32A-183 (17) 73 BRIDGE ST#17 BP-2019-1225
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mep:Block:32A- 183 CITY OF NORTHAMPTON
Lot, -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pennit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category INSULATION BUILDING PERMIT
Permit# BP-2019-1225
Project# JS-2019-001982
Est.Cost:83429.00
Fee:$65,00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sa.ft.): Owner: GERSHENSON OLGA C/O JASON W MORALEE
Zoning:URC(IOOU Applicant: JOSEPH GEORGE
AT. 73 BRIDGE ST#17
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON.*5=019 0:00:00
TO PERFORM THE FOLLOWING WORK.AI R SEAL ATTIC AND BASEMENT, ADD 12" OF
CELLULOSE TO EXISTING INSULATION IN ATTIC
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: 011, 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 Occuoancv Signature:
FeeTvoe: Date Paid: Amount:
Building 5/2/20190:00:00 $65.00
212 Main Street,Phone(413)587.1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of NoICEIVIE DepBuild2 NSULATION
212 Ma1 _RooNorthampto �,�phone413-587-124ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY //J. `/- Iq - I Z�5
SECTION I -SITE INFORMATION INSULATION PERMIT
7.1 Progeny Address:
This section to be�m by a ice
73 9TiAle tri, qpl, h Map 71.14 Lot Una
110fh,mpt�)A, pry Zone Overlay District
01060 Elm St District CS Dleblet
SECTION 2-PROPERTY OWNERSHIPIAUTHORUE AGENT
2.1 Owner of Record:
1)(1 GerJVAs0, 13 PfAe S4• Afi, 11
Nam(Pmrt) (� yr.-, Current MaAingAdd s: a6)-1W7-o99f
W f1l1_`I�tA Telephone
Signature
2.2 Authorized Agent
J9kL Geo 64 N1 weol GreenfK�, AIA, 0)1d
Name(Prht) - Current Mailing AddmsB:
(411) - 714 -3604
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicimt
1. Building 3, u (a)Building Permit Fee
2. Sec Tical I W (b)Estimated Total Cost of
Construction from e
3. Plumbing Building Permit Fee I
4. Mechanical (
(HVAC) (_Q5,Oo
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Num Oats
Issued:
Signature: 5- - 20q
Building Commheimerimspector of Bulkfings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervis11or. Not Applicable 13
Nsme of License Holder: 'T.Ok
Lkerme Number
64
HwV\NTA sk, Gfe?4 p olb) MVal
Address FxpYatlon Dale
Nli 74 .3(0
Signature UTelephone
S.Realstered Home Improvement Contractor.. Nat AppliosA6r
s,P. W!$ 04 50Ar Ill.
EC21119111113XHIM Registration Number
4 64,,,,00l St, Gran fIN, MA, OPO) 71a� n
Address ._. _ _ _ _ Expiration Dale/
.�� ' T�phppa 413)"77Y'3604
SECTION 6-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.0.162,5 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 permIL
Signed Affidavit Attached Yes....... ❑ No...... 19
Brief Description of Proposed Work NOTE: INSULATION ONLY
{lir Seal hic wA 6oam&h )
Add 'r of cellubR 10 eJddj Inblk4l0o i4 4)jc
� t . as Owner/Authomed
Agent hereby declare that the statements and information on the foregoing application are We and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
"rowo,
Print Name
Signature of OvmerlAgent Dale
L 0I1f4 uy jj f SOA .as Owner of the subject
Property
hereby authorize J&c1b Georlt
to act on my behalf,in all matters relative to work authorized by this building permtt eppficetioM
See koxyd 41aH/I"
Signature of Owner Date
City of Northampton
Massachusetts
c
a
IffiPARTtffiiT OF aQIZDING InWSCTIONa
212 Iain Strut • M cipsl suild g �
aorthamptw, Na 01060 ♦'
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("BIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair,modernization, conversion,
improvement,removal, demolition,or construction of an addition to any pre-existing ownercccupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"he
done by registered contractors.
Note:Lf the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of workIT1s� 11 Est.Cost: 3,4ag-(is
Address of Work_ 13 D43Q JTZ . 11
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Sob under$1,000.00
_Owner obtaining own permit (explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT RAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBHdTES FOR ALL WORK
PERFORMED UNDER TRE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of petjury:
I hereby apply for a building permit as the agent of the owner:
y z9 Ih P. Geo e MJ 30 n, Int. "30e4(y-(--` V )Acy6
Date Contractor Name Tq, HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property
Date Owner Name and Signature
i
City of Northampton
�•+ Massachusetts
`� DEPAATNENT OF BDILDING INSPECTIONS .y�^
212 M" Guest • Mu,itipal Building
a �✓
Nnxthampton, t 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 73 erijV St, At}- 11
Contractor
Name: �'P� CCoT4OVA Son, ZA(.
Address:
City, State: GrPPn(•lt�A1 MA
Phone: (N) - 714 -3o4
Property Owner
Name: C)lItA GC4501
Address: 73 00je St, Ag}, Il
City, State: N0rAM0(%n, IAA 100 0
I, dote Pl� (1PAr�C (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
City of Northampton
Massachusetts
i
DEPARTNENT OF BULDING INSPECTIONS Pt
�\ 212 win S' ..t •roniciPel Building � I^a
Northampton, to 01060
Debris 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 Peri[shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
]3 Bfiht ". ApF h
(Please print house numtrer and street name)
Is to bedisposedof at �] y�,
Bim 601``0 W4wf 431 4ftne Ave Vr 61kro JT'
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Per it Ap'plicarit or Vwner Date
If,for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts Print Fonn
Department of Industrial Accidents
Office of Investigations
IV I Congress Street,Suite 100
Boston, MA 02114-2017
www.massgov/dia
Workers' Compensation Insurance Affidavit:Buildens/Contractora/EleMdcians/Plumberg
Applicant Information P'lemepPrint
/L�eeidli ,
Name(Busineu/(hgmiratiuMmlividu'a—l):- ` IlY\W a... Yy I1a(V�-•��r"""C� LT-"' ((—
Address:— lFK-C.LJ Jam•
City/State/Zip: uk�\ S OA Phone#: 6//3)
Are you an employer?Check/he appropriate box: Type of project(required):
1.® 1 am a employer with -5 4. ❑ I con a general contractor and 1
employees((i(1 and/or part-time).• have hired the sub-contractors 6. ❑New construction
2.❑ I an a sole proprietor or partner. listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' y ❑Building addition
[No workers' comp.insurance courp.lmurm'ce.'
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12❑ Roof repairs
insurance required.]' c. 152.§I(4),and we have rm
cmployca.[No workers 13.9 Other i NSV�Q�OIA
comp. insurance required.]
*Any applkam than check.has 41 noun.I.Ml not am amnion below showing their workers'romp ssnum paltry informnim
I Humeu..... ho mhmitthis alndavit indicating thry arc doing all work and than hire waide conuecoora men submit a new amdovit imllcering such.
lComrenon thm cheek this box mus utn land ao additional M t shmaing 0a name of the suh-mnaamas.mi stam wheoherar cot ohtxe monies have
employacs. If the sub-cnnae[lors have c�luyaa,they moat provide their woken'comp.pnliry number.
1 am an employer that is pmriding wor1kem'compe,rsadoo insurance Jar my employees. Below is the policy and job site
Insurance b N( 1I�46,
Insurance Company Name: - UUP J^[)I 4
Policy#or Self-ins.�Liic.#: _ q`1 - — y 16 I-7 Expiration Date: fJ
Job Site Address: IJ Wit 51• Np. 11 Ciry/State/Zip: 9 Iron AN1 �IDba
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure museum coverage as required under Sermon 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a into
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 here b coni under the paires and m ter o er'ur that the info in provided above is true and correct.
Sanamre' _ Date
VM I)uj
phone
Official use only. Do not write in this area,to be completed by c0V or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
b.Other
Contact Person: Phone#:
Comnaunwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constructiop.SoWwgr specialty
CssL4)99372 Eypires:0211`112021
JOSEN ---PGiROE
e/HAN
GREEN NII�,018
�OIcc,1.1OXJ
Commissioner
HOME
IMPRO MENT,CONT a C1OR al
HOMEIMPnly
TYPEMEMrstan CTOR• Wore theiloation iralalid for ache. Iffodual usaetur
TYPE: ro E,rotr before of Consumer
and Bu iness to:
Renlabetle^ 07pimllg9 10 Po of Censumsr Atlehs and Business Regulation
-'i56SB6 0]24@019 10 Perk PMire 5170
tGELGE 850N INC Boston,MAA U11 M118
` JOSEPH GEORGE
84HAWVOOD ST ( g
GREENFIELD.MA 01301 _ �' Kai valid li NSIQnatunBfurB
Permit Authorization
mass saves Form
Sr,ngsltiuM enenlY elf 1�2y
Site ID: 3728106 Customer: OLGA GERSHENSON
OLgaa Gersk.eo-wv,
owner of the property located at:
(O nees Name,pnMed)
73 Bridge St APT 17 Northampton, MA 01060
(Property Street Mdom) (CM)
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.
OLga Gers 4zw
Owner's Signature:
3/227/19
Date:
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
J George cNd SDA , IV 4/rN
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
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