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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: Ara Site f /di Site Address: 51 u/,` / Polo g ,f J
pr1/d / /Ay /A fir .�/yrivelnCh Town: /10647/A /6"/
Applicant Phone: 1/, -- y_- 7 SW
a
Applicant Signature: 1 /__ i Date of Application: a/ -/ v
,/
NEW CONSTRUCTION: (ch ose ONE of the following two options)
780 CMR TABLE 6107.1
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA FOR
NEW ONE- AND TWO - FAMILY BUILDINGS
MAXIMUM MINIMUM
Ceiling or Slab
Fi Option 1: Basement
p Fenestration exposed Wall Floor Perimeter
U- factor floors R -Value R -Value Wall R -Value AFUE HSPF SEER
R -Value R -Value and Depth
National Appliance Energy
R -10 Conservation Act (NAECA) of
.35 R-38 R -19 R -19 R -10 4 f 1987 as amended, minimums or
greater as applicable
Note: This form is not required if you choose either of the two versions of REScheck as listed below.
n 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.energycodes.gov /rescheck/
ADDITIONS OR ALTERATIONS TO EXISTING BUILDINGS OVER 5 YEARS OLD*
*Buildings under 5 years old must use option #1 or #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)
2,.'- SF
100 x 6000 - 8 % of glazing
(b) Glazing area equals 6 0 SF b a
—
Tf glazing is < 40% use the chart below. If crla7,n" iq > 4 0 /,. procPed to ` S LJNR )01 d
r�
780 CMR TABLE 6101.3
PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING
LOW-RISE RESIDENTIAL BUILDINGS
[E( MAXIMUM MINIMUM
Fenestration Ceiling and Wall / 9 ;: , I o Basem n Wall Slab Perimeter
t R
Exposed floot� F � �q n , / Value
C,- faetar - 'aloe , 2 Y l y'� / V
33 R-Value eDepth
a B< R -19 R -10 R-10, 4 feet
a R -30 ceiling insulation may be used in place of R -37 if the insulation achieves the full R -value over the entire ceiling
area (i.e. not compressed over exterior walls, 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 fell out Consumer Information Form (found in Appendix 120.P)
iftvie.2 -?*/17/ //:. 7 Iv
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License: se: - 00
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{
NELSON A SHIFFLETT
tAt
340 RIVERSIDE DR P9X60627
FLORENCE, MA 01062. y, ;
i Ira: 3435
Board Building Regulations and Standards License or registration Valid for intik use onl y
•' t
HOME IMPROVEMENT CONTRACTOR before the. expiration date. If ftitiud return to:
i t s Board of Building Regulations and Standards t_� R gistratic, 1 5543 One Ashburton (lace Rut 13u1
Expiration; 7/17/2010 Tr# 270245
Boston, Ma. 02108
Typo: Private Corporation
VALLEY HOME iMPR VEL4Er#T iNC,
Nelson 5i3etlltt
772 3 j ` - tr
340 Riversidelih,
w e c 7 a //" Pit/ e t
Northampton, MA 01060 druitiktralor Not t Mier. ithoot signature
„- t1A1'fP�
O OA
9 . B Gx L7Z IIT�J tITt i =*
8 � -, ► 'i P 8 •
° =” -
t . IPi p + Alassadlnsetts °_ _it=
, m - w 1 DEPARTMENT OF BUILDING INSPECTIONS
• 212 Main Street • Municipal Building ���
Northampton, Mass. 01060 7.
WORKER'S COMPENSATIONSURANCE AFFIDAVIT
1, ,t/21-5cil' 5H /G7%W7 vAl -GL y /70/21-e_ . -7 / pzsfi sir, 7C
(Ilcenser/permittee)
with a principal place of business/residence at:
3 -to / el vfe_16.5 i iii` / //0, 7f '/lr ; g9, (phone #) '',61`/- 2
(strut /city/s i;dp) 4 /
do hereby certify, under the pains and penalties of perjury, that:
1 am an employer providing the following worker's compensation coverage for my
employees working on this job: -
%er24445sS _7-//S,- ea. Gv C ,7G G 5 1 Z / / ///
(Insurance Company) (Policy Number) (Expiration Date) •
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies: .
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company /Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additional shod if necessary to include information pertaining to all eomrectoss)
( ) 1 am a sole proprietor and have no one working forme.
( ) 1 am a home owner performing all the work myself
NOTE: please be aware that while homeowners who employ persons to do maintenance, ce c stru tioa or repair work on a dwelling of
not more than three units in which the homeowner resides or oa the grounds appurtenant thereto are not generally considered to be
employers under the worker's oompcssation Act (GL152,ss 1(5)), applira rion by a homeowner fora license or permit may evidence tlx
legal status of an employer under the Worker's Compensation Act
I understand that a copy of this statement may be forwarded to the Department of Industrial Accidents' Offioe of Insurance for the
coverage vcrificatioo and that failure to secure coverage under section 25A of MOL 152 can load to the imposition of criminal penalties
consisting of a fine of up to S 1,5OO.00 andfor imprisottmcat of up to one year and civil penalties in the form of a Stop W ode order and a
firm of 5100.00 a day against me.
Signed this 3 day of /71, ,2a/ O For departmental use only
17 d ,�'° A441 Malt Number Lot #
Signature of L c� ermittee 1
I SECTION 8 CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Nelson Shif fie tt 060300
Valley Home Improvement, Inc. License Number
340 Riverside Drive Northampton, MA ni 0_60 9 / 22 /`
Address Expiration Date
584 - 7522
Signature Telephone
9. Re_i'ster iiH ,1f fnz • rovertient- Contractor Not Applicable ❑
Valley H•me • • - ., - . • 105543
Company Name Registration Number
340 Riverside Drive _ 7/17/10
Address Expiration Date
Northampton, MA 01060 Telephone 584 -7522
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 l No 0
Fl ame. v ner Xemp ion
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 108.3.5.1.
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 -year period shall not be considered a homeowner.
Such "homeovkner" 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 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 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
t I
• WTIQN S. DESCRIPTION OF PROPOSED WORK (c!heck oil np.plicab1)
i
New House LI. Addition 1 --- Replacement Windows 1 Atteration(s) 0 Roofing 0
1 Or Doors 1.1
t
i Accessory Bldg. 0 1 Demolition° New Signs [ 1 Decks [ 1 Siding 1 ] Other [ 1
/ Bre Dtv: r I 7,Y, ! oft of pfcposw WO°:k: rem.strod 4 idl 44.-der gelo, Ado A/ igeelpeal tf
1.7, / P74 "WIC '
t, 4 of e>lsttne heeroorn _ Ye.!1 No ACIa new ne...atoryr res. No
[ Attached Nartatr,, ' ' Renovatinp unfinished bastmera Yes No
1 Plans Atachccf Rok _J . S _,
,...te lo J,/ 1 I . 1"
63. if:NOV house and or addition o ekiStie. iliititirt.lHconiletetheloiloWitt ,:
[ a Use of budding : On.e FamTly Two Family Otrer _ I
t
1, b. Number Of fC017.S:rf each rarrtiy untt: , . .... Number or BathrcoritS
, c, Is tiere a garage attachew ____ _ . .
i j prep squae foct.aRe or new construchon ? yki _____ Din /..),) a
1
C Wilnlb?' :)t
f. Vethoi of heatme ch ri7ev acts of wccd:-..,trivt, NUrnbt! (,..f each
g, Ener2 Ce7sQrvaticn Cor7pAarce, Maseheck Energy Cdmpliance form attached?
I ype of construction
. Is constutxtion within DX) ft, (of wetlands? ''s'es, 4-- is construetd-:A within 100 yr, TIO01platri Yei, flu
71 r ,. nf i'-'rArrrrrq " efq I r r l'OOr " '10w '1"fet t-050° 1 .
1 ,. ,..(.1",).. - Ja.0.... . c.. . ,... ., , a b& ow ., .i a . ...
1 k. Will OuAiing conforrn to the Buddinp, and ",oninR reg:lations? 1 ___. No ,
1 .
[ l. Septic Tank _ CtI::y Sewer
m,...,..--......—....... *,—
l
- SECTION 7a - OWNER AUTHORIZATION . TO BE COMPLETED WHEN
' OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
‘-..
0.90oki (0 d . . , . _ .,.. , _..........,___. , _............._., as Owner d tre subject property
h@enyattnnrin Nelson Shifflett,yalley_gope_jsvppyement,_lnc,
rriv bc P. tit aIl matter: retative .n work authirized by this b-uttriMp, permit anplicAion, _
- lob
7 ., • ' wit,
ova; 1 1;t0 -, r
...lielaonSitinietta___Valley lione_Improxement,_Inc..._ _. If 0wnerfAis1nori7e1 Aeent
hereby decline that trtz.. statements Ittio informittioli on the foregoirii auplic<3tion ;,ne true ;3fid iiccurRe, lo the t.)-et nt rry
prewledge cnc! belief.
Siz"ted '..inder 7.172 rThinS. ord vrwIties cif 1...:Ltri•,;°y. .
_NP1,son_Shi „ ______
I V r: r CiiiTIV.I .
.. / f r
1 e, - ,"
— • . _, „...„, ,—,__ . — ______,
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 33) 33) s _
s .
Frontage -
. s
Setbacks Front
t.
Side L: ? R: a) • r L: a • ' h R: a 1 •'
Rear
Building Height d G • t a
Bldg. Square Footage y
Open Space Footage
(Lot area minus bldg & paved
parking) 1 3 0 0 Yea l c3 O U 1 p
#_ofParking_Spaces _ a 1
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO t/ ci DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO '/ DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
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
No
IF YES, describe size, type and location:
.... _.� ::;74,,,, L Y ..„u artrll use,o x'ar
,,,,**,,z,..::..:.,...,,,,ii,...,,r, .
y��f No thampton St o r p e. t iov f 403:4,,,-.=,: 3
r - BUilding'�'epartment C urb- CUt /D vi "rgrtiTV'It',-.',t1.`,?':-:„:-.,:',:.::',...,T-::::' " k r
ws r S r w 212ili!r Street Se ��� + � +'
` L JUI -1 2010 Rah + 100 /v v i l' t x� �� � � x
Northam ton, lMA 01060 . be "of' :��t al I i a n s
i IxSM , rt 3 N . 4 , 0 of i l.' . : ; �� -z: 4.'i, 3 " of '�
l ` x :. i*P fax 413-587 -1272 Pl .,... 3t, -`P �� 4 - . A , '...ii,.. 54,0 Y� ,, t , ��
P
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENi,TTOl?D • - • G} TWO FAMILY DWELLING
r 1
,lUN - 1 201 � i
SECTION 1 - SITE INFORMATION .
') Lr >>
1.1 Property Address: % DE S _ c#pfrto p, leted.by office
ell 44 I
� tt - Lot Unit
Zone Overlay District
/lJe
Elm St. Distric# r CB District -
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
* v4' i `IP &47 &o ,S" 1
- W e • int) 0 Current lino Addr s :
.411h .... t... .••"‘ tk • Telephone
Sign. re
2.2 Authorized Agent: Nelson Shi f f lett
Valley Home Improvement. Inc. P.O. Box 60627, Florence, MA 01062
Name (Print) Current Mailing Address:
.
/ pi J4/41 584 -7522
Signature if Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
4O
2. Electrical (b) Estimated Total Cost of
.S,(70 Construction from (6)
3. Plumbing SO J Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection 611 e
6. Total = (1 + 2 3 + 4 1 5) ;� 00 Check Number 7 I l � E
This Section For Official Use Only
-{ Building Permit Number: Date Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -1087
APPLICANT /CONTACT PERSON VALLEY HOME IMPROVEMENT INC
ADDRESS/PHONE P 0 Box 60627 FLORENCE (413) 584 -7522
PROPERTY LS. o
04 " rd 'lam to 1 0 /
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out (?6.9
Fee Paid
Tyeof Construction: CONSTRUCT 2ND FLR B DROOM ADDITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 060300
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PIjr
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: § y 3 () \7)
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
f3jio
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.