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25C-041 Property Address: t'� G(/d Contractor Name: r l T (C S , � Address: 7 7 (7r �' fl City, State: 7 n /I/1 �� .P / 3 j Phone: 5 �� Property Owner Name: f (' L' / r 2-2 (-,,r / Address: - City, State: r , 1 ♦ / I, / co _ ( ntracfior) attest and affirm that the building J 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 prope ► owner with a copy f this affidavit. Contractor signature Date �� l x x WAP Work Order: Job Number: 12 -142 Storm Windows 0 $0.00 $0.00 Top Sash Lock 0 $9.50 $0.00 Weatherstrip Window /Schlegal or 0 $6.00 $0.00 equivalent Total $7,282.94 Contractor Instructions: e fore Starting the Job: During the Job: 1. Please notify us 24 hours before starting or schedul ng a job. 1. This residence was built before 1978. Lead safe practices are 2. Obtain required building permit. required. 2. Total for Heath & Safety and Repairs cannot exceed $2500.00. 3. Davis Bacon time sheets required for ARRA work on US Department of Labor Certified Payroll Report Form WH -347. 4. Photograph any air sealing or other work to be covered by insulation. Your Invoice Must Include.: 1. Client name, client address and job number. 2. Signed and dated copy of the work order. 3. Pre and post blower door test results. 4. Attic inspection form. 5. Copy of certificate of insulation. 6. Copy of building permit. 7. Manufacture labels from replacement doors and w ndows. 8. Photographs of air sealing or other work covered l:zy insulation. Additional Contractor Instructions: Certificate of Insulation posted? Yes No (Circle One) Attic Inspection form attached? Yes N/A (Circle One) Where Posted: Contractor: Date: WAP Auditor: Date: Page 7 WAP Work Order: Job Number: 12 -142 Wood clapboard/shakes /shings or 10 ! $1.79 I $0.00 I I vinyl (dense pack) l Window & Door Replacements 32 -36 in Steel pre-hung 0 $64050 $0.00 replacement door w/lite 32 -36 in Wood pre-hung 0 $609.30 $0.00 replacement door w/lite Basement window replacement 0 $25040 $0.00 (awning/hopper) Basement window replacement 0 $2504)0 $0.00 with a frame CDC Windows 2 0 $357 43 $0.00 Other 0 $0.011 $0.00 Prime window replacement w/low -e 0 $35L00 $0.00 to 73 ui Prime window replacement w/low -e 0 $35( .00 $0.00 to 74-83 ui Prime window replacement w/low -e 0 $354.00 $0.00 to 84-93 ui Prime window replacement w/low-e 0 $350.00 $0.00 to 94 -101 ui Replacement Grids (per window) 0 $4240 $0.00 Replacement window per 12/29/10 0 $353.00 $0.00 Tech Manual revision Sliding door replacement per WAP- 0 $1,. 00. $0.00 IM- 2011 -009 00 Sliding exterior door replacement 0 $1, .00. $0.00 per WAP -IM- 2011 -009 00 zCDC Door 0 , $00.00 $0.00 zCDC Window Replacement 1 0 $3: 2.00 $0.00 Windows Deadlights 0 $0 00 $0.00 Glass replacement per ui over 64 0 $1 50 $0.00 Glass replacement to 64 ui 0 $41.00 $0.00 Other 0 $C.00 $0.00 Side Press Lock 0 $S .50 $0.00 Page 6 WAP Wor 1 Order: Job Number: 12 -142 Seal ducts with mastic or butyl 0 $65.1 $0.00 backed tape Weatherstrip (Q -Ion or equal) & 0 $33. $0.00 R -30 attic hatch Weatherstrip (Q -lon or equal) attic 0 $31. 1 $0.00 hatch zCDC Airsealing 0 $62.• $0.00 Other Other 0 1$0.I 1 $0.00 Permit Building permit 150 $1.1 $150.00 Other 0 $0.1 $0.00 Permit $50 0 $50 11 $0.00 Permit $35 0 $35 11 $0.00 Wall Insulation Bay Window insulate above * below 0 $11 .00 $0.00 - your option as to method and Brick/Stucco (dense pack) 0 $2. ; $0.00 Double nailed asbestos/aluminum 1422 $ 1 $3,284.82 (dense pack) Drill finish patch plaster (dense 0 $1. 1 $0.00 pack) Drill rough plaster patch or finish 0 $1. ; 2 $0.00 wood plug (dense pack) Other 0 $0 11 $0.00 Single nailed asbestos /asphalt 0 $2 ' 1 $0.00 (dense pack) Spray Foam Walls - CDC ONLY 0 $11 2 $0.00 Test drill 4 sides 0 $ . 1.00 $0.00 Vinyl over asbestos (dense pack) 0 $ • 1 $0.00 Window Weight Voids (pair) 0 $ ►.00 $0.00 Page 5 WAP Wor Order: Job Number: 12 -142 Gutter Replacement (includes down 0 $6.50 $0.00 spouts) Knob & Tube Inspection, fuses, 0 $175. 1 $0.00 wiring Other 0 $0.11 $0.00 Vent kit/bath fan 0 $89.1 1 $0.00 Misc Insulation 2" Foam Board on Door 0 $54.1 i $0.00 Domestic water pipe wrap 0 $2. $0.00 Duct insulation R -5 0 $3.1 $0.00 Hydronic pipe insulation 1.25 - 1.5 0 $3., $0.00 in. copper pipe R -5 Hydronic pipe insulation to 1 in. 0 $3.' $0.00 copper pipe R -5 Other 0 $0.11 $0.00 Steampipe insulation 3 in. iron pipe 0 $7. i $0.00 R -5 Steampipe insulation to 1.5 - 2 in. 0 $6. $0.00 iron pipe R -5 Steampipe insulation up to 1.25 in. 0 $5. 1 $0.00 iron pipe R -5 Mist Measures Attic sealing with two -part foam 4 $7 00 $300.00 Piping Penetrations, Chimney Bypass Basement sealing with two -part 2 $7 00 $150.00 Pipes and Penetrations foam Blower door set -up with pre & post 0 $4 .00 $0.00 tests Cut/close attic - kneewall access 0 $7 .75 $0.00 Cut/ finish attic - kneewall access 0 $1 5.00 $0.00 Interior Air Sealing & Caulking 0 $ •.00 $0.00 Labor only charge 0 ( 1.00 $0.00 Other 0 100 $0.00 Replace Clothes Dryer Transition 1 ' 1.00 $40.00 Duct only Page 4 WAP Work Order: Job Number: 12 -142 Crawlspace overhead insulation 4 ft 0 51.87 $0.00 high or less R -19 Crawlspace overhead insulation 4 ft 0 $1.96 $0.00 high or less R -30 Garage ceiling cavity filled with 0 $2.11 $0.00 blown cellulose Other 0 $0. l 1 $0.00 Perimeter 2 in. foam board 0 $2.51 $0.00 Perimeter Wrap R -5 reinforced foil 0 $1.9 $0.00 or vinyl faced ductwrap Sill insulation Faced R -19 158 $1.5. $249.64 Sill two -part foam w /fiberglass batt 0 $2.2 $0.00 Doors 28 -32 in interior solid core door 0 $31 00 t $0.00 I Automatic Sweep 2 $23 f 1 $46.00 Basement/outside door - door only 0 $36 .50 $0.00 Basement/outside door - w /jambs 0 $43 .75 $0.00 Fixed Sweep 6 $1 5 $94.50 Lockset/Schlage or equal 0 $7 00 $0.00 Other 0 $0. 1 $0.00 R -5 Ductwrap or R -max on door 2 $5 00 $102.00 - Repair Striker Plate (WMECO 0 $8 ' 5 $0.00 only) Repair/Refit Door 1 $5 .00 $52.00 Slide Bolt 2 $9 ' 5 $18.50 Weatherstrip s/Q -lon or equal 8 • •.50 $364.00 Health & Safety Basement window w/framing - 0 $ - • 0.00 $0.00 building code compliance ( non- Clothes dryer vent including 0 :.' .00 $0.00 Exhaust Duct Page 3 WAP Wor < Order: Job Number: 12 -142 Reinforced poly/R -20 cellulose open 0 $1.84 $0.00 rafters Reinforced poly/R -30 cellulose open 0 $2.0 $0.00 rafters Site Built pull down stair insulation 0 $180 11 $0.00 2 in foam box Spray Foam & Mesh & Blow CDC 0 $1. ' $0.00 ONLY Tenmat Recessed Can Cover - 0 $30.11 $0.00 pending approval Thermodome or Magnetic pull 0 $1:100 $0.00 down stairway box Attic Ventilation 1/2 Window Gable Vent 0 $11: 00 $0.00 Other 0 $0.11 $0.00 Propa Vent 0 $4.11 $0.00 Rectangular gable vent 3 $92 11 $276.00 Above 3rd Floor Rafters Rectangular soffit vent 4 $27 11 $108.00 Ridge vent 0 $2 00 $0.00 Roof vent 135 (1 sq ft NFV) large 0 $9 00 $0.00 Roof vent 865 (.4 sq ft NFV) small 0 1 00 $0.00 Stack Vent 0 $1 .00 $0.00 Turbine Vent 0 $1 :.00 $0.00 Varipitch vent 0 $1 4.00 $0.00 Basement Insulation 6 ml poly on ground 0 i" 5 $0.00 Basement overhead insulation R19 0 $ 58 $0.00 Fiberglass Basement overhead insulation R30 0 $ 82 $0.00 Fiberglass Belly repairs - foam board 0 $ .00 $0.00 Belly repairs - labor 0 1.00 $0.00 Page 2 WAP Work Order Community Action of the Franklin, Ha npshire and North Job Number: 12 -142 Quabbin Regions, Inc. Work Order Date: 11/16/2012 P.o. Box 1432 Ownership: Renter Greenfield, MA 01302 Phone: 413 - 774 -2310 Eastern Weatherization Auditor: Brian Legg 79 Center St Email: blegg @communityaction.us Montague MA 01351 Cell: 413- 834 -0632 Phone: 413 -367 -2228 Phone: 413 - 376 -1116 Julie Heywood NGRID Electric $7,282.94 12 Woodbine Ave Total $7,282.94 Northampton MA 01060 413 - 727 -3370 Landlord Name: Mike Ciszewski Landlord Phone: 413 -586 -6330 Safety Issue s): Asbestos on Pipes / Lead Paint Possible Au'horized Actual Measure Description Qty Prue Total Qty Total Comments Attic Insulation Attic stairs - fill with cellulose 2 $131.00 $270.00 Attic/Kneewall Floor Transition 0 $2.52 $0.00 Dense Pack w /cellulose Kneewalls R -12 cellulose behind 0 $1.1B $0.00 permeable membrane Other 0 $0.00 $0.00 R -10 -12 restricted - slopes/floored 0 $1.-0 $0.00 fill w /cellulose R -10 -12 unrestricted - settled 0 $1. $0.00 cellulose R -11 FGB in open rafters/walls/ 0 $1.41 $0.00 kneewalls R -18 -20 restricted - slopes/floored 0 $1.42 $0.00 fill w /cellulose R -18 -20 unrestricted - settled 0 $1.29 $0.00 cellulose R -19 FGB in open rafters/walls/ 0 $1.47 $0.00 kneewalls R -30 restricted - slopes/floored fill 1201 $1 48 $1,777.48 Dense Attic Floors & Slopes of stairwells, etc. w /cellulose R -30 unrestricted - settled cellulose 0 $1 37 $0.00 R -38 unrestricted - settled cellulose 0 $1 47 $0.00 R -49 unrestricted - settled cellulose 0 $161 $0.00 Page 1 I - - . , ''. , .• .' t 34 - V ..1 ,'''''' . , - . ' • 4 " '''''' ,''''' ' , : ,,, / .,. I - - -- --- 'N., p husetts Department of Public Safety _ Board cif Building Regulations and Standards ( on.tNuction Supcni.or Specialt■ IIIII ,.. cense CSSL-100236 PATRICK G SMITH 79 CENTER ST. _.. Montague MA 01351 . 4 22„,„„„. ...&..."3(..¢ 0Orrttnissi an e• 04/05/2014 i '- ' le( fficeekotkinV iless egu ation IMPROVEMENT CONTRACTOR Fe gIStratIOn : 134741 Type: piration: 1/11/2014 DBA E'Ag+ERN NEATHERIZATION PATRICK .5. MITH 79 CENTER ST MONTAGLE, MA 01351 Undersecretary 1 i ACORD CERTIFICA = OF LIABILITY INSURANCE DA"E""°°""Y” 03/05/2012 THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMA . : ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY = ■ . EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT • - A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED REPRESENTATIVE OR PRODUCER. AND 71* CERTIFICATE • DER. IMPORTANT: Nth* eMBoats taldar Is an ADDITIONAL *MR - •' fire paled's) must be endorsed. If SUBROGATION IS WAIVED. subject to the tarns and aond ions of the pokey. oertain pakoks msy ' !. endorsenwd. A stalemate On this oartilicste dell not Darner rilhts to the cedllbste holder in lieu of such endorse nsat(s). mecum c + Webber & Grinnell Ins. A 4,— gency , Inc . � y , ; 413.586.0111 ' �,�; 413.586.6481 8 North King Street Northampton, MA 01060 0181Mit os, 0001493* _ MMIMI1�i Uo AFFOROSI0 COVERAGE HMC e 'Isom — — - — — - Ire A : Selective Ins Co of Southeast Patrick G. Smith yes: Safety Insurance Co. 773 DB* : Eastern Westheri zat i on EWER c : %CAR— ACE 79 Center Street INSURER o : — — Montague, NA 01351 INSURER IMAMS F : COVERAGES CERTIFICATE N , - Master Exp 02/13 REVISION MUMMER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE , • BELOW HAVE BEEN ISSUED TO INSURED NAMED MOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANONG ANY REQUIREMENT. TERM CONDFI1ON OF ANY CONTRACT OR OTHER OOOUMlNT VYIM RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND � OF SUCH POLICIES. UNITS MAY HAVE BEEN REDUCED BY PAID CLAIMS. L ' TYPU OF INSURANCE Four, NUMMIR ' .1. . s ; - LIMITS GENERAL UAIllUre S196874203/01/2012 0310112013 EACH OCCURRENCE $ 1, 000, • r I X C O + e + t r c A L GeeRA. t a t . — t PREMISES u S 100, 'AA/OS-MADE , x (nap MED EXP IA/Norm season) f 10, ' A r pEasot 1. a Aov INJURY $ 1.000, • t I _ _ GENERAL AGGREGATE $ 3,000, '.E4 AGGPEGA'E LIMIT APPLES PE, _ pRooucTs - ca.Prop AGG S 3 000 1 I I ■ X K.A. = -_• ■ LCt $ AU room LimmuTY 621663702/14/2012 10211412013 (E, sitooLE UMIT S 1,000,410 A's. kj" EMILY INJURY (Per orson) $ A.. wnec AUTOS $ B � X S:hEOIAED AUTO. � I scow( INJURY IPer scbdMel PROPERTY OHMAGE S ~ X t•I : Auto ! (Per ecdd (t) X l.^.t.. .VMED AUTOS 1 $ ! $ uNIMILLALAB occup I i EACHOCCLRR£NCE S EXCESS WI 4J4stS MADE AGGREGATE S CED. TIELE $ rl+!wnct. s ' S ANDS ItOVENEUNMET YIN 1 S62L 4495P63212 03/01/2012 03101/2013 X ':4 ER AKY PROPRETORIPA(tT� RJEXEC'J'.YE E L EACH ACCIDENT $ 500, I I I C ; Es ly EXCLUDED> N!A ! IM*r1UU•Y ti •e•) ■ E.L. DISEASE - EA EMPLOYEE $ 500, • I • • I. � elm unlit TI... 1 1 E L DISEASE - POL'CY LIMIT S 500 • 1 r maiiniminis OfeCR•TION of OPIItATION$1 LOCATIONS /VESICLES (ASKS ACORD 101, RENNIE Sehodulo. W men spec* Is nqur*d) •rkers Compensation policy does not provi coverage for Patrick G. Smith. CERTIRCATE HOLDER CANCELLATION SHOULD ANY OP THE ABOVE DpC1URED POLICES 1E CANCELLED WORE THE EXPBU'TIOH DATE THlRISOF. NOTICE WLI. BE D*J W N ACCORDANCE WITH THE POUCY PROVISIONS. AUTHORIZED REPRESENTATIVE _r1AY.✓ Ev dente of Insurance C thia Henderson CISR CINDY ® 1903,2000 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD n end logo are registered marks of ACORD \ The ColnI4nwealth of. ifassachusetis S: _ ` 1 6 eirfflle ©f ll4'us�llllllCCrdelris �w r K Offi « oflr2vestig,ations 4 s �,;,, 600 ashington Street u ~u• 131.ton ,MA 02111 w ' /dia Workers' Compensation Insurance Af ldavit: Builders/ Contractors /Electricians/Plumbers Applicant Information e Please Print Legibly l Name ( Business /organization/Individual): G A A l e, �,, O 1, / Address: G 1 v M M r - e ,47 O i ' S Ci ty /State/Zip:/neW / /C/ -�r- . /1!9 - 0 35/ Phone #: 4 ://3 ,' 7 „2---2 F , Are you an employer? Check the appropriate box: 4. I . ,'t a general contractor and I Type of project (required): 1. [� 1 am a employer with 5 [] g . employees (full and/or part-time).* ha hired the sub- contractors 6. D New construction 2.0 I am a sole proprietor or partner- lis, =d on the attached sheet. 7. 0 Remodeling ship and have no employees Th e sub - contractors have g, 0 Demolition working forme in any capacity. e.. , loyees and have workers' [No workers' comp. insurance co.... insurance, $ 9. 0 Building addition required.] 5. 0 W are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work o :i cers have exercised their g 11.0 PIutnbing repairs or additions myself. [No workers' camp. ri 1, t of exemption per MGL C. 52, 12.0 Roof repairs • insurance required.] t ye (No •• • 10 ees. o workers' have no 13 , 7Z.,4r, ' kers' 1— co ,. • . insurance required) Ct /AS, j .' ' W ji 4) !Any applicant that checks box #1 must also fill out the section belo showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing a' work and then hire outside contractors must submit a new affidavit indicating such. 1 Contractors that check this box must attached an additional sheet s ` wing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provi ,' their workers' comp. policy number. larn an employer that is providing workers' compen ion insurance for my employees. Below is the policy and job site information. insurance Company Name: a/4 e/" I" r /' 1 iv4/ ea Policy # or Self -ins. Lic. #: S 6,Q (28 Y ?5 PC 3.4 Z .Expiration Date: 3 //,4a? /3 Yob Site Address: L ivcia, /4440 4 Cit /State /Zip: t tio,714. / A / "II oYQ'(4) Attach a copy of the workers' compensation policy i eclaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section .1. A of MGL c. 15 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, 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 advise ■ that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage vent i cation. I do hereby eery under the pains and penalties o e:jury that the information provided ab a is ue and correct. 1 if Date: SIUII_ arra-6i _ 2� 6 2. b Official use only. Do not write in this area, t0 1 completed by city or fawn o ff cittL _ ~^ Permit/License # ____ City or Town: Issuing Authority (circle one): 1 Board of Health 2. Building Department 3 City /Torun Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Phone #: I. Contact Person: — SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Constructio upeer / : C Not Applicable ❑ i . Name of License Holder : l , - c" Jr11 TA 1002n (/v 2 n --- / License, umbe 1 .,/ ��e r /� M fro- ©l `1 5 Ad. s f Elpiration ate /,. 4 /nova 7ii? A ignature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ gr re( 40 4"> 74-Tide l 3 ` 7 // Company Name Registr do Number 27 C 4/fl` 3 41 o/-"/ 40 a/ ;5.7 // 7/ X Address - Expiration Date Telephone��f/ / 2 Q 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) ❑ Roofing n Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [D] Brief Description of Proposed /�� / ,.I �7 Work: V 2a '11'1 /2-4-- j ((/A"/ C e' // / LA- < i, / (�✓ #1 � I C . Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. If New house and or additio 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 I, r I C / 5 2 e w S , as Owner of the subject property /1. hereby authorize P :177 L �.�l (7 to act on my .ehalf, in all matters relative to work authorized by this building per it ap cation. A Signature of • , r D e I, Prr ( 5Tz4 I , as Owner /Authorized Agent ereby Declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. 4 s Signe- /pain -nd • nalties of ,,- Ar4 _d Pri Name ' _ .,. / A/ Y 2 Signature of Owner /Agent 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES o 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 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES © NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q 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 Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • ?k /4 AI/ V C t -K- Department use only City of Northampton Status of Permit: -- Building Department Curb Cut/Driveway Permit RECEIVED 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability r. — 7 gai Northampton, MA 01060 Two Sets of Structural Plans h e 4 13 587 - 1240 Fax 413 - 587 - 1272 Piot/Site Plans Other Specify DEPT. Or a I\ PFS.TIONS NORTHAMPTON, MA 01060 APPLit.:A I IUN 10 t.ONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Pro Addres This section to be completed by office 1 a tA/e /), •(,/L.( Map Lot Unit 4✓C't ! i M', 7-6's/ 41 , ' 7 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner o Record: Mt t' ClS Z- etvski /2 wool fhj % Name (Print) , ,' n • Cur e f t Mailin7Az ress: , 7e) i __ , �/� /- - � -� Telf ph one � '! S' •nature 6 2.2 A yrrized AQ : e t ar/ n/ t 77 ce,"--i - „Cr 4 /10 4-7 tt, Nam- ' inter Current Mailing Address: ® OW h pi,,, e 4 ,,zerA-- w 3 ,‘? ,20 S gnature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 7 :°2F X (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) : ? ?, TY Check Number / This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0635 APPLICANT /CONTACT PERSON PATRICK SMITH ADDRESS/PHONE 79 CENTER ST MONTAGUE (413) 367 -2228 PROPERTY LOCATION 10 WOODBINE AVE MAP 25C PARCEL 041 001 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 _��G7 / 0 55- Fee Paid ) Tvpeof Construction: WEATHERIZATION & INSULATE ATTIC & WALLS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 100236 3 sets of Plans / Plot Plan THE F . LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ►. ' ATION PRESENTED: t/ 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 lrtio1.9elay f � , � / /,.___,____,,,, ' te Signature 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. 10 WOODBINE AVE BP- 2013 -0635 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 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 -0635 Project # JS- 2013 - 001034 Est. Cost: $7283.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PATRICK SMITH 100236 Lot Size(sq. ft.): 3746.16 Owner: CISZEWSKI MICHAEL J Zoning: URB(100)/ Applicant: PATRICK SMITH AT: 10 WOODBINE AVE Applicant Address: Phone: Insurance: 79 CENTER ST (413) 367 -2228 WC MONTAGUEMA01351 ISSUED ON:12/10/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:WEATHERIZATION & INSULATE ATTIC & WALLS 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 12/10/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner