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31A-134 (2) mass save COWMACTON PERMIT AUTHORIZATION FORM I, �A N 1a2 , owner of the property located at: (Owner's Name, printed) y f"o23 5 l✓J /= i4 + AA Pi G r_/ ,f pI c U (Property Street Address) (City(fown) 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. Owner's gna /2. e /tz 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: 3.P. (r eorle on rll Sol\ I , - - ?°i Participating Contractor Date Rev. 12132011 71.-44:',i,, City of Northampton 0 .... % i M assachusetts p DEPARTMENT OF BUILDING INSPECTIONS 9 , 212 Main Street • Municipal Building °S., Northampton, MA 01060 e 1' V 1,:)\'''.* i\ Property Address: ` /i0 FarbeS AvemAt. Contractor JflS� Name: P1 &forIt Address: 64 1-401 woof 5 tree \ City, State: Grtenfitlet /AN Phone: t '03) 774 -3to4 Property Owner Name: b CM Nor Address: 0o �o i A*ro^t City, State: Nark\\ut pion ! , • ` I, SbSt fh &rcorlt (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 \0' `l't • Date S _IO,' , A ice Office of Irvestigations 600 Washington Street 94` Boston, MA 02111 r ,t • www.mass..gov /lam Workers' Compensation Insurance Affidavit: Builder /Contrac ors/,Electri clans/Plumbers A bicant Inform ' n ;�Plerase JPrint Legibly Name Q 3usiness /Organization/1ndividual) ^ : t . � � t'� - m '�' ` = Address: fCq \`TW- WOO 6 T City/State/Zip; � 't iVtle - \C� �+ ti C t3O E- Phone 4:, ( t\ 5 _1 7 H �� ' Are you an employee Check the appropriate box: Type of project required): 1. t'.L`l I am a employer with 14 4 ❑ I am a general contractor and I 6_ ❑ New cant ruction employees Cfail and/orpart time)_* have hired the sub- coutcactuas 2. I am a sole ptupiefor or partner- listed on the attached sheet,.; 7. ❑ Rtnnodelu.g ship and have no employees These sub. contractors have S. ❑ Demolitio working for me in any capacity. workers' comp. insmance. 9. ❑ Building addition ( N o w o r k e r s ' c o m p _ insurance - 5. ❑ W e area corporation audits - IQ.❑ E1refrieal impairs or additions required.] officers hive exercised their 3. ❑ I am a homeowner doing all work -_,OghtotexemptionperivIGL 11.0 Plumbing repairs or additions myself [No workers' comp. - : °c 452 l et) ; _aa 1 we have no 12.0 Roof repa insurance required.] t employees. (No workers' 13E1 Oche= inn ct 1 fri 01 ' comp_ ioStu'ance rciu ned.) Any erppiicautthat cheeks box #1 trust else ts"ll 'old the section below ehowiing &air workers' compeonadion policy information Homeowners who submit ibis affidavit indicating theyaiz doing all'worltand Rein his+: outshde caabnctorsmost submit anew aft da -5t indicating such *Conrsa tiny that cheek this boaanesat mad en additional sheet showing the nm:r ofthe snlfcontrnetots aid Their wickets' *amp_ 'policy idly u►e1ioa I txrn ,men employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Information. I - insurance CompanyNaine: .V i S Policy or Self -ins_ Lie. : ' Expiration Date: Job Site Address: g a Forkf e(\At City/State/Zip: NlYttatN , MA 0i Ot Attach a copy of the workers' compensation policy ,deciaratioa page (showing the policy number and expiration date). Failure to sect= coverage as required under Section 25A of MGL c. 152 can lead to the imposition o :` cries anal penalties of a e up to 5 1,500.00 and/or ante - year imprisonment, as :well ; as' civil penalties in the form of a STOP 'WORT : ORDER and a fine of up to $250.00 a day against the violator_ Be advised that-a copy of this statementmay be forwarded to tie Office of Investigations of the DIA for insurance coverage verification. - _ - I do hereby certij r underage f penaltes ofpejury - that the information provid above is true and correct Sig(' Mtn: � l \ ' : - Date: L1 _17 ' _ phone Y: '1') 4 6O' i Official use only. Do not write in this area, to be compleM4 bjr city or town ofciat: City or Town: Perrnitl sense # • Issuing Authority (circle oae)j — L Board of fleaIth 2- BeUdiag Department 3. Cityfrowu Clerk 4.. Electrical Inspector 5. F lumting Inspector 6. Other • Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable CI Name of License Holder : V fl? e Q\ Gec,rse. cSs 1 '1 '437 License Number 1� 0y 1 t ©ck 5 r eed Greenfieta,M 0 1 0 1 1-11 -),013 Address Expiration Date ( - 7 74 Signature Telephone ■ 9. Re • istere. ome I • rovement Contr. _ tor: Not Applicable ❑ \V" .'V ,11,. '"-. - r 15 6 i30 Company Name Registration Number Jai (e rgz w„,), So, itt, 1-It -x013 Address Expiration Date t'1 W &reenfilok1 41 30i Telephonel3 1 - 77`x" 33 in 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...... ❑ 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 ❑ Addition ❑ Replacement Windows Alteration(s) I I Roofing ❑ Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding [0] Other [O] Yn(vl c.t[o' Brief Desc,'iption of Proposed Work: it( Sfok cnkVC PntA btnSettcr S O{ Ce11u1oSe to eXiS i„svi( ^ ;n a�1; 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 to existing housing, complete 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 - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, D C" r t , \er , as Owner of the subject property p / hereby authorize 4-Die ve e to act on my behalf, in all matters relative to work authorized by this building permit application. See MioAed■ Dot Signature of Owner Date - QSC 6 ( r'5t , as Owner /Authorized Agent hereby declare that the statements and 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. lose OA Georg Print Nam - '��,► O . Signature of 0 n- /Age t Date Department use only j City of Northampton Status of Permit: I s ' 2 ,_ 2012 Building Department Curb Cut/Driveway Permit i 212 Main Street Sewer /Septic Availability i nE WI EcTioNs Room 100 WaterNVell Availability NosrHarv, <A 01060 i Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/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 completed by office U FQrbe.S }�vNl`+A t Nori n, M n Map Lot Unit Zone Overlay District Olobo Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: DOA FORY ' o For ties f geo,e Nor, e , m A ° i o bA Name (Print) See Current Mailing Address: 1 "� 0.�) ^ 3 ¢ - 7161 c See !ikont,�e (1 Telephone ` Signature 2.2 Authorized Agent: Tosep % Vor t 6 `+ 1iGa7w -pcloi. S \ stet 6reetkidl MA cE,?o 1 Name (P ' t) Current Mailing Address: 4C\ - . H-174.-3b04 Signature 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 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) A,001I'M Check Number r(s This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0237 APPLICANT /CONTACT PERSON JOSEPH GEORGE ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604 PROPERTY LOCATION 80 FORBES AVE MAP 31A PARCEL 134 001 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 L[ (K Fee Paid 7W � �Vv Typeof Construction: ATTIC INSULATION, AIR SEALATTIC & BASEMENT 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 INF9RMATION 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 Peanut 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 i/S Signa of 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. 80 FORBES AVE BP- 2013 -0237 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 134 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- 2013 -0237 Project # JS- 2013- 000388 Est. Cost: $2001.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH GEORGE 99372 Lot Size(sq. ft.): 5009.40 Owner: FILLER DAN Zoning: URB(100)/ Applicant: JOSEPH GEORGE AT: 80 FORBES AVE Applicant Address: Phone: Insurance: 64 HAYWOOD ST (413) 774 -3604 WC GREENFIELDMA01301 ISSUED ON:8/31/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:ATTIC INSULATION, AIR SEALATTIC & BASEMENT 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 8/31/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner