18C-127 (3) 4.. ,�vv�� City of Northampton
h N Massachusetts
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x; ^ �f,�fi DEPARTMEPTT OF BUILDING INSPECTIONS ,'�•�g
s,- "_�-.�� 212 Main Street • Municipal Building ;,,5 �;•
Northampton, MA 01060 '" ='''
Property Address: 6t, 131(41 0 Lc/At
Contractor
Name: JoSetAN &NV, f a,P. Gene (ANA Son) 3rtt,
Address: 111 Hilnicoa Stre£i
G
City, State: r8'r4;elA i MA o$3O1
Phone: (413)-714- 304
Property Owner
�,�°���
Name: Nell t
Address: i b gt &(%'Cr['f Lf,v.t
City, State: NO11.1\w� , mil'
1, Joe \ &eorf4 (contractor)attest and affirm that the building 1 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, , 6:_iL-Lct__fi-w
Date (4 l 7f 13
mass save mum
Sewv+gs xrveugh cnagy?Meter.
PERMIT AUTHORIZATION FORM
S 3JVA_\\T , owner of the property located at:
(Owner's Name, printed)
(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.
Owner's Signature
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:
Q Bore. 04 Son , Inc. 06/13
Participating Contractor Date
Rev 5/24/2012
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(l3usinesslOrganization/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):
1.0 I am a employer with 4 4• ❑ I am a general contractor and I 6. [-=I New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
These sub-contractors have
ship and have no employees 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.=
required.] 5. ❑ We are a corporation and its 10.9 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 12.9 Roof repairs
insurance required.]' c. 152,§1(4),and we have no 1nSUiation
employees. [No workers' 13.0 Other
comp. insurance required.]
Any applicant that checks box#I 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.#: Vd i a`i/b )0- I ) Expiration Date:4/29/2014
Job Site Address: b 61(AC Terri v c, City/State/Zip:f(Or c r^0:Mnt M f 0 0 t)
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 S250.00 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 certifj'under the pains and nalties of perjuury that the information provided above is true and correct.
Sicnature: t. �v L. Date: v/r 71) 3
Phone i<;:(413)-774,04
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License it
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: (r�n Not Applicable ❑
Name of License Holder: 3-Ose�\ Gent. bl
CD) 131 a
License Number
Hotwoo ■ s -e Gree,Ai tld+, Niq 0 301 a-Ri-aoi�
Addr� - Expiration Date
�, -. �t,�1�(, 413)77 -3 toy
Signatur.t d Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
a. P. Creory o.Abk San, Int, 156686
Company Name Registration Number
Ctk \GI'fWJq j\ Site-e\ (refr f\e 111`, PAN o1301 7-1S-aoi
Addres \ Expiration Date
1 { l
�� Telephone t;J 7 711`360 y
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(t) 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,von 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
Electric,Plumbing&Gast.p,, do
rthampton, MA 01060 Two Sets or auucwia�r
Nor harnpt*. n�n pht�ne 41 -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
This section to be completed by office
1.1 Property Address: Va b ikKbt-`V L f∎fl .
I Map Lot_ Unit
NO OA\0 4\ON i M P\ Zone Overlay District
MOO Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
';1 t 5. Zvi^ 6 1314/1( tr t y hue,
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Jose�1. t 64 �lUyv,00d' s't, Gc ef`i�it,M.A oi3'3
Name(Print) Current Mailing Address:
Y'--, i3)-71 -36o
Signature Telephone
\-N*34 ' _
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 _ 9
6. Total=(1 +.2+3+4+5) 5'i r);),,71 Check Number (OP
f h 6 6r
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
0
A ► A. ( 71P
Signature of Owne I,e ent Date
.
File#BP-2014-0254
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 86 BLACKBERRY LN
MAP 18C PARCEL 127 001 ZONE URB(l00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 5:3 -/Q
S5
Fee Paid
Typeof Construction: AIR SEAL&INSTALL ATTIC INSULATION
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
`- Delay
�
j7 r3d/5
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.
86 BLACKBERRY LN BP-2014-0254
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 127 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-2014-0254
Project# JS-2014-000419
Est. Cost: $3322.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 19384.20 Owner: SULLIVAN DONALD A
Zoning:URB(l00)/ Applicant: JOSEPH GEORGE
AT: 86 BLACKBERRY LN
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON:8/30/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL & 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 8/30/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner
..— 1 C L n V —'' Department use only
�J r City of Northampton Status of Permit:
.� Building Department Curb Cut/Driveway Permit
Ate 2 9 2013 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Electric, Piumb;ryas lnspect;oh§Orthampton, MA 01060 Two Sets of Structural Plans
Northamm-- 'OA phone 411-587-1240 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
This section to be completed by office
1.1 Property Address:
(6 L bikk6er`y Lo..n . Map _ Lot Unit
do r ,\U 0o i M DI Zone Overlay District
010
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
myti 5:Allowv S6 e1ultI( berry kme,
Name(Print) Current Mailing Address:
See AA�a(1.e� yl3�_��Ij-3�7'r
Telephone
Signature
2.2 Authorized Agent:
S0Set:/1, (reor,t 69 Hoof‘.04 s).. CrreNkeip,M.A oft3
Name(Print) Current Mailing Address:
Signature IP 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) 3J1 1 S/'']'1 Check Number 6:1 A6 it 6-15---
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date