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Florence. MA 01061 office and fax 413-529-7140
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ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR
ONE-AND TWO-FAMILY DETACHED RESIDENTIAL CONSTRUCTION (780 CMR 61.00)
Applicant Name: C%im tQ � Site Address:
print
Town:
Applicant Phone: 47-H 61
Applicant Signature: Date of Application: 13 bud
NEW CONSTRUCTION: choose ONE of the following two options)
780 CMR TABLE 6107.1
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR
NEW ONE,-AND TWO-FAMILY BUILDINGS
MAXIMUM MINIMUM
Ceilinz or Slab
IIOption 1: Basement
Fenestration exposed Wall Floor Perimeter
U-factor floo R-Value rs R-Value R-Value Wall R-Value AFLIE HSPF SEER
R-Value and Depth
National Appliance Energy
3 5 R-3 8 R-19 R-19 R-10 R-10, Conservation Act(NAECA)of
4 ft. 1987 as amended,minimums or
eater as applicable
Note: This form is not required if you choose either of the two versions of REScheck as listed below.
❑ Option 2: REScheck Version 4.1.2 or later variant software analysis must be completed
780 CMR 6107.3.2
REScheck—Web which can be accessed at http://www.enerLyvcodes.gov/rescheck/
ADDITIONS OR ALTERATIONS TO EXISTING BUILDINGS OVER'5 YEARS OLD*
*Buildings under 5 years old must use option#1 cr#2 in New Construction section above.
Complete the following formula to determine the% of glazing:
(a) Gross Wall&Ceiling Area equals Formula: (100 x b-a)
J SF
100 x %of glazing
(b) Glazing area equals _SF b a
If glazing is:5 40%use the chart below. If glazing is>40 % proceed to"SUNROOM"section
780 CMR TABLE 6101.3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING
LOW-RISE RESIDENTIAL BUILDINGS
MAXIMUM MINIMUM
Ceiling and Slab Perimeter
Fenestration Wall Floor Basement Wall
U-factor Exposed floors R-Value R-value R-Value R-Value
R-Value and Depth
.39 R-37 a R-13 R-19 R-10 R-10, 4 feet
a R-30 ceiling insulation may be used in place c f R-37 if the insulation achieves the full R-value over the entire ceiling
area(i.e.not compressed over exterior wails,and including any access openings)-
❑ SUNROOM—An addition or alteration to an existing building/dwelling unit where the total
glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the
addition.
Note: Owner to fill out Consumer Information Form (found in Appendix 120.P)
HOLE OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation/footings (before backfill).
sonotube holes (before pour) a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancv
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
The Commonweal i of,Vzssacnusetz
B. a,rr:nent of I.,iatzzsrria 1 4ccidenrs
Ofjtce oflnvesr.7 ar:,ns
660 ff"ashington Street
Boston, 414 02111
www.mass.g ov/dia
Ve'orkers Compensation Insurance Affidavit: Builders/Contractors,,EIectricians,Tlun:bers
Ar,alicant Information Please Print Legibly
N a77e (Business/OrganLarionilidividual'i:_
"4Crt-ss:
City;/Start/Zip: Phone
Are you an employer'Check the appropriate box: Type of project(required): I
4. I a-n a general contractor and I
1.[] I am a e plover with 6. [f New construction
ployees (fall and/or part-tune).* have hired the sub-contractors
2.EY I am a sole proprietor or partner- listed on the attached sheet. . V/Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9 [Building addition
(N'o workers' comp. insurance comp. insurance.+
required.] D. ❑ We are a corporation and its 10.7 Electrical repairs or additions
3.❑ I am a homeowner doing all work officer have exercised their 11.0 Plumbing repairs or additions
myself. ['N-o workers' come. right of exemption per MGL 12.7 Roof repairs
insurance required.]' c. 1f2, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
"Any applicant that checks box"r must also fill out the section below showing their worker'compensarion policy information_
Homeowners who submit this affidavit indicating they are doing ail work and then hire outside contractor must submit a new affidavit indicating such.
}Contractors that check this box must attached an additional sneer showing the name of the sub-contractors and stare whether or not those entities'rave
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 thepolicy and job site
inform ation.
1nsuranct- Company-Name:
Policy-or Sew ins.Lic. T: Expiration Date:
Job Site Address: City/State/Zip:
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 2fA ofMGL c. 152 can lead to the imposirion 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
o:'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 DLz for insurance coverage verification.
I do hereby certiift tender thepains and penallrices ofperjury that the information provided above is true and correct
Signature: ( �f -� /� Date: /I�CL�1r• C A
Phone
i
Official use onlh. Do riot write in this area, to be completed by city or town ojjiciaL
City or Town: Permit:License f
Issuing Authority (circle one):
1.Board of Health 2.Building Department 5. CiryiTown Clerk 4.Electrical Inspector . Plumbing Inspector
1 6. Other
i
Conroe*Person: Phone
rr
SECTION 8-CONSTRUCTION SERVICES
8.1 _tee.^.sed Construction Suner-rsor Not Apppllicable ❑
Name of License Heider: 1 �'`9 [ !✓��• C--s. Ate'
License Number
address Expiration Date
Signature Telephone
I
is Reuistered Horne Not Applicable ❑
:omoanv Name Registration Number
�-,��►�.{ ��� I-�,rrac� �u�'L�c�c� d1��7 X31 r.sl�c�
.ddress Expiration Date
Telephone
ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,
Porkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
oned Affidavit Attached Yes....... ❑ No...... ❑
bme't3 e - gea fan
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.CINIR 730. Sixth Edition Section 103.3.5.1.
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-vear 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 buildinz 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 1533 (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 undersi_ned"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
> a►
ISECTION 5-DESCRIPTION OP PROPOSED+NORK(check all aoolicable�
New House Addition , Replacement Windows Alteration(s) Roofing
I
Or Doors CJ
iAccessary Bldg. Demolition I New Signs Decks Siding(C? Other[»]
Brief Desonptipn pf Proposed
�'Jsrk: �t�.i�d /�1X _Ir'G'�✓1 �-���" �11'IG� G{�[Qi�-►� �Z ��tt�f� �i�,
Alteration cf existing bedroom ✓^ Yes No Adding new bedroom ✓ Yes No
Attached Narrative Renovating unfinished basement Yes _JNo
Plans At ached Roll -Sheet
6a.'if New house and or ada tioa'tb exi:at rlA housing:corr�r Teta ttie^fot[owina:
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? ✓ ,`11 -7 �/
d. Proposed Square footage of new construction 2 y Dimensions / �' C .Z a✓ics)
e. Number of stories?
f. Method of heating? 4:tyuil +Cl Fireplaces or Woodstoves Number of each
c. 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. floodp lain Yes_LZNo
j. Depth Of basement or cellar floor below finishes'grade
k. WIII buiidinc conform to the Building and Zpninc regulations? ✓ Yes No.
I. Septic Tank City Sewer ✓ Private well City water Supply
SECTION 7a--OWNER AUTHORIZATION-TO BE COMPLETED 1! kEN
OWNERS AGENT-0 EZ'CONTRACTOR APPLIES Etlf iBCfI fNC P1= IVlIT
as Owner of the subject
property
herby authorize
to ac n my behalf, in ail reIatjve to work auti&zed by this building permit application.
SignatLke of O ner Date
A)� lY`�1 y- <, /� S as Owner/ uthcrzed
en- ereby deciare sat the Slate eats and info atlOn Oregoing apciicatl are tree and accurate, t0 the best Ci my�;OWIEdgE
belief.
Signed under the pains and penalties of perjury.
Print Blame
i _
I2- AA&,, _& Do i
ate
cat_re er wne�'/ceni -'
n
I
!Section 4. ZONING I All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
j ExisnnQ Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage _..-_..._""_� ... . _.__._._.._ _�_._._�✓'f t'►'° ,.. "�_,... _".._.,......
Setbacks Front
3 _...
Side L:....-t0— R L AL R:_
Rear
Building Height
Bldg. Square Footage % _..._.,..
Open Space Footage °o
(Lot area minus bldg&paved
nazidne)
#of Parkine Spaces 3--rr - -
Fill:
(volume&Location) ---
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:`
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page!: _ _ and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued w N
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 0-
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,excayation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Managemenf-Permritfrom the DPW is required.
• "'"� Department use only'
City of Northampton Status'of Perm t:
Building Department Curb CutfDrivewayPerrriit
212 Main Street SewerfSepticAvaitability
Room '100 WaterWeliAvailability -
Northampton, M1. 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
Z Z. )avi Map Lot Unit
F(0 Overlay District
Elrri St.District CS District
SECTION 2-PRO.PERTYOWNER'SHIPfAUTHORIZED AGENT
2.1 Owner of Record:
P� a\r\I\ C' ;r\ k . Ai I-ru, �� 22 �•�� �-� �1 of oc,?z
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
I l 1za.b-M-\ L60 k- And(- b _ ,1111 j Sl er,;(rc( e vlr tl a&,oiG' 7
Name(Print) Current Mailing Address:
Signs ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost(Dollars)to be Official Use-Only
completed by permit aooiicant
1. Building ,. t:' (a)Building;Permit.'Fee
5
2. Electrical r.� (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) ,� � �
5. Fire Protection 1
6. Total= (1 +2+3+4+5) S j Cl L Check Number CJ
This Section For Official Use Only
- -
Building Permit Number. Date
Issued:
Signature:
Building,Commissioner/Inspeto or ui sings Date
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File#BP-2009-0741
APPLICANT/CONTACT PERSON ELIZABETH HOOK
ADDRESS/PHONE 51 RIDGEWOOD TERR EASTHAMPTON (413) 529-2189
PROPERTY LOCATION 922 RYAN RD
MAP 35 PARCEL 060 001 ZONE SR(100)//VISP II
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: CONSTRUCT 2ND FLR DORMER(BATHROOM)&2 SOTRY 7 X 14 ADDITION
(EXPAND KITCH/ADD BEDRM)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 079641
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
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.
r r
X922 RYAN BP-2009-0741
GIs#: COMMONWEALTH OF MASSACHUSETTS
ibl�p:l3 ock:35.ot;o " CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category BUILDING PERMIT
Permit# BP-2009-0741
Project# JS-2009-001100
Est. Cost: $55000.00
Fee: $330.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ELIZABETH HOOK 079641
Lot Size(sq. ft.): 50616.72 Owner: ADELMAN KAREN D&MARY CURTIN
Zoning: SR(100)//WSP 11 Applicant: ELIZABETH HOOK
AT. 922 RYAN RD
Applicant Address: Phone: Insurance:
51 RIDGEWOOD TERR (413) 529-2189
EASTHAMPTONMA01027 ISSUED 0N:313012009 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2ND FLR DORMER (BATHROOM)
& 2 SOTRY 7 X 14 ADDITION (EXPAND KITCH/ADD BEDRM)
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 3/30/2009 0:00:00 $330.003083
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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;r'' - A n. �s^� sit�'",��" :I� ` s^ ��` �t s�" ����..' # ,i , �1�a� �� .-�'' �� r��• r k <. :k,s. ." � � ; f�, �}(
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Fee. 33Q00 P " SSIUNItS E�,$Y'ta►X 1�T T't�
Gonsc Glass: Cn, i`r ctor« License.
Use Graup: ELIZABETH HOOK 079641
Hot Siae(sa it 1 '`
ion-- R1b0�l�51a' ,A 11
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At 922
Phone: Xnsuruncec
413 29- 1
1 E
EASTHAMPT3NMA1127 ° rtr SOM O:t1t1f1t1
To PERF4 �F�LL(�W W W+��:COWTRUCT 2ND FLF DORMER (BATHROOM)
& 2 STORY 7X '14 A6001TION (EXOM-D KIT-DM/ADD BEDRM)
T S E tE
Inspector of mi tuhing Inspector of Wiring Building Inspector
Underground: Service: Meter:
p Footings:
Rough �-� / , Rouge House# F oundatioTC
/ -° l f ,�- = Driveway Final:
Rough Frame, C
� X15
Gas: Fire Department Fireplace/Chimney:
ti
lnsuaon:6 ., �, t5 9
Rough: �:, I � f
Final:' •1�� Smoke: Final: alC Obit'Og tow's r "
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. �
Cel'tifEGBte f QCLU i1 cvexl §Iggature:
FeeType: . Date Pala:,_E4;WMAI:
Building 3/30!2009 0:00:00 $330.003083
212 Main Street,Phone(413)587.1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo