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36-359 (3) Home Specifications Form POWERHOUSE The information on this form will be used by Power House Energy Consulting to complete a Home Energy Rating and advise you on how to meet your project goals. Please fill out this form to the best of your ability. Missing or incomplete information may affect the accuracy of your preliminary rating. Your final rating will be based on as- built information obtained through inspections and performance testing. This form must be submitted with the following: • Plans: floor plans, elevations, foundation plan, and any sections & details necessary to clarify the building envelope • Complete window schedule with rough opening dimensions Contact Information Company Name: ROSEMUND, LLC Phone: 413 - 695 -4195 Primary Contact: GREG QUILL Email: ROSEMUNDLLC @YA OO.COM Project information Project Street Address: LOT 10 - EMERSON WAY Permit #: Project Town & Zip Code: FLORENCE, MA 01062 Estimated Completion Date: JAN 2013 Insulation Insulation Type Insulation Thickness/ Framing Size & R -Value Spacing Foundations & Slabs Foundations Walls CLOSED CELL 1" R -7 NA Slab Perimeter (required if RIGID FOAM 2" R -10 NA any portion is at grade) NA Under Slab NA Framed Floors DENSE PAC CELLULOSE 10" R -35 Basement Ceiling NA Garage Ceiling CLOSED CELUDENSE PAC R -28 Cantilevered DENSE PAC CELLULOSE 8" R -28 Floors /Overhangs DENSE PAC CELLULOSE 6" R -21 (PLUS FLASH R -7) Rim /Band Joists, Exterior Walls NA Rim /Band Joists LOOSE CELLULOSE 15" R -55 TRUSS 10" HEEL 240.C. Exterior Walls NA Basement Framed Walls RIGID FOAM 6" R -30 NA Kneewalls to Attic Attics & Ceilings Flat Ceilings Sloped Ceilings Attic Hatch ROSEMUND, LLC Lot 10- Emerson Way - Building Permit Fees 1ST FLOOR 1196 $0.50 $ 598.00 2ND FLOOR 1400 $0.30 $ 420.00 3RD FLOOR 0 $0.20 $ - GARAGE 513 $0.20 $ 102.61 BASEMENT 1180 $0.20 $ 236.00 PORCHES 272 $0.20 $ 54.40 REAR DECK 0 $0.20 $ - Total SF Usuable 2596 Total Fee: $1,411.01 1 Emerson 10 7/23/2012 The Commonwealth of Massachusetts f Department of Industrial Accidents ,........1, Office of Investigations 1 F SIT =,....,1 = ,4i, -- 600 Washington Street Boston, MA 02111 yii www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Leeibly Name ( Business /Organization/Individual): Rosemund, LLC Address: 23 East Hadley Rd City /State /Zip: Hadley, MA 01035 Phone #: (413) 695 -8795 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. Di New construction employees (full and/or part- time).* have hired the sub - contractors 2. ® I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. 9 Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.9 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.9 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.9 Other comp. insurance required.] *Any applicant that checks box #1 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. *Contractors that check 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Main Street America Assurance Co Policy # or Self -ins. Lic. #: MPF659979 Expiration Date: 5/26/2013 Job Site Address: Lot 10 - Emerson Way city/state /zip: Florence, MA 01062 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 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 coverage verification. I do hereby certify under the pains an na ' s perjury that the information provided above is true and correct. / Date: �f Si nature: C. � Dat — 1 7 c I Phone #: 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder GREGORY E. QUILL 105857 License Number 23 EAST HADLEY RD, HADLEY, MA 01035 04/29/63 Address Expiration Date 413 6954195 Telephone 9. Registered Home Improvement Contractor: Not Applicable Company Name Registration Number Address Expiration Date Telephone 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 X No 11. - Home Owner Exemption 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 Q Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [Q Siding [O] Other [0] Brief Description of Proposed Work: CONSTRUCT A SINGLE - FAMILY TWO -STORY RESIDENCE WITH ATTACHED 2 -CAR GARAGE Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition existing housing, complete the following: a. Use of building : One Family Two FamiJ Other b. Number of rooms in each family unit: 8 Number of Bathrooms 2 - 1/2 c. Is there a garage attached? YES 2,596 40' - 8" X 57' - 4" d. Proposed Square footage of new construction. Dimensions e. Number of stories? 2 f. Method of heating? HOT WATER BASEBOARD Fireplaces or Woodstoves NO Number of each g. Energy Conservation Compliance. TIER 3 Masscheck Energy Compliance form attached? h. Type of construction WOOD- FRAMED i. Is construction within 100 ft. of wetlands? Yes X No. Is construction within 100 yr. floodplain Yes X No j. Depth of basement or cellar floor below finished grade 7' k. Will building conform to the Building and Zoning regulations? X Yes No . I. Septic Tank City Sewer X Private well City water Supply X SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. S ignature of Owner Date 1 E , as Owner /Authorized AgenT> iereby decla t th state ents and in ion on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. C >VCC6 1 c\;G1 Print Name iJ 4 ' T e of Owne/' !ent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size 12,717 Frontage 80.03 Setbacks Front 25' Side L: R: L: 20' R: Rear 60' Building Height 30' Bldg. Square Footage % 2596 Open Space Footage (Lot area minus bldg & paved 78% parking) # of Parking Spaces 4 Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW ® YES o 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 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 ® NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit JUL 2 3 2012 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability N rthampton, MA 01060 Two Sets of Structural Plans DE V F BJi . PECTIOW, NORTHAMFi . M 587 -1240 Fax 413 - 587 -1272 Piot/Site Plans Other Specify 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 comple by office ? Map 3 (0 Lot Unit LOT 10 - EMERSON WAY Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ROSEMUND, LLC 23 EAST HADLEY RD, HADLEY, MA 01035 Name (Print) Current Mailing Address: 413 -695 -4195 Telephone Signature 2.2 Authorized Agent: GREGORY E. QUILL SAME Name (Print) , Current Mailing Address: Signature �\ f Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 185,000 (a) Building Permit Fee 2. Electrical 14,000 (b) Estimated Total Cost of Construction from (6) 3. Plumbing 16,000 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 17,500 6. Total = (1 + 2 + 3 + 4 + 5) 232,500 Check Number J to ( This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date .. File # BP- 2013 -0085 APPLICANT /CONTACT PERSON GREGORY QUILL Nf Et 5 ATM M -t S ANC It- ADDRESS/PHONE 23 E HADLEY RD HADLEY (413) 695 -4195 foitk rk. rs s i-ke 0 PROPERTY LOCATION 95 EMERSON WAY / _ , < MAP 36 PARCEL 359 001 ZONE � � P -7 J r 3 o 1(2-- t'^ 1 3 THIS SECTION FOR OFFICIAL USE ONLY: , /-7-- _ ,( PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE 3h ZONING FORM FILLED OUT K� Fee Paid Building Permit Filled out 09C3 Q / IS / 98.0/ Fee Paid �P Typeof Construction: CONSTRUCT 2 STORY SFH W /ATT GARAGE/PORCHES New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 105857 3 sets of Plans / Plot Plan THE FOLLOWING 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 73,c4Z Sigir 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. 95 EMERSON WAY BP- 2013 -0085 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36 - 359 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: New Single Family House BUILDING PERMIT Permit # BP- 2013 -0085 Project # JS- 2013- 000135 Est. Cost: $232500.00 Fee: $1411.01 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GREGORY QUILL 105857 Lot Size(sq. ft.): 12719.52 Owner: OAK RIDGE ROAD LLC C/O ROSEMUND LLC Zoning: Applicant: GREGORY QUILL AT: 95 EMERSON WAY Applicant Address: Phone: Insurance: 23 E HADLEY RD (413) 695 -4195 WC HADLEYMA01035 ISSUED ON:7/31/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 2 STORY SFH W /ATT GARAGE /PORCHES 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 7/31/2012 0:00:00 $1411.01 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner