42-053 (2) iml
mass salve NWO11
PERMIT AUTHORIZATION FORM
1, J rn,a._ {`�.�lcr�,�A , owner of the property located at:
(Owner's Name, printed)
S63
(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.
1 r v
0716' 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:
7,�, ( C(ne s�R, �� 019,7/13
Participating Contractor Date
Rev. 12132011
City of Northampton ---
S .
c' Massachusetts
4
fi DEPARTMENT OF BUILDING INSPECTIONSF
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address: P
Contractor
Name: Jbse6 r D!V /a, Gei ne tMdk S qy
(\c.
Address:
City, State: G rye n 1 k M A 01301
Phone: ( P-77q- 3LO4
Property Owner
Name: [
Address:
City, State: rcArpor, >
I, joSq . r (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
-T1,-(r(qi1mc)1f1w1111t License or registration valid for individul use only
_Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:
=-
iaOME IMPROVEMENT CONTRACTOR Type Office of Consumer Affairs and Business Regulation
I ` Registration: 156686 10 Park Plaza-Suite 5170
6 ,•.Expitation: 7/25/2015 Private Corporatio Boston,MA 02116
JP GEORGE&SON INC
JOSEPH GEORGE
o L A21 -
64 HAYWOOD ST - — i
GREENFIELD,MA 01301 Undersecretary NO�t vali Without s nature
CSSL-099372
JOSEPH P GEORGE
64 HAYWOOD STREET _
GREENF'IELD MA 01301
0111111015
The Commonwealth of Massachusetts Print Form
Department of Itzdustrial Accidents
--= Office of Investigations
I CofYa t•ess street,Suite 100
Boston,MA 02114-2017
i ivw.3nass.g ov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print L.eaibiv
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):
1.0 1 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 constru ction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship nd have no employees These sub-contractors have
P S. ❑ Demolition
working for me in any capacity. employees and have workers'
insurance. 9. E] Building addition
[No workers' comp. insurance comp.
required"] 5" ❑ We are a corporation and its 10.E]Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their
11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per iti1GL 12.E] Roof repairs
insurance required.]' c- 152, §1(1),and we have no
employees. [No workers' 13.El Otherinsulation
comp. insurance required.]
applicant that checks box=1 must also till 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 shoving 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'COnlpensatiOn i11S11T1Mce fOr my employees. Below is the policy and job site
iiiforniation.
Insurance Company Name:Arbella
Policy#or Self-ins. Lie.4Y: Expiration Date:4/29/2014
Job Site Address:_ �� weir v m Q4 RDO A City/State/Zip:_ 64Utr+ brtr'A A 01 0 W
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 1VIGL 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 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 certif under the pains an6l ,nalties of perjury that the inforination provided above is true and correct.
Sianatul-e: Date:
Phone x:(413)-774-3
Official use on111 Do not write in this area,to be completed by city or town official.
City or Town: Permit/License##
Issuing Authority(circle one):
L 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: ,,,,��yy Not Applicable ❑
Name of License Holder: vOSus ITGO;y�. 031 gil3^1�
License Number
(,4 c �p O
Addres I Expiration Date
h t (q13)-M-3b64
Signature Telephone
9 Registered Home Improvement Contractor: Not Applicable ❑
_ J- e, G-14 �0r\, 2nt, ISW(i
Company Name Registration Number
0 vlc- vwA 6 S+re-6 P-e,&e Id, AA .01301 7-z-)-013
Addre 1 '7 Expiration Date
Telephone �l�l J-77 -36°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 Dweflitws 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 10835.1.
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 buildina 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 I53(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 171
Accessory Bldg. ❑ Demolition ❑ New Signs [Ca] Decks Siding[0] Other(�
�nStn to}ton
r
Brief Description of Propos �
Work: it Sp,j #�%, (,,I
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.
1. 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
I �(Amps t �`�Vkr- as Owner of the subject
property
hereby authorize 5asepl� {��
to act on my behalf,in all matters relative fo work authorized b this building permit application.
Yee k,) ct -a
Signature of Owner Date
I �OSQP�\ 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.
UCS2 Gear 2.
Print Name
Signature of Own+Agent Date
( Department use only
o
ity of Northampton Status of Permit:
DEC 3 uilding Department Curb Cut/Ddveway Permit
{,� �� 212 Main Street Sewer/Septic Availability
r
Room 100 Water/Well Availability
j orthampton, MA 01060 Two Sets of Structural Plans
ciior
phone 4" 3-587-1240 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
Address: 3
7.1 Property W t?s h This section to be completed by office
(�
A0 Map Lot Unit
r �,,�0�rN M zone Overlay District
O 10 6 d Eim St.District Ca District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�aMt I
Name(Print) Current Mailing Address: l
See ww'W 4'I3 -58�-583
Telephone
Signature
2.2 Authorized Aaent:
SoSg kr:iv t 64 4tnY,-4 S�, GfCef*,C1 /%A 01121
Name(Pri t Current Mailing Address:
Signature Telephone
SECTION 3- STIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
complete bypermit 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) r C1 011,04 Check Number
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0759
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 563 WESTHAMPTON RD
MAP 42 PARCEL 053 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
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 99372
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demolition Delay
Si re of Bui ding 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.
563 WESTHAMPTON RD BP-2014-0759
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42-053 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perrnit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2014-0759
Project# JS-2014-001306
Est. Cost: $4992.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq.ft.): 66646.80 Owner: RYAN JAMES P&MARYANN C
Zoning: Applicant: JOSEPH GEORGE
AT. 563 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON.1213112013 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 12/31/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner