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29-281 4W ME rmss save PERMIT AUTHORIZATION FORM I, —Nrvi- 2a , owner of the property located at: (Owner's Name, printed) "'bu–D -e,- �(�Co , (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. ner's Signatur 1 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: � 1 + (761C U�� SARI �flt , �A0 m Participating Contractor Date Rev.12132011 t City of Northampton Massachusetts f f�: DEPARDONT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, Mh 01060 Property Address: Llo� �CD4�,�� l;rL�� Contractor Name JbseeS RD!* s,►'\, _hC Address: Sjre£7 City, State: GrRon 'I lk MA 01301 Phone: (413)-17q- 3604 Property Owner p r)� tANFi C .ny Name: � 1_��1 I Address: ') 1 L r() �S��`'l ci City, State: b(ekej MA I, Josep� karj iP (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 (�o� � The Commonwealth ofMassachrtsetts Hint Form Department of Industrial Accidents - = Office of Investigations 1 Congress Street,Suite 100 - Boston,MA 02114-2017 iviviv.nlass.g ovldia 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?Cbeck the appropriate box: Type of project(required): 1.21 1 am a employer with 4 4. 0 I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g_ C1 Demolition working for me in any capacity. employees and have.workers' . insurance. 9. El Building addition [No workers� comp. insurance comp. required.] 5. ❑ We are a corporation and its I0.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [No workers' comp. rig?ht of exemption per MGL 12.❑ Roof repairs insurance required.]' c. 152, §1(4),and we have no Insulation employees. [No workers' 13. Other comp. insurance required.] _Any applicant that checks box T 1 must also till out die 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 ivorhers'compensation insitrance for»t)'employees. Below is thepolicy and job site iii/by-mation. Insurance Company Name:Arbella1 Policy#or Self-ins.Lie. : 1 6 `:?` Expiration Date:4/29!2014 �LL pp Job Site Address: �V D l(�Z C 1(L1r` City/State/Zip:��` t%, �h ©I��'4 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains acrd penalties ofperjurfJ that the information provided/above is true and correct. Signature: . Date: 4 1� Phone :(413)-774-360 Official use only. Do not iorite iii this area,to be completed by city or town official City or Town: Permit/License 4 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(�'G�t� Not Applicable 0 Name of License Holder: abxf1 IT 031 t-t�� t License Number (j H"Wool)i S �ee� ceen rely, 1t�tA 1301 a,-lo1a�►� Addres, Expiration Date (413)IN-43`4 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ I Q• GPor�e Cnn� Son! 2nt� I S 664 Company Name Registration Number 0 "rA f\r,az d\ S}reel &Ift\ ce 4i MA 301 7-Z-bll Addcass xp iration Date Telephone Jl-771-360 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)l 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....... 19 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.CM 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 Berson 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 insulting 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 [--J Addition r—] Replacement Windows Alterations) Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[t3] .}Other[l � nStn l on Brief Description of Propo q Work:_Wr UW tlIL W`e� � � er,� AM 3 of Cei(yil0k i l'.XM!] INSV tton ;n c4�M� . 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 stones? f. Method of heating? Fireplaces or Woodstoves Number of each g_ Energy Conservation Compliance. Masscheck Energy Compliance form attached? h_ Type of construction 1. Is construction within 100 ft.of wetlands? Yes No. Is construction within 900 yr. noodplain 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 �1, ! ` 1, ' w,e, as Owner of the subject property hereby authorize SflSgph &fOrdie to act on my behalf,in ali matters relative ro work authorized by this building permit application. Sep uc�e� 1 / y)/ Signature of Owner Date 1, 3os% �2or��, 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.t Print Name Signature of Owne/A nt Date Department use only i FStatus of Permit: of Northampton utlDriveway Permit 3 2QI4 11 ilding Department 12 Main Street Septic Availability Room 100 WaterMell Availability Two Sets of Structural Plans �eoort ampton, MA 01060 �\ phone 413-587-1240 Fax 413-587-1272 Plof/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: ) ��q� ys�� C'I(t�� Map Lot Unit JC�IY / Zone Overlay District 1` Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 361 bmoUk Circle f(�r��c�I Name(Print) Current Mailing Address: (ji��1_�il�}_j See 'tf!►thet� Telephone A Signature 2.2 Authorized Anent: 3oS Q G eoc t 64 l Uy\-'0(4 SN, Gr'e{'jlCq! w Name(P Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only complete by ermit 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) Check Number This Section For Official Use Only Building Permit Number. Date Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2014-0797 APPLICANT/CONTACT PERSON JOSEPH GEORGE ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604 PROPERTY LOCATION 367 BROOKSIDE CIR MAP 29 PARCEL 281 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out 4V C4_ 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 INFO ATION PRESENTED: oe 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 De olitio el y Sign re 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. 367 BROOKSIDE CIR BP-2014-0797 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 29-281 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-2014-0797 Project# JS-2014-001359 Est. Cost: $2236.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JOSEPH GEORGE 99372 Lot Size(sq. ft.): 16639.92 Owner: ZADWORNY ALLEN M&ANNA MARIE Zoning: Applicant: JOSEPH GEORGE AT. 367 BROOKSIDE CIR Applicant Address: Phone: Insurance: 64 HAYWOOD ST (413) 774-3604 WC GREENFIELDMA01301 ISSUED ON.1/13/2014 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 1/13/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner