44-111 (3) 982 FLORENCE RD BP-2022-004d
GIS#: COMMONWEALTH OF;MASSACHUSETTS
Map:Block:44- 111 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-2022-0045
Project# JS-2022-000072
Est.Cost: $5160.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: POTENTIAL ENERGY-LLC 106184
Lot Size(sq. ft.): 31493.88 Owner: Erica Shaver
Zoning: , Applicant: POTENTIAL ENERGY LLC
AT: 982 FLORENCE RD
Applicant Address: Phone: Insurance:
1 HARTFORD SQ BOX 2E - (413) 798i-0273 ()
NEW BRITAINCT06052 ISSUED ON:7/13/2021 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION/WEATHERIZATION
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. .
i CS-I'I •
Certificate of Occupancy Signature: � ` i
FeeType: Date Paid: Amount:
Building 7/13/2021 0:00:00 $65.00
•
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
1.
/1
/
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C9049/ FIR ,
The Commonwealth of Massa' useo.:
' : ip4ITY
' •J4,, EZ
..., tau/
Board of Building Regulations an: tania ?4: „,
lir{ Massachusetts State Building Code,781 • ' 4'.'444P/AIGN
ciA, s.Psr. usq
Building Permit Application To Construct,Repair, Renovate Or "..,_.--.•i' :fti0/0A18 Revi ed Niar 2011
One-or Two-Family DwellingThis
SectionFor Official Use Only
Building Permit Number. 6 .
, '. ' ,-'' - • .. • i ii au - ' , - ie
Building Official( Signature
INFORMATION
1.1 Property Address: 1.2 Assessors Map&Pa, el Numbers
4 cl
crs2, Pin Mil c.o '2_81.. 4 -1 i I b
- -
1.1a Is this an accepted street?yes_____ no Map Number Parcel N i.
1.3 Zoning Information: 1.4 Property Dimensions:_anct
Zoning District Prop6sed Use Lot Area(sq ft) Frontge(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards ' Rear Yard
Required Provided Required Provided Required 1 Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 17(/ Private
OctIti:IcteifFyloeosnd,Zon-e? Municipal eon site disposal system 0
0 Zone:
, . SECTION 2: PROPERTY OWNERSHIP
2.1 Owners of Record:
-..1.rem:4- 10 lay 2-
Eri r-c... N.c..ve.c
Name(Print) City,State,ZIP
Sc a- F10 ce."ce- U. eq calab.czwin.
NS'-111'1°2( -" Gedl..SinimaifAddress
Telephone
SE
No.an' Street
CIDESCRIPTION OF PROPOSED AiTORI(2,(check all that apply)
New Construction 0 ExistingT°N3.
Buildin Owner-Occupied E3 Repairs(s) El lt. erafion(s) 0 Addition 0
Demolition 0 Number of Units Other Specify:-,f‘S‘....1A4VO4‘.Accessory Bldg.El , ...,It g.„...._ .111„,_,.Cetkliblao
Brief Description of Proposed Work2: 4!vs c,,c- )1/4:c Sectit48) . . F_a_be24'73....f.Lrip..........646,,,, i
C-74
ita,105e- C5/ 1
Ce:a 10" Clerbig-cle-erc 0-$LA -4‘,114,,,c().7
--b:c.r.41L142: s5R-1-4-6e;ic.C‘aaceX6 C SZN3LP, 14.c1iN- 41% "TtAeay..4 Motner y ,
CONSTRUCTIONSECTION 4: ESTIilATED COSTS
' - Official Use Only
Estimated Costs: , .
Item
(Labor and Materials) . '. ,
Indicate how e is determined:
1. Building Permit Fee:$ . `. F
1.Building $ S.1(s0..11-
2.Electrical $ o Standard'City/Town'Application Fee
3.Plumbing $ iti Total Project; 'cost3(Item 6,)x.inultiPlier
2 Other Fees: $
4.Mechanical (HVAC) $
5.Mechanical (Fire
Suppression)
$ Total All4.
V Check No. e ,
Cash Amount:
6.Total Project Cost: $ S 0 Paid in Full
, ,-1(.0 61 . . , CI Outstanding Balance .
,- . ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
C SP4 - i-t( y-2-1-2451%
Ali C)r.t11C.% Nte j r License Number Expiration Date
Name of CSL Holder
2,44 )A .e.�,S .$- Q,!'�,^ List CSL Type(see below)
t.
No.and Street Type; Description
Unrestricted(Buildings up to 35,000 Cu.ft.)
, Cr- OCC/t () Restricted 1&2 Family Dwelling
City/Town,Sta.*,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
TS(40 G7,-,-tt4 \c e-Ro \e , rS,Comer. I Insulation
Telephone Email ad�f�ss D Demolition
5.2 Registered Home Improvement Contractor(HIC)
PO tG,, iike•
• ��2zsaK t®'2.t(2Date
HIC Registration Number Expirationn Date
HIC Company Name or rim Registrant Name p @�!�y
'
Tt- C .- &ol de 4• 140—V8 Email d i ts. a Cav
No.and Streetess
Nei() 1SCIAA), cc Go s2_ 413 -7 S r
City/Town,State,GIP Telephone
SECTION 6: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 No ❑
SECTION 7a:OWNERAUTHORIZATIONTO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Qbkrxic.A. &in,to
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER1 OR AUTHORIZED AGENT DECLARATION,
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this a plication is true and accurate to the best of my knowledge and understanding.
7 I (zou
Print Owner s or Authorized Agent's Name(Electronic Signature) Date
NOTES
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c.142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) I2% l.(- (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) -LAIC s .,IX Habitable room count (,
Number of fireplaces p Number of bedrooms 3
Number of bathrooms Z Number of half/baths 0
Type of heating system ts)aleetC. Number of decks!porches 3
Type of cooling system 1sIo44.i Enclosed Open 5
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
•
City of Northampton '
o t Xro ♦5 ..a,.C
' MassachusettsLy
' ° 1 DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building J6 bti
•.;,.�,.-„�'-- Northampton, MA 01060 sMjy aro),
CONSTRUCTION DEBRIS AFFIDAVIT •
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: `"Duww,es-4ers 3 �cic� S5GA1. A bil,cT ora _
The debris will be transported by:
Name of Hauler: Pb-kegkle,,1, ei142r5y, 1N4-641.144era.sItzeorit
Signature of Applicant: Date: 7/Rlu3,
DocuSign Envelope ID:147631DF-9E68-4A3A-84FB-1EF8FDD8304C
Permit Authorization
ass save Form
Site ID: 4156222 Customer: ERICA SHAVER
Erica shaver
I, ,owner of the property located at:
(Owner's Name,printed)
982 Florence Rd Northampton, MA 01062
(Property Street Address) ; (City)
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.
DocuSigned by:
Owner's Signature: Ca SLAW'
3B85l31-5DF95470...
Date: 3/15/2021
00000 OOOQOO 00000 00e00OOOO00000000000000000000OOOOOOOO{ O0000000 +OOO
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Vo4Pmkcj £a2 Y. LU' 3-1S-2cZl
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Office Use Only
Rev.102015
DocuSign Envelope ID:147631 DF-9E68-4A3A-84FB-1 EF8FDD8304C -
CLEAResult i CONTRACT
•
CLEAResult
50 Washington Street, Customer Name:ERICA SHAVER
Westborough,MA,01581 Email:DandEShav@yahoo.com
Phone:315-717-7021
Premise Address:982 Florence Rd,Northampton,MA 01062
Mailing Address:982 FLORENCE RD LOT 9,Florence,MA 01062
Project ID:4156222
Date:Jan.30,2021
Applicable Customer Required Actions: Notes:
• Flooring Removal Customer agrees to remove plywood flooring from
around hatch in attic prior to Weatherization upgrades
being completed
Job Description
Contractor will perform or cause to be performed the following work on these"Premises"in a professional manner and in accordance
with the terms of this Contract,including the attached recommendations/work order describing the work in detail(the"Work")which are
incorporated herein by reference.
,Measure,Descr►ption ' Location, „Quantity .,, Unit Total Cost , ` Customer Cost;
Air Sealing at Estimated 62.5 CFM50 Per Hour 4 hr $370.32 $0.00
Exterior Door Weather Stripping(with AS hrs) 3 each $90.21 $0.00
Door Sweep(with AS hrs) 3 each $75.93 $0.00
Hatch-2"Thermal Barrier Polyiso 1 each $46.28 $11.57
Damming 50 each $119.50 $29.87
Propavent 72 each $299.52 $74.88
Garage Ceiling-10"Dense Pack Cellulose 572 SF $1,887.60 $471.90
Attic Floor-9"Open Blow Cellulose 1248 SF $2,271.36 $567.84
Total: $5,160.72
Program Incentive: -$4,004.66
Customer Total: $1,156.06
Payment
Customer agrees to pay Contractor for the Work,the Customer Share of the Contract Price as follows:Payment#1:FSt?fi?T0CI as a
Deposit payable to CLEAResult upon signing the Contract(not to exceed 1/3 of the total retail costs). Mail check&contract to
CLEAResult,50 Washington Street, ,Westborough,MA,01581.Final Payment:P5aTOCEii as the final payment for the Work shall be
payable to the Home Performance Contractor(HPC)or Independent Installation Contractor(IIC) upon satisfactory completion of the
Page 1 of 4
DocuSign Envelope ID:147631 DF-9E68-4A3A-84FB-1 EF8FDD8304C •
Work.Customer understands that he/she will not be required to pay the Utility Incentive Share of the Contract price in the amount of
lX•.$e.Changes to individual line items and/or previous incentives may increase or decrease the size of the Utility Incentive Share.
Dispute Resolution
The IIC and Customer hereby mutually agree in advance that in the event that the IIC has a dispute concerning this Contract,the IIC may submit such
dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and Customer shall be
required to submit to such arbitration as provided in M.G.L.c 142A.
You may cancel this agreement if it has been signed by a party at a place other than an address of the seller,provided you notify the
seller in writing by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the
signing of this agreement. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES.
p OocuSigned by:
3/15/2021
i®iii Mnture • Date Indicate your selected IIC here,if applicable Initial here if you
want the Program
to assign a
Participating
{y 1 Contractor(�V Co cto
V
3/8/2021 KEVIN COTE
•CLEAResult Signature Date Name of CLEAResult Representative
Page 2 of 4
RCS PLANVIEW DIAGRAM
Customer q CI G.( � s1'IG:VP e Home Phone: C )- -
Address: i le • Ft orizi)Gt% (Z,io,. Work Phone: f 3-
1 Town: NJ or .vt ip EV A ' Cell Phone: ( 3►S )- 71''J
Any limitations for access by large truck? No' k Yes If yes,describe: a . l
14ny specific directions or landmarks?; No X. Yes If yes.describe: :
Site ID: •q 15 G.Z2.2 f Energy Specialist: S� G,fh 1i Reviewed by:
r
Q w114111% .Stc4P91 $- pocr S s (`� Doors
1 re
f' p¢11St factG 9ar`a 4.1) : /an,C'a.1�1: 5'11.i' •" .
Dam' 5P . J
s3 Nr. ,o...fv , �i, i i
Q ca.Q r
0. . �er. ,6Cow .MR_: gkc f( : 1Z-Ht �
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1
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i,•
1
I
- C:rZ — - el '.. . .., . ,
c) 0 . . . - - - - :
. .
. ,
,.. ..
For;Office tine C)n1,F _
EuT fs Ladder . Neighbor Proximity ") :" Pocket Doors Insert!Radiators f Fence(s)
-Existing Cond+'tlons' X_Access • „ Ej=.Vents"Note Inside Square • °., R=Roof ,S Soffit G=Gable
RV Ridge Vent CS=Continuous Soffit " COE_.Continuous Drip'Edge T=-Triangle ,
°instal''' 0=i4r7w Ac•cs !,tote in Circle C-Ceiling W Wall S Sheathing; Temp Unless Noted Otherwise
. • A "Venit Note sri friar le 8 Roof S Soffit ' , G=Gaole ' m-12'mushroom For Access
, •n R
1„
2200 10 13t,,
u€: `. BAR A a s 'I" SUP ORTINGW °?€'a,.ss , .,
3 r r �. 'fO1Al.
nar►1 tZ+ Iz 2(� :S o
•
•
_ .
•
_ _
I l
•
1•
I -
5
•
•
•
'Recommended
Ventilation LCaiculatiorl _ ,, _ .•
Recommended -
Ventilation Calculation " .
'' - Ia WORK HOURS'' ;i
��°�,..&..t,.-. .a s: ,r�.. .s <� ,
Air Seaimg Work Hour r)
Calculation -- ' ''uv
Work Hours 4` 6 8 10 • 12 14 16 „ () '•
•
Attic Sq Footage 500 `501 800 801 1100 1101 1400 1401 1700 1701,2000;,.i 200t.-9400 Ever�°,300^,. '
Exceptional AFL.Hours` Primarily Floored Attics -:Chimney or BF=1 Hour Multiple ChimneylBF 2 Hours
Prefab/Modular Hours No aimney•
=4 Hot Ch•imney 6 Hours x
Exceptional KW Hours X<20 feet }r 20 ft<X<40 ft 2 Hours : X> 10:'ft 4 Hours jlii
Rim Joist.,Only Hour's° RJ<150 ft l Hour RJ>ISO ft 2 Hours
BMT Ceding Only Hours Ceiiling Area<2 00,0 sq ft 1 Hour Ceding Area 2.000 sq ff 2 H.ours
'NOTE You MUST be,IUSULATING RJ or Basement Ceiling to specify RJ.or BMT Ceiling ONLY Air Sealing;Hours`"•
"0 >6 'L.00.e InSuiatton Cross Batt lrisulatiori
Multipliers -�-'-
�, 5 Mix Batt&Loose Insulation Truss Construction .
'LdKf�
F'or Gittlt t�l Ls:t Only
,
RTL It' 3 2 CI Project ID: Date: I/3°/Z1 GENERAL INFORMATION
l
Customer: efICA Sh4 re Address: 713Z. Floret%e gJ Style: ranch
City: Nertiu.-iv hn Zip: Primary Phone II: 3 i 5.)1 11 - 962,I Basement:
4 Area: 15-10
Email: Shelli 937 e "i.e.,,,,
Floors: /
„
DIAGRAM Year Built: i/0 6
ail= , II Bedrooms/People: 3 / Lt.
cH,= Siding Type:
HEATING SYSTEM DETAILS
Heating Ty•e: (41,93/itilCt
.7
Fuel: 1""', teC,irre
C 5 Yeisatrr:D buti : B 6 -
Make:
Serial:
ri
Heating Type : 3 Ye.
- - Ilt@
YFueaeri 22::Distribution 2:
Ceill'e-C3
1‘
—
(a-. cePe Make 2:
Model 2: ilL
Serial 2: lik.
HOT ATER HE• R DETAILS
r\
(5 TYPe' 4aAk
Fu : eAeC fel t
Yea :
Size( I): 5)0 ...,......)
— _
COOLING SYSTEM DETAILS
1
Cooling Type: nil tl li
N
•
N./ EIV
/ Year:
\ Wlake:Model:
Serial:
Size(Ton):
NOTES 1-112 y-7,-E) jsr,
0, ,. .'4 ,....
..... ....„4„,,,, WASHER/DRYER DETAILS
v.,)
a 30_ I Type: "off(ito .e / Front Load
1 Agitator: Y /0
Make:
3 144 :; ‘ Model:
p0 - Dryer Fuel: -e... 1,
1 REFRIGERATOR DETAILS
Prima Annual kWh: •
' ,
Make:
El.e.11 El Model:
lividy Annual kWh 2: ,.... ,
For Office Use Onl
11 ,
^ BLIND FRAMING DIMENSIONS 1:XISLING
LOG4TIUN SPEC Typ.p( C}its ENCLOSED SQ FT&RECOMMENDATION DETAILS• ,
1 ATnc ' 0 2. .x_ 6 x I b (0 L ❑ .i" cza/ t . `
Arrrc SLOPE'i ❑ x• x 0 .
KNEE WALL ❑
x x0
KNEEWALL FLOOR ❑ x x , 0
TRANSITION x x
EXTERIOR WALL. - Q x x /-t ❑
GARAGE CEILING a 2.- x I x • �(o G�.I/h (o%) ❑ I6'rl�/ G�/(
❑ x x J 0
❑ x x ❑
Single Pane Window It Attic Access Type AAf01 Qty I Attic Access Type QtV'_
cE
ATTIC VENTILATION ' Attic Sq Footage 1'j; 300= ,t Existing Total �'� `r1
Bath Fan# Z, BF(s)Vented? Y&N 'Propavents Needed?&/ N ont.Soffit g p.12/ t Dripedge .O6/ft
12 x 12 Gable, 0.50 2 x 18 Gable Z, . 8"Roof Vent • 0.35 12"Roof Vent 1.00 4 x 16 Soffit. 0.22 6 x16 Soffit 0.33
1S x 24 Gable 1.50 Triangle 0.50 I Ridge ItQ .13.1 /ft 12"Turbine 4.00 8 x 16 Soffit 0.44 2"Popvent 0:01
1,
COMBUSTION SAFETY
" Exterior Temper.ture "F Heating System Vent Type: Atmospheric Powervent Sealed PVC SS Vent
(Exterior Temp )-2.75= pa', Hot Water Vent Type: Atmospheric Powervent Sealed PVC 5S Vent
CAZBaseline pressure •TL outside pa. ,
Ambient CO: CAZ ppm
CAZ worst case pressure WR .outside pa. -
} Ambient CO:Living Space ppm
Total change in presusre:
s
$ DHW System .•rst Case 1 ;V.;=a A .-.
CO of undiluted flue gas: / ..m
Draft: pa. Pass Spillage: Y /N - V
Draft with Heating System Firing: pa.
Heating System 1 Worst Case .`,:. r
CO of undiluted flue gas: / /f_/_ ppm r•\!, _ _ _ .
, I Draft: pa; Pass Spillage: Y /N
14
li I Heating System 2 Worst Case ; s
' CO of undiluted flue gas: / / / ppm
Draft: , pa. Pass Spillage: Y /N
Dryer Qty: Doors; Notes(open/closed):
Bath Fan(s) . Qty: Interior Qty, Gas Ove 0:, . ppm Ambient CO: V ppm ' "
Kitchen Fan(s) . , Qty: Basement ` Qty: Gas Dryer CO. ppm Ambient CO: ppm
Air.Handler Qty: CAZ , Qty: -
'ROADBLOCKS CUSTOMER REQUIRED ACTIONS 1
/ ,
I CO Detector: lJ N .{
1 1 , . Knob&Tube: Y /C
Asbestos: Y/ N
Structural: , Y /0
Back Plaster Walls: Y01
• -
i Moisture Concerns: Y
,
•
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
p,="}}l-�l Office gf Investigations
NOR • - 600 Washington Street
•
Boston,MA 02111
www.mass gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIumbers
Applicant Information _ Please Print Legibly,
Name(Business/Organization/Individual): > , a.•k.
Address:_iAlko c&•' Sic,cc _ _Sik_14-e.. tier 'iDo c SS Aie4.3'3c:, (\., Ci`o c
City/State/Zip:Ne.ej Ze;-1-a,n ,CT o(v Phone.#: y l3-- 7qt s0a.2
Are you an employer?Check the appropriate box: -Type I of project(required):
1. I am a employer with 1 4. 0 I am a general contractor and I 6
employees(full and/or part-time).* have hired the sub-contractors CI New construction
2.0 I am a sole proprietor or partner- listed on the:attached sheet. 7. 0 Remodeling
•
ship and have1to employees These sub-contractors have g, Q Demolition
working for me in any capacity. employees and have workers' g Building addition
[No workers'comp.insurance comp.instuance. -
required.] • 5. 0 We are a corporation and its 10.ti-Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
' myself,[No workers'comp_ right of exemption per MGL
mp_ 12. 00f repairs
insurance required.]t c.152,§I(4),and we have no
employees.[No workers' 13. Other ins►llation
comp.insurance required.]
*Any applicant that checks box#l must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tCemtractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: J\i;S t,e, c,:ka rant p Sec,r:(-
•
Policy#or Self-ins.Lic.#: LA q 6R-3„2$a Expiration Date: IR I0.4 11.c \
Job Site Address: 982 Florence Rd. City/state/zip: Northampton,-MA01.062-
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 tip 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 3250.00 a day against the violator. Be advised that a copy-of this statement may be forwarded to the Office of
Investig lions of the DIA for insurance coverage verification.
I do hereby certify an thep r 'es of perjury that the information provided above is trueand correct
Signature: Date: 7/9/2021
as
phon •: `4 1,�---1 , —a ^a -
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): . •
•1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other •
.. •
Contact Person: Phone.#:
CITY OF NORTHAMPTON
SETBACK PLAN
MAP: LOT:
LOT SIZE: ( 1Z.AClft
REAR LOT DIMENSION:
REAR YARD 2 0
SIDE YARD I C,..J SIDE YARD {(
Lb
FRONT SETBACK
FRONTAGE z9