18C-101 (4) mass save
AUTHORIZATION FORM
1, v , owner of the property located at:
(Owner's Name, printed)
3 / {�7. / c° 5 CiYl 12.-d - 1 J i >
(Property Street Address) (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.
V
Owne Signatu L d �-
q/Z- //
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:
Participating Contractor Date
Rev. 12132011
h.
a
ry� Office of Investigations
=-' i = - 600 Washington Street
Boston, 11 02111
% w e www.ntass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
A I 'cast Informati • t - - Please Print Legibly
Name ( Business /Organization/Individual): C ' 1" p _ V (
Address: woo 6
Cit /State/Zip: Phone #: (4v) -
Are you an employer? Check the appropriate box: • Type of project required):
1. (y�, I am a employer with Li 4. 0 1 am a general contractor and 1 6. 0 New cowl ruction
employees (, li d/or part-time).* bave hired the sob - contractors
2. I am a sole pioluietor or partner- listed on the attached sheet 7. 0 Re mc�delu,g
ship and have no employees These sub - contractors bave 8. 0 Demolitio i
working for me to any capacity. worker's' comp. insurance. 9. C] Building addition
[No walkers' co mp- insurance • 5. We are corporation and its •
] Officers brave exercised their IQ ❑ Electrical 'epaiis or additions
r e q ,
3.0 I am a homeowner doing all work light of exemption per-MGL 11.0 Plumbing re pairs or additions
myself [No workers' comp. G. 1-52 i X1(4) And we have no 12.0 Roof repo rs
insurance repined.] t employees, [No workers' 13.0 Otte~ 34 -14 v1 1 (4 1911
corm_ insurance required.)
'Any applicant that chaos box #1 must also fill out the section below showing their workers' compensation policy information
T Homeowners who submit this affidavit indioating they are doing all work and than hire outside contractors must submit anew aflfide tit indicating such
;Contactors that check ibis boa must ate an additional sheet showing the name of the anbreaotractors and their workers' omg).'f olicy inrFormarion-
I am an employer that is providing workers' compensation insurance for my employees. Below is the po,icy arul job site
information.
Insurance Company Name: i S
Policy # or Self -ins. Lic. #: C S -' Expiration Date: j_ ( k
Job Site Address: \ e kA') 0..\ cit N o rtt, w m F )-0 n AAA Q i 0 0
Attach a copy of the workers' compensation policy. declaration page (showing the policy number and expiration date).
Paiaze to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition o:: crin dmal 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 WORT : ORDER and a fine
of up to $250.00 a day against the violator_ Be advised that a copy of this statement may be forwardo1 to tie Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify er the p an , enalaes of perjury that the information provided above is true and correct
Si ague: ' . A-11k Dec 0 ' 00.
Official use only Do not write in this area, to be completed by city or town offl ial
City or Town: Permit License #
Issuing Authority (chicle one}
1. Board of health 2_ Building Department 3. City/Town Clerk 4_ Electrical Inspector 5. P lunch rug Inspector
6- Other
Contact Person: Phone #:
City of Northampton
Massachusetts
fit I +
I
s! y DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street • Municipal Building
";,•'"°" `� Northampton, MA 01060 SN ' y , : iii°
Property Address: I & : )cltA
Contractor
Name: o f pt> (len e /at F, Ito!- e son ZA c,
Address: 64 th (Ay wod■ S tre 6
City, State: (-rerr∎cjeo P 01301
Phone: (4 — 779 — 3 04
Property Owner
Name: Tuft/ AjoeZ
Address: 3i UiG+
City, State: NO (AMpi MP\ 01 0t�
I, 50st Ueo (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.
q
Contractor signature
Date
10- -0 cl
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
V
Name of License Holder : o Q ON G brit (SS 1 vI i 3 7
License Number
(oy 14 ( Al Woodl re Cfeen { ;eld,MI\ plea i 1-11 - ).0 1
.. ress i' Expiration Date
Sig at re Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
j s ( t,%
Company Name Registration Number
3, Pt (re ("4 Son I„‘ , -1.t- /013
Address ( Expiration Date
(A NG`�+ wee\ (rreenf'L' M� 0130 Telephone \I 3l 77' ° 33it3
—
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 M 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) J Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [CO] Decks [0 Siding [0] Other ['HIV
Brief Description of Proposed TI +� Ot f L � " A
Work: p p ���' �u +iK �X�f6x wL+115 v��fi10 C � ll�ti�� t{;r Svil. 4 c � �
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
J uji � t 0 .V Z , as Owner of the subject
property
hereby authorize sOSt (roe
to act on my behalf, in all matters relative to work authorized by this building permit application.
See AkkoNw, lolao .os. ∎)-
Signature of Owner Date
1, YO Se fr‘ P 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.
Jot — G- t
Print Nam r
-� " / 15 /0C1f9s a
Signature of Ow r/A e Date
9 9
1 F a \ " Department use only
�j City of Northampton Status of Permit:
r 1 2 2d�� Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
CPT. OF BUILDING INSPECTIONS N rthampton, MA 01060 Two Sets of Structural Plans
NORTHAMPTON, MA 01060
p one 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
3 (l[✓uor f ttict6
Map Lot Unit
No rk c fit ^n, ^A, A
Zone Overlay District
0 \( !�
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
J' `j vo ik 7� 6 - let or,,, wri -kiA y1 oti / Mh "7 ,�'
Name (Print l Current Mailing Address: ( ) 1 3 _ „
N ciAk '� Telephone `T J
Signature
2.2 Authorized Agent:
Jo,,e lv ( r• L 64 N��, ���ti Pee 6-reemiele I MA- o 130 '
Name ( 'nt) Current Mailing Address:
4 , ` . H13)- 77-y
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) 3 1 � � Check Number ,./. ji (5
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0444
APPLICANT /CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604
PROPERTY LOCATION 31 GLEASON RD
MAP 18C PARCEL 101 001 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 ‘5'
Typeof Construction: INSULATE WALLS & BASEMENT, AIR SEAL ATTIC & 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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
Ie '. e a
2 mod# /6
Signature of B di (1 ficia r fr 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.
31 GLEASON RD BP- 2013 -0444
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 101 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 -0444
Project # JS- 2013- 000713
Est. Cost: $3291.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 7143.84 Owner: VAZQUEZ JUAN M & JUDY K
Zoning: URB(100)/ Applicant: JOSEPH GEORGE
AT: 31 GLEASON RD
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774 -3604 WC
GREENFIELDMA01301 ISSUED ON:1 0/1 7/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE WALLS & BASEMENT, AIR SEAL
ATTIC & 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 10/17/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner