28-071 (7) mass save
PERMIT AUTHORIZATION ������
v �~v�v�"" o ���� x xo��"�x�~��o "�°v� FORM
L owner of U ic property located at.
(Ow^c/s printed')
" - - r -- - -- - - ----- - -
(P^ peny5ooc/ (City/Town)
hereby auUhnnz,e 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/"rm,eathen/a(i^n work o
'-- ~
Ow '- --- r ---- - ----- —�
v
Dale / /
i0RC8C0FR[EV8EONLY
�un�o.�ahuo Se/ucau 0/oup has ass/gned U'eh,Umwmg Mass Save Home L nrqv Services
t-artvipatirig Car tro ctoi to the aboVe referenced project:
7` D. Creole r^ilS T��. /4 7 ps
Participating Contractor Date
upv 12132011
tHM City of Northampton
�' 1 f Wit.. . .. ,,
f ' Massachusetts f.::''' * '' %
`. ¢" { DEPARTMENT OF BUILDING INSPECTIONS 9
8 212 Main Street • Municipal Building /.- `=
rte
Northampton, MA 01060 ry 4
Property Address: , () 5`11V0tCr Rovoil Frente) MA 0)0E,
Contractor
Name: ) (rt,o r r on,) Jo Int, / Jo Seek (rfrrV
Address: Of EI licn�virnntll SI reei
City, State: Cr`b c‘'e'io\ 'M �1
Phone: ( V3 .)-77`t — 3E,cL1
Property Owner
Name: E ric Flea164 5
Address: 1b3 SyI 'Jetref gAc
City, State: f Oterce , MA
I 5Se Qh (reore (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 Ni 0 t 4, e
,
Date (A_7 -xo 1.)-
r""'— O of Investi ttions
-, 600 Washington Street
u 1 Boston, M4 02111
' tom www mass.gov /din
Workers Compensation IUSUraBee Affidavit: Builder3/Comtraetvrsglectrici s/Piunibers
Applicant Information �r -n -ML-
Print Legibly
Name ( Busines Jaxgarazafianffnaividual): - P. � �1 .fi �i _i_4
�i yfState/Zip�, .{ � e - i ` G t3c Phone #: 6-0. �} 1 `-
f
Are you au employer? Check the appropriate box: - Type of project required)-
I - V. I am a ezvjoyer with 14 4 Q 1 am a general contractor and I & 0 New c on niction
employees (fa amalorpaxt tBme)_" laavebJXed The sob - ontraUws
2. I arc a sole pop zietor or partner- listed on foe attached sheet. ?_ El Re?ncrdelii.g
ship and have no employees These snb4sontrastnr5 bale 8- H Demolitio'
working warkcts' co insa working for me in any opacity. �• 9. 0 Building addition
(No woTkets' coil _ insurance - 5. El We are corporation and its - I4.0 Electlicai epairS of additions
required? OBI= have exercised their
3, 0 I am a Iiorneowner doing all wok ' s.ifiglit of eicemptiaa p IGL 1_.O Plumbing repairs or aadilions
myself [No worke ' comp. = = c IS?,i §s 4 } ac7 rovebavc no 12.0 Roof repairs
insurance required..] t c aPIP ees O worlcets' 13_[x} Oi 1n5 `l i tnY► r l
comp- insmtaneo r�9.t red l -
Ally applionarthatchecks boa #1 mat also fall vat - the section balow.sao?/n compensation policy lianamiiixr
Hatnsownets who submit ilia am devitasdicatina tbeyai+e doingallwai d tan Ili*Owiside oontraetoisinosE sebedt anew *fade - itindice#nngsu is
- FConen �v' m atc/scolcetis bozzannt embed an additional elect allowing the Aeneofthe anb- cantx8etorssnd emir workers' vamp_ policy iurv.. boa_
Lain tilt employer that isprovWIng workers compensation insurance for my employees. Below is the polity and job site
information. !l - .. _ : s
Iztsmcance Company pallyNaaue: r -
I W — S i C-' Expiration Date: 3 'I -W1 i
ins_ Lie. �- ' ! a
Policy r or Self-
Job Site Address: �b3 s ', R o'u\ • __ GIs n: Fl ° ren ce1 MA 01OD.
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expirafion date).
Failure to soeum coverage as requited under Section 25A of MGT.: c. 152 can lead to theituposition o:. cxiudnai penalties of a
fine up to $1,5OO_OO and/or one -year imprisoIIment a swelliascivlpeua1ties in the ferns of STOP WiVOR] : ORDER and a foe
of up to £250.00 a day against foe violator_ Be advised-that-a copy this smtmentmay be forwarded to € Le Office of
Investigations of the DIA for insurance coverage very cation. - -_ -
rrlo hereby certify , • erthe , dins , , enables ofperjury information provid above is true and correct
Si nature: tom) � '' - _ - _- . Date: -7 - )p la
Phone : t 4, l3) .� �- -3C? --1 -_ - ~ _
Official Arse only. Do not write in this area, to he complety d'by city orti lvn of`iciaL I
City or ToWII: - - - - -- -- -- Pertnitt ,icanse # .
Issuing Authority (circle on of - =
I. Board oil : lean 2_ Bonding Department 3. City/Towu Clerk 4. Electir'ai Inspector 5- plumbing Inspector .
6.Other
Contact Perm: I'boue #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ` °' (\ j
Geor . CS) I "I"I 3 7
License Number
6y H61W SfiIC \ (rreentie'1o1 NA 01301 ', -II "a013
Ad. -ss Expiration Date
\ A I \ ..OVA , y . (413)._ 77 ,) 04
), C
Signa i . Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
�. Q (o ry anti or t1 c, 66g
Company Name Registration Number
l lirrywnot S1. (srt'er\f',el MiN 0101 7- a 5-10 1 )
Addr I 74
*3) Expiration Date
Telephone V 1 7/'1 3� °
—
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 t 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) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding [D] Other tI]
Tn3�,l avo"
Brief Description of Proposed cA 1300 f�enfi Rd d " �� c! ';, I Q 10i f i n % 1 nji o i t'n }f .
Work: �i f.)Pr�l A�TiC Gn
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 CONTRACTOR OR CONTRACT I, R _ APPLIES FOR BUILDING PERMIT
I, E iL FriecA 6,4 - f , as Owner of the subject
property
hereby authorize Joie() G
to act on my behalf, in all matters relative do work authorized by this building permit application.
See Afifirfi 0 1 - 7 40 i
S ignature of Owner Date
05Q IN, ( (f , 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.
'OSe
Print Name
11:Ag �.. v�- 7 - �,o\
Signature of Owne /A. -nt Date
,
rtirl• "
II
Ve
n e , -, • 1 ; 1 ,
■•• ' '
•
RF(.FIVED I
Department use only
City of Northampton Status of Permit:
sEP I 0 2012 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
opt OF IMMO INIPECTIOMI Room 100 Water/Well Availability
Pionokrummolos 'orthampton, 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
This section to be completed by office
1.1 Property Address: lc 1 c i,, e I ROC " (J
7 Map Lot Unit
F1roce MA
Zone Overlay District
O\ 0 62-
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Eric. F 64 - Ktiys 11,3 .fy(UCJter K FlorenCQ,j N(A 0 \ 0
Name (Print) �} t Current MailinaAddress _ b 6
`J e. f; / 1 �^ c' Telephone ll ��``
Signature
2.2 Authorized Agent:
Jo3epk (r'orle tit (PywvA St. (Tree4ielci MA Q)301
Name (Print) Curre t Mailing Address:
41 i 1 N O �y3)_779 -3b04
i i Signature Telephone
SECTION 3 - !MATED 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., 5 X 0 Check Number ij� . `
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0273
APPLICANT /CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604
PROPERTY LOCATION 163 SYLVESTER RD
MAP 28 PARCEL 071 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY: jb
PERMIT APPLICATION CHECKLIST 1J`
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Pr
Fee Paid
,\
Building Permit Filled out f
Fee Paid " A ' .,ior w
Typeof Construction: AIR SEAL ATTIC & BASEMENT, ADD ATTIC INSULATION
New Construction ,-
Non Structural interior renovations d
Addition to Existing
Accessory Structure U
Building Plans Included:
Owner/ Statement or License 99372
)r- 14 f ie)
3 sets of Plans / Plot Plan t
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS PPLICATION BASED ON
I FO 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
Sig e Bu riva,
il. ing O icial
Date
N ote: 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.
163 SYLVESTER RD BP-2013-0273
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 28 - 071 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 -0273
Project # JS- 2013- 000441
Est. Cost: $2537.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 40249.44 Owner: KAYS LAURA B & ERIC FRIEDLAND
Zoning: Applicant: JOSEPH GEORGE
AT: 163 SYLVESTER RD
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774 -3604 WC
GREENFIELDMA01301 ISSUED ON:9/13/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL ATTIC & BASEMENT, ADD ATTIC
INSULATION - IN PROGRESS INSPECTION 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 9/13/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner