42-053 (3) City of Northampton
t
fr �lj Massachusetts n
DEPAROWNT OF BUXLDING INSPECTIONS ` J
r.ti= -;�" 212 Main Street • Municipal Building
_ Northampton, MA 01060 :`;....
Property Address:
Contractor
Name: 3-4$ep1 creont Geot-le tN.dt
l
Address: bt ';jrn��wool� STr�23
City, State: � �� � �� �� '01301
Phone: (tD-17'1- 3�04
Property Owner �UV�)�f f? M
Name:
Address:
vN J�- tern O���� R�C
City, State: _ t ;
l jo&q� &eor-I�p (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
g�®ta+rror�p,6
mass save CONTRAC PARTICIPATING
PERMIT AUTHORIZATION FORM
I, JAMES P RYAN ,owner of the property located at:
(Owner's Name,printed)
563 Westhampton Rd NORTHAMPTON
(Property Street Address) (City)
i
hereby authorize the Mass Save Horne 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.
x
err''ss Signature
Date
i
{
FOR CSG OFFICE USE ONLY
Conservations Services Group has assigned the following Mass Save Horne Energy Services
Participating Contractor to the above referenced project:
f'),� CA^J s��, ��, _ a -a10
Participating Contractor Date
f
C]f`0
For Office Use Only
Rev. 12132011
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Print Form
T Ize Cotrzrrzorzwealtli of I fassachz£seas
Y De_par•t;;zefzt of b2 izrs&ial�ccidetzts
-- —_—. - fjace of1;zvesiijcztiolzs
otzp ass fit;eat,3 zcite!00
OSi0i2, �_1 0?771_2017
7'Vo y2rs' COl�r'}eusai iop-n-sa space_��3 daviit: Builders/Co.isle ors/Eie&LriciaLs/Pl'c., er S
A N;1-1 ca77i Ingo_- aEi0R ?lease Pr iiit LeGibli
N. (Business/Organization;Individual):J-P_ George and Son, inc- /Joseph George
<,_ddre5S6^ Haywood Street
C:M./StatelZip.GreenfieldiMA/01301 ;?1_Zone=:(L13)-774-3604
j ?. e y an an employer?Check the appropriate ba-1- type of project(required):
1 1.I I am a employer with fit- –`-- ❑ I am a general contractor and I �ipr construction
lemployees(null and/or part-time).= have hired the sub-contractors 6
2-❑ I ara a sole proprietor or partner- listed on the attached sheet. 7_ Remodeling
ship and have no employees These sub-cori ractors have S. Demolition
-%vorlcins Pot me in am capacity- employees and have workers a
[No 1,forkers- comp. insurance
comp_msutance_- 9_ ❑ Building addition
required] 5. F-f ),1"e are a corporation and its 10-❑Electrical repairs or additions
U i am a homeowner doing all 1yorh officers have exercised their 11_❑ Plumbina repairs or additions
tr:YSeli. o workers' corn right of e_amption per yMGL ?
P- I_❑ Roos repairs
insurance tequiree�_] C_ 152, 5l(4)_anti we have no
employees. lido workers 1321 Otherinsulation
comp_insurance required.]
'`:Any applicant that checks box=l must also till our dtc saction below showing their workcrs'compensation policy information-
Homcowners who submit this affidavit indicatine they are doin__ail tt'oric and then hire outside contractors mustsubmit a new affidavit indicarinz such.
-Conlractars that checl•this box must attached an additionni sheet shotcin,ilia name Of tltc 51lb-COntraCtorS and 5inte tClicdier or nol those eriiities have
employe s- if the sub-contractors hax•e emploi,ees,the} must proride their u•ork.-r'comp-pofie} number-
1 anz an ez;zpinver-that is providing workers'compensation insurance fat'1721)employees_ Below is the policlt and job site
!i j(1r1TZQt10;t.
Insurance Company Name:Arbella
c = �[ in __�)` ' > ?1291201 b
Policy�or Sahin.._Lic.:': Expiration Date:
job Site Address: 50 We1�I�(A ty)00 CitviState/Gip: Phr?'w4tvtn t�N 6
Aztttcl; a copy of the worhers� compensation policy declaration page(showing the policy number and expiration date)_
railure to secure coverage as required under Section 2SA oFMGL c. 152 can lead to the imposition or criminal penalties o;a
nne up to$1;500.00 and/or one-year imprisonmen4 as Well as civil penalises 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 or
InvestiQarions of the D1A ;or insurance cavern ae veri tcaior,-
I rlo hereby certify tattler the pains andpenalries ofperjrrrt-that ilia inforinarion provided above is trite and correct,
SiE nature:
Date:
Pi cne-:(4`13)-774-36 4
h
iI of iclal use o;iljt_ Do nor n7i7£e by this area,to be conzplered Dv eify Or town offrci zL
ci t v or:018111: Permit/License=
:sluing Authorir;.(circle one)_
;oai d of H ealth 2. Building Department 3_CitvlTown Clerk A.iiectricai inspector 5_PIumbing inspector
I �.metre:-
ji ;,,utauf ersop: NI one rr:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Superpvii�sor: Not Applicable ❑
Name of License Holder: �oSeQ� at C531 g 931 a
License Number
bpi 49►ywooM S�tfeN Veen T`E�d�,
Addre Expiration Date
- (�13)771-3 ,mow
Signature Telephone
9.Registered Home improvement Contractor: Not Applicable ❑t
Company Name v Registration Number
CIA i(A w51;3 d� � &fe-64A W, NIA 01301 7-)S = X)17
Addre 1
l Expiration Date
Telephone�4 -775-3604
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....... 2 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 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 Cbapter 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 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 Alterations) ❑ Roofing ❑
Or Doors M
Accessory Bldg_ ❑ Demolition ❑ New Signs [O] Decks [0 Siding[Q] Other(to
Insvi laiton
Brief Description of Proposed Work: !\' S NJ (net t r �(1�� n ( 1 1 �g(rGid�il�� / C�f� U of t� ��u)r1ti� 1 1
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
a. 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
���'(i I�
(, � y CW'� ,as Owner of the subject
property
hereby authorize 3asf 6 ts?orIr
to act on my behalf,in all matters relative Fo work authorized by this building permit application.
Signature of Owner Date
�OS �Zpbrlt as Owner/Authorized
Agent hereby declare t'— hat 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.
JOSP-0,
Print Name
N�Tv�.
Signature of Owner/Agent U I Date
Department use only
i of Nori:harnpton status of Permit:
Dng Department Curb CutlDriveway Permit
SEP 3 U L� � 1 Main Street SewerlSeptic Availability
oom 100
Water/Well Availability
toil, MA 01060 Two sets of Structural Plans
>fc'ptumair+9 p1
Horth�m -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
This section to be completed by office
1.1 PropertYAddress: J map Lot Unit
! f j
nA A Zone Overlay District
�cl Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: 4
Name(Print) �j Current Mailing Address:
S-ee, Telephone
Signature
2.2 Authorized Agent:
3-OS eD &e-QTAt
Name(Print Current Mailing Address:
($3)-77`t -36a
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building �J 4 2, (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 c(1 +2+3+4+5) 0 Check Number
This Saction For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissionertinspector of Buildings
Date
File#BP-2016-0438
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD01301 (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 WALL 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:
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
De 0 ' lay
Sig a i di ffici 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-2016-0438
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42-053 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Build'Inq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0438
Project# JS-2016-000723
Est. Cost: $5007.00
Fee:$65.00 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.913012015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL WALL 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 9/30/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner