25C-121 1 '
COMMUNITY ACTION Work Order # ) ( 0
393 Main St
Greenfield MA 01301
413- 774 -2310 800 - 370 -0940
ENERGY CONSERVATION OFFICE
OWNER WORK PERMIT
I 11 I li' f
Near 1 certify that I am the owner of the following
(Print Name)
property and give my permission to allow heating syste work to be performed:
.______/0 I I ZAt i I.
(Street)
/i/ ��Ji4AmPTaN
(Town)
' _9 /- e Ale, (7 )--: — /O 4 /
(Own • r Signature (Date)
TECHNICIAN INFORMATION
System Type: (Check One) f �ti 06 � / �� y z-
_ (Technician)
OIL GAS
Forced Hot Water tL ¶ f I / (- T 64 2 L
(Company)
Forced Warm Air
Steam Note: Enter post efficiency data all jobs:
Other
Net Stack Temp: Comments:
KA/067 U 5 e IA-3p.
Smoke: C I 0S-e.. 0 Pe w Y- 630\A_ .
Breach Draft: /6 nr) 5 C4 w CO2 / 02:
rib
ti 51/ 4 - t-P_ .
EFFICIENCY %:
CO: Amb:
Flue:
•
WAP Work Order
Community Action of the Franklin, Hampshire Job Number: 11 -021
and North Quabbin Regions, Inc. Work Order Date: 2/6/2011
P.O. Box 1432 Ownership: Owner
Greenfield MA 01302
Ronald DeSellier Electrical Auditor: BRAD COUNCILMAN
175 East St Email: bcouncilman @communityaction.us
Ludlow MA 01056 Cell: 413- 834 -4043
Phone: 413 - 478 -6192 Phone: 413 - 376 -1149
Robert Billieux Sr UNKNOWN $145.00
15 Elizabeth St Total $145.00
Northampton MA 01060
413 -584 -7164
Safety Issue(s): Knob &Tube Wiring
Authorized - Actual
ctual
Measure Description Comments
Qty Price Total Qty Total
Health & Safety
Knob & Tube Inspection, fuses, 1 $125.00 $125.00
wiring
Repair open junction box basement 1 $20.00 $20.00
Total $145.00
Contractor Instructions:
Before Starting the Job: During the Job:
1. Please notify us 24 hours before starting or scheduling a job. 1. This residence was built before 1978. Lead safe practices are
2. Obtain required building permit. required.
2. Total for Heath & Safety and Repairs cannot exceed $2500.00.
3. Davis Bacon time sheets required for ARRA work on US
Your Invoice Must Include:: Department of Labor Certified Payroll Report Form WH -347.
I. Client name, client address and job number. 4. Photograph any air sealing or other work to be covered by
2. Signed and dated copy of the work order. insulation.
3. Pre and post blower door test results.
4. Attic inspection form.
5. Copy of certificate of insulation.
6. Copy of building permit.
7. Manufacture labels from replacement doors and windows.
8. Photographs of air sealing or other work covered by insulation.
Date: 02/06/2011 Page 1
COMMUNITY ACTION
ENERGY ASSISTANCE DEPARTMENT
393 Main Street
Greenfield, MA 01301
413 - 774 -2310 or 800 - 370 -0940
February 24, 2011
City of Northampton
Building Inspector
To Whom It May Concern:
Attached are documents relating to the electrical system at the home of:
Robert Billieux
15 Elizabeth St
Our contractor, J.P. George will be applying for a building permit to install insulation.
My inspection, and that of our licensed electrician indicate that the entire home has been re- wired.
The client, Mr. Billieux, tells me that he received a rehab loan in order to get that work done. I expect
there is a record in your office.
One other issue is that he is currently on a payment plan to resolve a water bill. I have previously spoken
with your office and was told that as long as he is current it is not an obstacle to the issuance of a permit.
Please feel free to contact me at 413- 376 -1149. After 7:30am and before 10:30 is best.
Thanks,
Brad Councilman
•
3`" t la..achu.cti. -
Departntent of Public Si
Board of 8 uifdin , � Ifct�
C onstruction_ Su Re:rufa pec and tandarrf.
im
pervisor SpeCialty,Liceanse
cznse: CS SL 99372 •
Restricted to;
WS,IC 6
JOSEPH GORGE STREET
GREENFIE DD MA O130
1301
„ + +anir EXPiration: 2/11/2013
Tr=t: 99372
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
jermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
. The Commonwealth of Massachusetts
— Department of Industrial Accidents
=filt .= 4 ' Office of Investigations
9. �
600 Washington Street
It c k1- ' Boston, MA 02111
r. www.mass gov /din .
•
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A , $ licant Information —3--; Please � Prrint L - ' . Iv
Name (Business/Organization/Individual): , � �-!l
Address: k� Ot <c
City/State/Zip: {. \'A Phone. #: (. ‘3 -1 � � y
Are you an employer ?.Check the appropriate box: Type of project (required): /�
1. I am a Io..er with g 4 .- I am a general contractor and I
y have hired the sub- contractors 6. ❑ New construction
employees l part-time).*
and/or
2_[] I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees 8. have 8. ❑ Deaolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' con insurance CQ� 1ASS�ranrr _ . .
required] 5. 0 We are a corporation and its 10 Q Electrical repairs or additions
h
ffi
ocers have-4xi hi
ercsed their . 11. Plumbing r epairs or additions
3. ❑ I am a homeowner doing all work ,• _ ❑
myself [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t • c: 152, §1(4), and we have no
employees- [No workers'
13.g. Other '�\t VI
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below ,showing theirworkers'- 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
:Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those eatides have
employees. lithe sub - contractors have employees, they must provide their workers' comp. policy number.
J am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: C 1
Policy # or Self: ins. Lic. #: W C J 1d -4 1 O Expiration Date: I A - 2A- don I
�W ('� -�� -..
Job Site Address: IC { I � 4 I � ` ` City /Stafe/Ztp. �'�. ( V4 : i O be)
Attach a copy of the workers' compensation policy declaration page•(showing the policy number andexpirati date).
Failure to secure coverage required under.Sectiiiii25A °ofMGL c d 152 can lea to the i of criminal' Penalties of a
fine up to 51500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK -RDER. and a fine
of up to $250.00 a day against the violator Be advised 'that a copy of thus statement maybe forwarded to the Office of
. _
Tnvestieatlons of the pa for insurance covera`ae verifica .. , , _ _
Ida ;web 'certify under the p and penalties of peljtay that the information provided abov_e_rs nze and corrprt
\k. Signature: v__ D at: a ^ k k • . . _ ,
Phone #: l -1.` 7). [ 3W -
Official use only. Do not write in this area, to be completed by city or town offiklaL
City or Town: - Permit/License # _ . -,_
Issuing Authority (circle one):
.'1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical, I 5. Plumbing Inspector
6.Other .
■
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : \ "-- SL 51
fA� License Number
kklik SI (...) 1 L
Addres + Expiration Date
Signature Telephone
O.' .�,.<; imizaziagnagiti Not Applicable ❑
G CORCI - L , /-5
Company Name Registration Number
CO`s E WWt 5i . G
Addr ss Expiration Date
"'(J Telephoneei 3� 71 918
—
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 ❑ No ❑
ii. ome,O e Exem 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 "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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [0] Other [[Q
th
Brief Description of Proposed , ts
Work: (kk &AtA v230 C e � e isw vk ' ( (X AS �i �.�h�la5e
`
R13 �
Alteration of existing bedroom Yes No Adding new bedroom Yes No olt
Attached Narrative Renovating unfinished basement Yes No 1►-'
Plans Attached Roll - Sheet
6a: ernrise k�.actc�l�t�rs �iisingrvie`ttrefio�i ti+:
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
RA leA,r\ 1 i e_ru s , as Owner of the subject
property p C'
hereby authorize �
to act on my behalf, in all matters � i € tive to work auth zed by this building permit application.
Sign ure of Owner Date
(S"A , as Owner /Authorized
Agent hereby declar that the statements d 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.
V>e thVI cx
Print Name di
Signature of Owne Ag: nt Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Inf. mati l ` 4
Existing Proposed Required by Zon g `` : , i¢
This column to be S -din y or
Building Departm S ` '
Lot Size . 1 ..� _ . .., _ _ � *a»:.
Frontage , '-
Setbacks Front i I ! .
Side L:1 R: _.
L:1 R: i
Rear
i
Building Height F ; i
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg &paved 1 _ ; �i L __.
parking)
# of Parking Spaces — Fill: i _,�� _ 3
(volume & Location) l ;
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
i
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book P age ' 1 and /or Document # i
B. Does the site contain a brook, body of water or wetlands? NO C,I DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued
C. Do any signs exist on the property? YES 0 NO Q
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 Q
•
IF YES, describe size, type and location: ,
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
s ��� �3 '
Building Department t4
' 212 Main Street 9
Room 100 �_�
Northampton, MA 01060
CO
4
• - 13- 587 -1240 Fax 413- 587 -1272 m 4
A ONE OR
1111 1111r; APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map ' - Lot _ Unit
1
` 5 Et r « " "'
"_� bane" Overlay District
Elm St. District ' CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
� 01� crT J B /GLJ.2"4 x S Z_ i t. jiZr�IDt✓RAS4 -,N L T t=v1
ame (Print) ' ng Address:
/ , (LEL ki�3) r 3 ` C C t(,y (tk' S' V -
k 7I N
....w. — tic.%.. — _ — - Telephone
Signure '
2.2 Authorized Agent:
j am � y�' N C c e eat 4-�k� . C � (-, m 0 � �
Nam: rint t) `1 Current Mailing Address:
N , , 6 A _(46ii_S((----(Ak- (4_E4iikUlitiiifiKittl 61 144/4140
Signature T elephone 5 3 k (Ci"j t r•j 4 360-k
SECTION - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (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 = (1 + 2 +3+4+5) ? (.l_ 1 ) Check Number ! O - A5S
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0698
APPLICANT /CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604
PROPERTY LOCATION 15 ELIZABETH ST
MAP 25C PARCEL 121 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 2 / a _
Fee Paid vl Ca_ 7
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 FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
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: §
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
re 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 Conunission, 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.
15 ELIZABETH ST • BP- 2011 -0698
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C -121 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- 2011 -0698
Project # JS- 2011- 001149
Est. Cost: $4000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 3005.64 Owner: BILLIEUX ROBERT J SR C/O DEBRA HAWKINS
Zoning: URB(l00)/ Applicant: JOSEPH GEORGE
AT: 15 ELIZABETH ST
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774 -3604 WC
GREENFIELDMA01301 ISSUED ON:3/3/2011 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 3/3/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner