15B-020 PARTICOMMIX
save mair
PERMIT AUTHORIZATION FORM
,------
, , owner of the property located at:
(Owner's Name, printed)
N.i
je tif5"7 P gE
(Property Street Address) (City/Town)
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.
er's Signature
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
I iorh
Participating Contractor Date
Rev. 12132011
Property Address: /6 7 P
Contractor
Name:
Address: `-niv ENERGY SOLUTIONS
12 PISGAH ROAD
- IUNTINGTON, MA 01050
City, State:
Phone: t t7 3 eeeb -7 'i/ 5C)
Property Owner
Name: Joh Pct. sonS
Address: __
City, State: � -`e Pis /MA-
I, pay /3d p Q /1 d (contractor) attest and affirm that the building I intend
to insula pay 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.
" e
Contractor signature
•
Date /
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ` Q / Not Applicable ❑
Name of License Holder : ., t 4 t IJL� /�(I f..- s s �.� I 6 3
v License NNum er
HOME ENERGY SOLUTIONS
Address 12 FISEtAHROAD Expiration Date
HUNTINGTON, MA 010,50
g1a• (e6 3)36
Signature eall&Khone
s
Req,ste ed
Horne:- inprovement-Contractor: Not Applicable ❑
/ / ta3
Company Name HOME ENERGY SOLUTIONS Registration Number
12 PISGAH ROAD
HUNTINGTON, MA 01050 /64249 /13
Address Expiration ate
Telephone Y� 3 ( . 3 3i✓
. SECTION'. 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L c 152, § 25C(6)) i.
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 A No ❑
o `
eDwiter4Ltemption
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)
.r
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing ► I
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [0]
Brief Description of Proposed j .J-c /
Work: (94 so 1 ,i . au
Alteration of existing bedroom Yes X No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement es NK No
Plans Attached Roll - Sheet
sa, if New house and,or adds itit o to existing'; housing, compl�ete.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
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 7a . OWNER AUTHORIZATION TOBE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
90h 1'► 1 aASty , as Owner of the subject
property (�
hereby authorize h.n f � 5 �
to act on my behalf, in a afters relative to work authorized by this building permit application.
dh PemSdr►s.
Signature of Owner 9 Date
HOME ENERGY SOLUTIONS
12 PISGAH ROAD , as Owner /Authorized
Agent hereby decla4{Rt4]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.
oal Print Name d
• 601 ' • �
Signature . Owner /Agent Date
4
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information }
Existing Proposed Required by'Lonin '... S
This column to be filledgV ,.
Building Department
Lot Size I , 3 I ' 3
Frontage
Setbacks Front i {
� i
Side L: R: U. ! R:' �_j 1
Rear I 6
Building Height E g i i
Bldg. Square Footage i i % — ` 1
i I i i t
Open Space Footage
(Lot area minus bldg & paved 1 I 7 € € €
parking)
# of Parking Spaces
Fill: 1 .._._.._ �
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 6 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 4 YES 0
IF YES: enter Book j I Page I and /or Document # j
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
,
C. Do any signs exist on the property? YES 0 NO 0
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 0
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r�
C� € De • artnie t _us o
ity of Northampton Status o Permit: t
/ r ullding Department Olt ®nr tt i . pft 212 Main Street S SepticAvaitabili �, .,
r o� Room 100 U Uater el, a x i t �
NpP TyA a , , � ",��e � � ^"> 5 a,�x 5 ' � sr x ��' r �� �
�„„//4-0-c0-6 ;�� -�.. ort ha mpt on, M 010 - �woSe •fStr,qcrara - 1 ar�s u�= �,� .� � c ion 13- 587 -1240 413- 587 -1272 PI .Sie ans�
Other Specify , a t e.- '- , , v 4 x , ,. ? „ a r , °
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
/ 0 -:Map e Unifi }
V a
Z Overlay District - ` . t
r°
+:Elm St: District . "- CB District.
SECTION 2 - PROPE OWNERSHIP /AUTHORIZED AGENT!
2.1 Owner of Record:
oiA 4 Pa 5 / 6 7 aUl /
Name (Print) Current Mailing Address: / ��
Q i iLed J art) n`i./14 ll4 '4/LTelephone �W / O `�
Signature
2.2 Authorized Agent: HOME ENERGY SOLUTIONS / /
HUNTIN[;TON, MA 01Q50 I a ��� Gi 1 17 (. )1 II`)l }
Name (Print) Current Mailing Address: Lid
lev
I 2 i /Y1 .� f i l 6'6 :2 313(3
Signature Telephone
• 3 - E S T I MA TED 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 Tota o
Construction f -(8)
3. Plumbing Buildi pmit
ng er Fee ,
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) CheckNumber
=This Section. For Official Use Only
Date
Building Permi N umber:' Issued: "
Signature
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -1030
APPLICANT /CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413) 214 -2414
PROPERTY LOCATION 107 CHESTERFIELD RD
MAP 15B PARCEL 020 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST �(
ENCLOSED REQUIRED DATE
ro-e
ZONING FORM FILLED OUT
Fee Paid Ki t
Building Permit Filled out
et 466
Fee Paid j C
Typeof Construction: INSULATION �/ J
New Construction
Non Structural interior renovations l C'
i ( 1-
Addition to Existing �L
Accessory Structure
Building Plans Included:
Owner/ Statement or License 101880
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
molit' %n G -1
Signature o it • l ing 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.
107 CHESTERFIELD RD BP- 2012 -1030
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 15B - 020 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- 2012 -1030
Project # JS- 2012 - 001768
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 29707.92 Owner: PARSONS JOHN E & VIRGINIA M TRUSTEES
Zoning: URA(100)/ Applicant: JAY BOLAND
AT: 107 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214 -2414 WC
HUNTINGTONMA01050 ISSUED ON:5/25/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATION - FINAL INSPECTION REPORT
REQUIRED
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 5/25/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner