44-009 mass save:
PERMIT AUTHORIZATION FORM
i, iw► • as e • ,owner of the property located at:
(Owners Name, nted)
r . r 10.1--t • 1rCa- t. u.G r .d 4a c�
{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.
as 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:
(5enry, (MA 5O , I'\c,
Participating Contractor Date
Rev.12132011
— -
'7I%(''6 01111110 le/MUNI(/ 7r17.;;(1(11(6(14.
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
_ _
•ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
If.k.Registration: 156886 Type: Office of Consumer Affairs and Business Regulation
fl)
74Expiration: 7/25/2015 Private Corporatio 10 Park Plaza-Suite 5170
Boston,MA 02116
JP GEORGE&SON INC
JOSEPH GEORGE
i2A1. Y-17k.
64 HAYWOOD ST
GREENFIELD,MA 01301 Undersecretary N t vali t without s 'nature
11Ip 7:- 7- ~"-
\ Board a:
Constructilm Super
_c :38 CSSL-099372
JOSEPH P GEORGE
64 HAYWOOD STREET
GREENFIELD MA 01301
02/11/2015
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly-
Name (Business/Organization/Individual):J.P. George and Son, Inc. /Joseph George
Address:64 Haywood Street
City/State/Zip:Greenfield/MA/01301 Phone#:(413)-774-3604
Are you an employer?Check the appropriate box: Type of project(required):
1.12 I am a employer with 4 4• ❑ I am a general contractor and I
employees(full and/or part-time).*
have hired the sub-contractors 6. ❑New construction
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 s. ❑ Demolition
working for me in any capacity. employees and have workers'
comp. insurance:: 9. ❑Building addition
[No workers' comp. insurance P
required.] 5. ❑ We are a corporation and its I0.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their i 1.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.]' c. 152, §1(4),and we have no
employees. [No workers' 13.12 Otherinsulation
comp. insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
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.
Insurance Company Name:Arbella
Policy#or Self-ins. Lic.#: I b In-115 Expiration Date:4/29/2014
Job Site Address: 1 1\flLrc-1 "'" ``o�t� City/State/Zip: �� fnt M 61°
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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certf'under the pains and penalties of perjury that the information provided above is true and correct.
Signature: °A ,il� -=1�' Date: 0 11S/1
Phone##:(413)-774-3604 1
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
City of Northampton
i
itil rr4� n\-:-Massachusetts l..-t 1 (r 1;_ '_. f,P DEPARTMENT OF BUILDING INSPECTIONS
s. ;-?:`--._ 212 Main Street • Municipal Building
P 4 mss,:. ._.i
.%'c.' Northampton, MA 01060 "',
Property Address: 451 (' ')bK l )4 fo�i Flo rerieet w\j} q\Ot?
Contractor
Name: Jp$epIN Game /a,P. Geory &AA Set\1 Ti-N(..
Address: ,bcl �a+./woo(j r ei
City, State: G rP($'e 1dk, M A 01301
Phone: ( 1(3)--17,i- 304
Property Owner ,.
Name:
�.c��`t
Address: 45 \ .oc(1 WiA RG)4
VbffiVi �PI 0IOCA
City, State: f I
I, Jost?t (arl Q (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 ` 4 �1/4A
Date �/ 1Vi5
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 0SeQ1\ G2Oto t CS31 `10131
License Number
(" Hc"p"o00t st-e\ (.ceenvelo‘t Mq 0130\
Addres Expiration Date
413)-771/10b°4 Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
J. Q, Berea- Cnnd■ San, 'tnt 15664,
Company Name Registration Number
Cy Vtol a S re-e\ (yrffrtf e id, MR .01101
Addr Expiration Date
Telephone�I;)-774-36°‘1
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 1083.5.1.
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 1]
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding[D] Other[till
Irtivt h 4ion
Brief Des nption Qf Propo ed + Rd $ 6 Iff ,
Work: r )ecotl kt tiA)e etili (roe INA4 $ Of �� InoJ; �Sln J
coo t,
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. ftoodplain 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
L��l C71 1�l ,as Owner of the subject
property
hereby authorize SOS I &fOr %
to act on my behalf,in all matters relative fo work authorized by this building/permit application.
Set 1\ o, e1 4c / 1;
Signature of Owner Date
3.0 St \ Create, ,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.
UOSe Gepr- t
Print Name � T JIMA
Signature of Owner!, Date
C:Cgi‘4745 Department use only
City of Northampton Status of Permit:
AUG 2013 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
DEF iF 131.111,AG INBFECTONS
OFTHAtv'TON,MA01060 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: This section to be completed by office
� ��sky H;'�� �
Q Map Lot Unit
\OT el)C e l C'^1 t
Zone Overlay District
\ Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A\■1 451 R,ut.i H►11 Fo0A 1nfe+ite 1NIP' 0106.
Name(Print) l
f� ed�1rn Current Mailing Address: ] -5)p 7 �`3o 3
See AVolG Telephone
Signature
2.2 Authorized Agent:
/OSeW Ge r 64 HoIN.Noa S Green{;eIWA.A ofto
Name(• Current Mailing Address:
' t IIVIA N{3)-77 -360
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) , hn°Y.5 Check Number .536 / 0v5s
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0201
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 451 ROCKY HILL RD
MAP 44 PARCEL 009 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out h%� 6
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION&AIR SEAL ATTIC&BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 99372
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION 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
n Delay
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.
451 ROCKY HILL RD BP-2014-0201
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 44-009 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-2014-0201
Project# JS-2014-000337
Est. Cost: $2750.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq.ft.): 10541.52 Owner: MAURER KYLE P
Zoning: Applicant: JOSEPH GEORGE
AT: 451 ROCKY HILL RD
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON:8/21/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION & AIR SEAL ATTIC
& BASEMENT
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 8/21/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner