12C-041 41
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mass save coNmame
PERMIT AUTHORIZATION FORM
�� I, I ASE I L e1,a rt owner of the property located at:
(Owner's Name, printed)
a3t1 5" 6ro e Pie f/of
(Pr rty Street Ad ress) (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.
Owne 's Signature
�/ t 3)0� --
Date dddddd
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
Rev. 12132011
M City of Northampton
ap. y _ .. C
I Massachusetts w %
' 1 * DEPARTMENT OF BUILDING INSPECTIONS y !' * '
" c a .r J,, `i;"
212 Main Street • Municipal Building f ,
Northampton, MA 01060 s t'V )\
Property Address: 434 S.1 r'ik COQ , C
Contractor
Name: -I C C e --- SCAv / 731k
Address: c) 401 WOOt t3) .
cEi4V Lt 0.
City, State: � i3L ,
Phone: (9) 7 4 S LC; 1
Property Owner
Name: ' k OA ( LtA
Address:
-` 3'` - ‘ j '( \V% 3 O\J -Oe-
City, State: \O(tkAU_1 hi 0 I 014-
--
I, 1 Qs , L , s� (contractor) attest and affirm that the building I intend to
insulate does not ave any ope 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 11.x1/(,,,
Date c i .-+ l - l a..
f
•
( Office of Investigations
600 Washington Street
' = ,Boston, M9 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Anal icant Information (� ' ; Please Print Legibly
Name 0BusiuesslOrgat�azatianitndividvai ): . l rev ' - C' `" _1_ 1i .
Address: fv1 \ 4 WOO S -
z `
City /State/Zip: `�yZar� �C� `� 4 3 � CA Phone #: " 3. TN
Are you as employer? Check the appropriate box: Type of project required):
1. a I am a employer with 9_ 4" Q I am a general contractor and I 6_ New cons ruction
employees (fgaincVor part-time)_"` have hired the sub - contractors
2. I am a sole pit/pieta or partner- listed oil the attached sheet. t 7. ❑ Reraodelu.g
ship and have no employees These sub - contractors have 8. D Demohtio
working for me in any capacity. workers' comp. insurance. 9. ❑ Building 2dditioa
(No workers' comp_ insurance • 5. We area corporation and its •
required.] officers lrave exercised their IQ ❑ Electrical °epairs or additions
3.0 I am a homeowner doing all work right of exemption perMGL 11.0 Plunobiag : or additions
• myself (No workers' comp. c: 1 §1(4) and we have no 12.0 Roof reps is
insurance required.] t euiplaoyees, NO workers' 131a Other S" ► Iti }! �n
corm. insurance required.]
'Ashy applicant that chocks box #1 must also fill out the section below *bowing their workers' compensative policy information
t Homeowners who aubmit thin effidavi$ indkating they sae doing all wort and then hireautside conbactors must admit anew affida fit indicating such-
;Contractors that check this box must attached an additional sheet showing the name of tine sob- contractors and their workers' comp. olicy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the po,'icy and job site
information.
Insurance Company Name: .2 S
Policy it or Self-ins. Lic. #: _ tJ i C � :J 9 %t. Pxpitration Date — (- ( -
Job Site Address: 1 . 0 l v v- I¼'-
Attach a co workers' w G
the n ' sdioa oli .declarutiom a (showing the policy number and e� iradon
of a con en�� wua
pY P P c 3' p� ( $ Po cY p
Failure to seem coverage as required under Section 25A of MGL c. 152 can lead to the imposition o- cria anal penalties of a
fine up to $ 1,500.00 and/or one-year imprisonment, as wags penalties in the form of a STOP WOR} _ 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 tie Office of
Investigations of the DI.A for insurance coverage verification
I do hereby ce under the ' an , of perjury that the information provided above is true and correct
Sie nature: `.. 1' / ILVA, Date:
Phone #E: ` �3 � '?�
Official use only Po not write in this area, to be completedtby city or town officiaL
City or Town: Permit/License # •
Issuing Authority (circle one): - --
1. Board of Health 2.. Building Department 3. City/I'own Clerk 4_ Electrical Inspector 5. P lumt lug Inspector
6.Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : U C.) Y \ V �* (� `j L
JJ License Number
\i/A1 weCt 6 o 4 1 3
Addr Expiration Date
A ` Catj 77y3J(
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
(0\1 \` tta ` • G . r V })c '7 :4-S
Addres.lk Expiration Date
4Ch R L Telephone_ I j) / i `�_ 3tw t
SECTION 1 0- 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) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [❑ Siding [DL Other [V]
is/VS-4
i ]� 1 0 + 1
Brief Des ipti of r s ed A f S & A, L- "� (3 Gic r LI'e'i�, ?-- vU`�f'k. to,A�i.S -(C,.
qq(�� i T
Work: MtA.4 ((J okici I�" h�',' -ik..SSS i� r✓ L I ( 1` cL e..i ,.
tow ,
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
`
\� \( \ACt4 T 1 \.L\ %AOJ, � , as Owner of the subject
property
hereby authorize Q ,Se �-
to act on my behalf, in all matters relati to work authorizei. by this building permit application.
Signature of Owner Date
I, -4 46 , as Owner /Authorized
Agent hereby declare thiat the statements nd 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.
le) Se-/V1 L
Print Name f
r 2 T.-1A C1 – c --
Signature of Owne A. - nt Date
' REV Department use only
City of Northampton Status of Permit:
C Building Department Curb Cut/Driveway Permit
SEP 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
, ,- OFBUUDING'NsPEC Northampton, MA 01060 Two Sets of Structural Plans
.. f ,,MA01t.:
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
Map Lot Unit_
d s;. 4 'S\ y, ;cc,a r . Ave. Zone Overlay District
1
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
t AVVA A 1. CAA ) * c cc) Q� f URt
Name (Print) Current Mailin dr ess :
r •p ( L C ¶ 7 7 f
7 6 e /101-0 6i Telephone
Signature
2.2 Authorized Agent:
\
-- Te ( S'ti r k CTer 1/1 ' wcct 57: (-
Name (Pri ` Current Mailing Add ss: 0 \./:; i
. �', � �� , ( Z ° 771 (0 4
Signature I V � 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) (0'34 ; 343 Check Number 96 i - 53
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0315
APPLICANT /CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604
PROPERTY LOCATION 234 SPRING GROVE AVE
MAP 12C PARCEL 041 001 ZONE RI(100)/URA(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out v 41/40
Fee Paid
Typeof Construction: AIR SEAL ATTIC & BASEMENT,VENT 2 BATH FANS,ADD ATTIC INSULATT�N
New Construction CgS`
Non Structural interior renovations " /
Addition to Existing Ir Accessory Structure
Building Plans Included: p
Owner/ Statement or License 99372
3 sets of Plans / Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
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
De •.f ay "PO'
.4i0
Sig .1 e :uil.' g Officia 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.
234 SPRING GROVE AVE BP -2013 -0315
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C - 041 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-2013-0315
Project # JS- 2013- 000512
Est. Cost: $3683.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 13503.60 Owner: KRUEGER MARJORIE R & MICHAEL P LEAHAN
Zoning: RI(100)/URAQ100)/WSP(100)/ Applicant: JOSEPH GEORGE
AT: 234 SPRING GROVE AVE
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774 -3604 WC
GREENFIELDMA01301 ISSUED ON:9/24/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL ATTIC & BASEMENT,VENT 2 BATH
FANS,ADD ATTIC INSULATION - in process 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 9/24/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner