24A-196 (2) Office of Lops me r A tttai z it sines Kegula ion. License or registration valid for individul use only
r � n HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
;rte + Registration: 156686 Type: Office of Consumer Affairs and Business Regulation
kI g (1 Expiration: ,7/2512013 Private Corporatio i 10 Park Plaza - Suite 5170
Boston, MA 02116
JP FORGE & SON INC
JOSEPH GEORGE ° f
64 HAYWOOD ST i �i 1 ! � " 1
, ,„ki GREENFIELD, MA 01301 •' _ , j s i
Undersecretary I Not vabd (thou# slgnatdre
�- dlassaebusetts - Department of Publie Safet■
I Board of 6 uitdin�2, Re2tilatiuns and Standards
Construction. Supervisor Speciaht Lice -se
F.. iL 39372
Restricted to WS,IC ' ,' ,
JOSEPH GEORGE
64 HAYWOOD STREET
GREENFIE! D, MA 0''301 `
e..-----e--- �"' Expiration: 2/11/2013
( „mmi..i,,nt•r Tr 99372
Property Address: (9 A
Contractor
Name:
e _
Address: ( C).1
City, State:
Phone:
Property Owner
• Name: - -\t\A 6\ \OC
Address: W-)C
City, State: k CO&Cb,AKOZDV\ AM, 0 0 60
1, -- -S - C_)SekisA (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 \ lq
*LTV
Date
•
_ . .
•
•
•
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
•ermits 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
. • .
7
- ,
The Commonwealth of Massachusetts
=-*--:: 2.----- Department of Industrial Accidents
Office of Investigations •
600 Washington Street
t. .... — ,.., Boston, MA 02111
il
,..• ---,,—,
. ,
www.mass.gov/dia
' • -a '
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
......„
Name (Business/OrgantationfindiviciiinD: 0 A-- C t_cOW1SVC
Address: C \ • ,. - -
/ . ....
City/State/Zip: ( k(1 e '001 Phone .#: \- 1. (3) 77 9 e3431•3‘t
1 'I
Are you an employer? Check the appropriate box: Type of project (required): /
1. fjg I am a employer with IA 4.. 0 I am a general contractor and I
- 'on
employees (full and/or part-time).* have hired the sub-contractors 6. 0 New co
2. 0 I am a sole ietor or These sub-contractors have
listed on the attached sheet. 7. 0 Remodeling
• propr partner-
ship and have no -aloyees 8. 0 Demolition
working for me in any capacity. epployees and have workers'
9. 0 Buildini adclitiOn
[No workers' comp. insurance -. conip.insunince_t_
10.0 Electrical repairs or additions
- 5. 0 We are a corporation and its
3.01 am a homeowner doing all work officers have4xercised their .
1. 11.0 Plumbing repairs or additions
myself [No workers' corop. right of exemption per MGL
12.0 Roof
insurance required.] t c. 152, §1(4), and we have no 13.gg Other N vxs) kOLtkcvt
employees. [No workers'
comp. instance required.]
*Any applicant that checks box #1 must also fill out the section belcrtv showing their workers' compensation policy information. — •
t Homemmers who submit this affidavit infficating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
*Contractors that are* this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp. policy number. •
• lain an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
—1 1
Policy # or Self-ins. Lic. #: ‘.13 L )19 '° Expiration Date- - '#Y 3 k3
Job Sim Address: 3 V . s \AA , k VALe City/State/Zip ( k(AirAil MCI 0 k0 60
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Faihme to secure coverage as required udder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up 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 $250.00 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 coveraze Verification.
_ /do here_b_y_ciril under the p ' and penalties of pediaythat the infOrinationprovideil:aiiove_iintLeorrect_______
Signature •6
: '4' . Date:
Phone ifi: ( I \ i . 1 - (00k-i - • •
'A 3_ .
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 I.- .
■
Contact Person: Phone #:
•
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
� � G � CSs� gi3 -7
Name of License Holder : � s
License Number
. k 4 "1 03 606 Gie-etAkicia,M6ocsc
Add Expiration Date
"A Y ()) TN3CO
Signatur 0 Telephone
w >, � � . �1 it r A t;- a �< - rAgablgal Not Applicable ❑
SCN
Company Name ((/�( Registration Number
ro`\ b S . c ?(t-�1�'t� , ` k(k. \3 c) I 7r� Sr � 1
Addr / Expiration Date
qq-‘ Telephoned 4)7793 66 4
—
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 Elk No ❑
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 D
Or Doors C]
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [p Siding [D] Other .,
sv�c '� 1
Brief Descriq)iQrt of�Propo�se ��`c _ , �5� t (� �a� C Q tell- C\ -1/1 kA,() 1 Vl5 Q G V\
Work: ����1� W
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
® ; F4t i � fin e1e T :
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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
IA/ as Owner of the subject
property ('
hereby authorize C3
to act on my behalf, in all matte e to work authorizedby this building permit application.
Signat • f.y� -� Date
\ o Y \ O( ,� , as Owner /Authorized
Agent hereby declare the statements OM 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.
oV \C s5
Print Nam = ,
Signature of • ne • gent Date
1
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zonings i ' . :,.
This column to be filled irfby
Building Department
Lot Size i ! i .,
Frontage I I i ' I —1
Setbacks Front ,
Side L:t R: 1 L s R:3 F 11—
,
Rear ,
Building Height I
Bldg. Square Footage = I 1 % 1 I
Open Space Footage % = (Lot area minus bldg & paved �� 1 s._.....�.
parking)
# of Parking Spaces 1 I 1-- . -.
Fill: 1 �...,4
(volume & Location) 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
i
IF YES: enter Book f Pa I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (2) 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
1 7
IF YES, describe size, type and location: ' i
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
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.
City of Northampton
_ uilding Department • ° , �
212 Main Street � ° V
Geer. _ 76i Room 100 b
NORTt�AMP, 0 ; PE C . a r€
N MA O7oso rthampton, MA 01060 � �9 , �
113- 587 -1240 Fax 413- 587 -127 ��� ;
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
V,Q' -VVV‘ �"£'.{ c(� Map a Lot Unit
1
:Zone Overlay bistrict
Elm St. District ' Cs District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) ) Current ailin Address:
Telephone
Si to
-1.
thorized t:
7,,VOS ()-(etuccie4a,11AP\,c. Oz.
Name (Print) Current Mailin Address:
Signature Telephone
SECTION 3 - E 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 Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ( )7 6 S.. C19 Check Number % &
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -1088
APPLICANT /CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604
PROPERTY LOCATION 20 MURPHY TER
MAP 24A PARCEL 196 001 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
Fee Paid ✓ V $55
Typeof Construction:_ADD 12" CELLULOSE IN ATTIC
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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
6/7/12---
Signature Building Official Date
g g
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.
20 MURPHY TERR BP- 2012 -1088
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 196 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 -1088
Project # JS- 2012 - 001871
Est. Cost:
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 8102.16 Owner: CHERESKI REGINA & AMY J CORBETT
Zoning: URB(100)/ Applicant: JOSEPH GEORGE
AT: 20 MURPHY TERR
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774 -3604 WC
GREENFIELDMA01301 ISSUED ON:6/8/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 12" CELLULOSE 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: 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 6/8/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner