22-022 (2) i
P ER IT AUTHORIZATION FORM
► RICHARD DIEMAND owner of the property located at:
(t3wner's Name,Printed)
247 Ryan Rd FLORENCE `
(Property Street Andress) (Cityl
t
P
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.
l `F
0
1
owller'S Signature.
Date
FOR CSG OFFICE USE ONLY
Conservations Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor -Date
Vii :
Rev. 12132011
City of Northampton
r Massachusetts
a �£ DEPARTMENT OF BUILDING INSPECTIONS 5,
f 212 Main Street • Municipal Building ; �, �5
`-. Northampton, MA 01060 Fy T-'
Property Address: %� /��•S �"
Contractor /
Name: rq
Address:
City, State: �,�c✓r..,�,�
Phone:
Property Owner
Name:
Address: y 7
City, State: 'C ^-41
(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 signatur
Date
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: aZ Y 2 J --mac.
The debris will be transported by: JI S
The debris will be received by: _
Building permit number:
Name of Permit Applicant _iy� J� t
7
S
Date Signature of Permit Applicant
41 The Commonwealth of Massachusetts
Department of Industrial Accidents
S _4 Office of liz r'e a ations
I Cong ress Street trite MO
Boston'.M- 02114-21017
www.m,ays.,-ov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual):
The Energy Specialists
Address:212 Ames Road
City/State/Zip: Hampden, MA 01036 r,One �:413-566-1058
Are you an employer?Check the appropriate box: Tvpe of project(required):
1. i am a employer with 3 4. ❑ I am a general contractor and I
employees(full and/or par-t-time)." have hired the;ub-contractors ! 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. ?. [] Remodeling
ship and have no employees These sub-contractors have 8. r_� Demolition
working for me in any capacity. employees and have workers
9. [l Buildina addition
[No workers' comp. insurance cotnp. insurance_-
required_] 5. We are a corporation and its 10.0 Electrical repairs or additions
?.❑ !am a homeowner doing aI1 work officers have exercised their 1 l.❑ Plumbin2 repairs or additions
myself [No workers' comp. right of exemption per MCL 12.❑ Roof repairs
insurance required.] c_ 152, §1(4),and we have no
q r 13 X Other insulation
employees. [No workers'
comp. insurance required.]
"Any applicant that checks box='l 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?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.
t am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Associated Employers Group
Policy#or Self-ins. Lic. =:WCC5009547012012 _ — Expiration Date: 10-16-2015
Job Site Address: J sr _ _ City/State/zip: – r.,.rr ✓`'!�}
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. I r2 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment, as well as ci.i!penalties in the form of a STOP WORK ORDER and a Tine
of up to$250.00 a day against the violator. Be advised that a cope of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification,.
I do her the pat enal ' of pe ty that the information provided above is true and correct
Signature: < Date: 9.1J S T
Phone#: 413-566-105
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):
I.Board of Health 2. Building Department 3.Citv/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector,
6.Other
Contact Person: i's,ne#•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /�"/ Not Applicable 11 Name of License Holder: �� e-/< el/ 4*,- tN fA>OC.t 9,5 h-
License Number
sir e/ A o A J_ +� s'� 9
Addre Exp�ira ion Date
Signature Telephone
5. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
—___Telephone
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 rmit.
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 !08.3.5.1.
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 facnily dwelling,,attached or detached structures accessory to such use and/or farm
structures. A person who constructs more than one home in a two-- car 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 per°rnit.
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 assuures responsibililV tar 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 El 1 7
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other ]
Brief Descri of Pryo�pPosed / ,
Work: ��% �r'�b CCU/v�0 Sv' A �'r � C /7'�/c/ �/'ar�y C'!r_�is �'r S /�?'''
Alteration of existing bedroom Yes ,/� No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes V No
Plans Attached Roll -Sheet
6a. If Now 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.
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
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative toYj6rk auttArized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare thMVe statem nts and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and ppe'nnalties of perjury.
Print Nam
Signature of Owner/Agen — —__ Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L. R. L R:_
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking) I
I
#of Parkin=Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW , YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regi try of Deeds?
NO 0 DON'T KNOW Pf YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW e YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 1, ) Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO er
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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exepivation, 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 Management Permit from the DPW is required.
— Department use only
L City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
5 2015 J212 Main Street Sewer/Septic Availability
i` Room 100 Water/Nfell Availabilio ampton, MA 01060 Two Sets of S#ructural Plans
ing&Gas inspe ion ton, eW 3-5 7-1240 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
a y 2 Map _ Lot Unit
Zone Overlay District
�J
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: I
Name(Print) Current Mailing Address:
lhal
Telephone O
Signature
2.2 Authorized Agent: ` / /�- j�
` ` �iC /�✓`l/3 s" /min✓1[1 zt:4
Name Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
/l! Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2+ 3+4+5) tl e c Check Number (Q
This Section For Official Use Only
-- --1 —
Building Permit Number: — IIsssued:_ -.--
Signature:
Building Comm issioner(Inspector of Buildings_ — _ `_ Date
File#BP-2016-0355
APPLICANT/CONTACT PERSON THE ENERGY SPECIALISTS
ADDRESS/PHONE 212 AMES RD HAMPDEN01036(413)566-1058
PROPERTY LOCATION 247 RYAN RD
MAP 22 PARCEL 022 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid r
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 99381
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved 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
m De
Sig re of Building Offfc'ilf 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.
247 RYAN RD BP-2016-0355
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22-022 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-2016-0355
Project# JS-2016-000566
Est.Cost: $2300.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THE ENERGY SPECIALISTS 99381
Lot Size(sq. ft.): 19079.28 Owner: DIEMAND RICHARD A&ANITA
zoning: Applicant: THE ENERGY SPECIALISTS
AT: 247 RYAN RD
Applicant Address: Phone: Insurance:
212 AMES RD (413) 566-1058 WC
HAMPDENMA01036 ISSUED ON.911712015 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 Sisnature:
FeeType: Date Paid: Amount:
Building 9/17/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner