 4$ 4- o a 0 )... 44 ,., 44 • ( = g a ,... '.4 j) • t — .40 4 ,,,, 4.... 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U'l 0 VI E CI: ' • a. 12 >- 0 111 Zii 0 , , ■ Z 1.1.1 > u. , ill u .j c u. ,J .• z ( . 5 ::::: ,. ° ■4" , : ),. . , '.,"'. 171 1 . i 1 ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID JA DR7 P`00"Y" Jx - 11/02/12 HEIR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Chase Clarke Stewart & Fontana HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 101 State Street, P.0 Box 9031 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Springfield MA 01102 Phone: 413 - 788 -4531 Fax: 413- 731 -9234 INSURERS AFFORDING COVERAGE HAIL* INSURED INSURER A Arbella Mutual Insurance (055 Liberty Mutual JASM Enterprises LLC Jeff Bradshaw INSURER c 10017 PO Box 1276 ...UREA D Chicopee MA 01021 NSURER E COVERAGES THE POLICES OF MAN= US TEL {FLOW NAVE BEN C=UED TO THE INSURED NAMED ADOVE FOR THE PoucY PERR)O Np(wTEO. NOTNTNSTANDNNi ANY IEOLARBENT. TERM OR OONMIDN OF ANY CONTRACT OR OTHER DOCUMENT VRTI RESPECT TO MINN THIS CERTIFICATE MAY SE NSUED OR MAY PERTAIN. THE NEIMANCE AFIVROEO M THE POLICIES DESGRIOED NERER, • SUBJECT TO ALL THE TERNS. EXCLUSIONS A■0 GONP710115 OF 5UCN POOGES. AGGREGATE LRBTS SNOW NAY HAVE SEEN REDUCED EY PAID CLARE RISK ADM POLICY EFFECTIVE POICY EXP LTR 'ISRD TYPE OF MIIRAMCE OATS tMWm•YI DATE (NIAIDD^IY) LJrtf GINN9RALLAS{JT5 EACH OCCURRENCE 31000000 D.A... REMI E ( RENTED s 100000 A X X commia.LaENERALUAxn 8500040304 06/20/12 06/20/13 0 T nEKTED wan MOE X OCCUR MED EXP DAN w wing s 5000 PERSONAL A AP/ INJURY 1 1000000 GENERAL AGGREGATE 1 2000000 OEM AGGREGATE LENT APPLIES PER - LR PROO. S • COMPIOP 500 1 2000000 _ PRO. Loc POLICY JECT AYTONOINLE UA•IfTY COMBINED WERE LRAM s 1000000 C ANY AUTO 12726400004 10/05/12 10/05/13 (EFAOw.' ALL GYRED AUTOS 500B5 5SN11 $ X 30EpULEDAUT06 IFRr PRRm) X NREOALTOS "MAY INJURY 1 (PM Y 5*00) 7( MONaAINE0J11Rd PROPERTY DAMAGE _ Ir (Pr .005X) AUTO ONLY. EA ACCIDENT s GARAGE NARIfT'P EA ACC 1 Ally AUTO O THER THAN AUTO ONLY A00 5 EA;N OCCURRENCE $ 1000000 SRC[SIKOM IL AA Wallin A I pf%TJR I I CLAIMS MAOE 4600052470 09/01/12 09/01/13 AGGREGATE s s 1 =mum 1 X R TION ETH s 10000 — i I 'NC 3TATU OTI WOMBS TOM AND I TORY LINTS I ER eR°FSEr WC1 -31S- 372772 -012 05/02/12 05/02/13 E.L EACH ACCIDENT 1 1000000 B ANY PROPRIETOMPARTNEREXECUTIVE OFFICERMEINER EXCLUDED, E . DISEASE • EA EMPLOYEE s 1000000 R/w. INSNM IPISN E OLSEABE •POLICY DINT s 1000000 SPECIAL PROP MDNS raw 0111R DESCRIPTION O F I LOCATORS / IeIOLES /EXCLUSIONS ADDED SY E DORSEMENT I SPECUL. PROVISIONS CST, National Grid, The Berkshire Gas Company and their respective offices, agents and employees are included as additional insureds with respect to General Liability. Waiver of Subrogation applicable to CET in respect to general, to waive all rights of recovery against Center for EcoTechonology or any of its affiliates for any loss or damage covered by said policy. CERTIFICATE HOLDER CANCELLATION • MOULD ANY 05 THE ASOYE DESCILSEO POLICIES EE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE *SUMO INSURER MILL ENOCA0OR TO MAIL 10 Dons YYRRTT 1 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, OUT FAILURE TO DO SO WALL. Center for $Co feChnClogy , Inc. IWO3E NO OOLIGA11041 OR LIABILITY OF ANY IOW UPON TN INSUE& Ts AGENTS OR 112 Ela Street REPRESENTATIVES. Pittsfield MA 01201 AUTHORIZED REP RESEITAT YE Paul P. Petell ACORD 26 (2009/08) © ACORD CORPORATION 1888' io Massachusetts Department at Publ,c Safety Board of Building Regulations and Standards (. +n*tructiiin Supcn Ltcense: GS- 094734 JEFFEHEY A BitADSilliAAV PO BOX t . * i A Cmco = m . ; q z . ��,..!. va , Expiration Cornmrsstaner 10113/2013 Unrestricted - Buildings of any else group which contain less than 35,000 cubic f. et (991 m of enclosed space. p to possess a current edition of the Massachusetts • State Building Code is cause for revocation of this license. For DPS licensing information visit: wwvriMass.Gov /OPS The Commonwealth of Massachusetts _:__ ,_._ Department of Industrial Accidents t . = l lwh Office of Investigations r ' 1 Coe, Suite 0 i i4.,._., _ '� Boston , MA Street 02114 -20110 7 "• "_'` www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Anplicant Information /) Please Print Legibly Name ( Business /Organization/individual): I C / may —', v - . / -J L ww Address: P O & k - /0 v /4/2 - X5 -- V7 City /State /Zip: _ . LSO • / LLe Phone #: � Are yo n employer? Ch the appropriate box: Type of project (required): 1. am a employer with S 4. ❑ I am a general contractor and I employees (full and/or part have hired the sub - contractors 6. ❑ New construction 2. ❑ lam 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 any capacity. employees and have workers' 9. 0 Building addition [No workers' comp. insurance comp. insurance.: r uired. 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions �1 ] 3. ❑ I am a homeowner doing all work officers have exercised their 1 1. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.E Rpef re P insurance required.] t c. 152, § 1(4), and we have no 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tConuactors 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. lfthe 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. Company Name: / Policy # or Self-ins. Lic. #: t-1 !� (— 3 ) 570 t 1 Expiration Date: OS t;" ` /3 Job Site Address: fl illtritkr.t 49 w j i.. City'State /Zip: », pi 36 J 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 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 hereb ce the pa . - ' penalties of perjury that the information provided above is true and correct. Sil-ii : 1 4.m.._ . dd. Dater /10 r 1 L Phone #: / ( //3 - - 1, 5" .- c) - V7 VC 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 Su isor: //n��, Not Applicable ❑ Name of License Holder : / ((I A '! ( O 1 j License Number (d ODAi Y I fhit pp & 1 j� /J .) 3.1 3 Address / ( Expiration Date (// . ti) /�) natu Telephone e 9. Registered Imerevergertt Contractor: Not Applicable ❑ �� 4 � � ���� /' a79 Comp nv / /' Registration Nufnber ddress 1 ( Expiration Date A 4\-112"y".. Telephoned -/3' SECTION 10- dORKERS' 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 El Accessory Bldg. ❑ Demolition ❑ New Signs [O] � - DeclW Siding [El] Other [ Brief Work Description of Proposl t` � e' c2/tk f (6C. A, 0I''7✓) / t 441, (` Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No 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 , as Owner of the subject property U hereby authorize Jl Jul ` 1 " - / to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date a ff r A4'h ,LI `✓ r /Authorized Agent hereby decla e that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under t e pains and penal ies of perjury. � � vim/ Print Name /!,„A ?/- /- Signature of Owner /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 e r been issued for /on the site? NO 0 DON'T KNOW YES IF YES, date issued:.' IF YES: Was the permit recorded at the Regist of Deeds? NO Q 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 0 DONT KNOW it YES 0 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: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO ec 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. Department use only RECEIVE , .f Northampton Status of Permit: uild ng Department Curb Cut/DrivewayPerinit llfef _ 21' Main Street Sewer /Septic Availa bility 11 Room 100 Water/Well Availability N rth. mpton, MA 01060 Two Sets of Structural Plans DEPT oF-o ni N A oioso i rr: " -5: -1240 Fax 413- 587 -1272 Piot/Site" Plan9 ' 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 59 Map Lot Un j , 1 g; v a e k Zone , Overlay District /& /O ( 11,r 01 1 r v--4 0 /�60 EIm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: _ L0 S �� 2 4 v 41-,,;t /7I J Nam (Print) Current M • ing Addres 3 / _ C / J / `/� / (�/ Telephone Signature 2.2 Author' d A ent: i__>rrik2i I 'Lx ' ( 6 li e n /0`-) Name (Print) .-• Current Mailing Address: 418- 4 A% )- 7 - g 1 / .7 ) 0 *?.7 ' Signature - ' 1 7 Telephone SECTI ESTIMAT I 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 c- 6. Total = (1 + 2 + 3 + 4 + 5) L� � < C Check Number 11/bc) f This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Bu Date At File # BP- 2013 -0911 APPLICANT /CONTACT PERSON JEFFREY BRADSHAW ADDRESS/PHONE P 0 BOX 1276 CHICOPEE (413) 427 -5481 PROPERTY LOCATION 59 RIVERBANK RD MAP 25 PARCEL 069 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out j // Fee Paid Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 094734 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION PRESENTED: pproved 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(J,,, De olition Delay ., .. y___, ../._ Signature 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. 59 RIVERBANK RD BP- 2013 -0911 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25 - 069 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 -0911 Project # JS- 2013 - 001556 Est. Cost: $2400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEFFREY BRADSHAW 094734 Lot Size(sq. ft.): 13155.12 Owner: LONG JESSE Zoning: Applicant: JEFFREY BRADSHAW AT: 59 RIVERBANK RD Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427 -5481 WC CHICOPEEMA01201 ISSUED ON:4/10/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION 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 4/10/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner