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18C-125 � MY _ City of Northampton A /4�' r-.., °1-.,, S AS . ,. ! sic 7' : Massachusetts if e f ��; j ,t r w ` v- e ; DEPARTMENT OF BUILDING INSPECTIONS s al e.. 212 Main Street • Municipal Building J A. . Northampton, MA 01060 'N N � Property Address: 33 .s,{n S • Contractor Name: / i / , o SS SS 1 r Address: 2 2. S iS-Q0 & --('- City, State: 7I / P i D e' Phone: (/(3 • 3 22- 3iu Property Owner ,M, ` /� / � fj � Name: j 7 ,fix / Address: 3 3 5d/7 5/- Cit State: , AP/ AA, .41e .4r i I, _7 S SS /ka- SSI (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 Zbi,, ,,,,... ' — Date :///27////-.5 The Commonwea of Massachusetts print Form Department of Industrial Accidents ,,, d Office of Investigations 1 Congress Street, Suite 100 a; Boston, MA 02114 -2017 t A ' . v> www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information / Please Print Legibly Name ( Business /Organization/Individual): ` P • QJ Z. - Address: 212. Sag Ik S City /Stat /Zip: / / - Al , 1 D t ' D Phone #: I/3 • 32. - S11 Are y an employer's Che. the appropriate box: Type of project (required): 1. I am a employer with / 4 ❑ I am a general contractor and 1 6. ow construction employees (full and/or part- time).* have hired the sub - contractors listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurances required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.]'' c. 152, § 1(4), and we have no employees. [No workers' 1 3. Other S4//4 / 0 comp. insurance required.] Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub - contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: a- Policy # or Self -ins. Lic. #: _ 41 2 / / Expiration Date: _ Job Site Address: 33 /,. cgn City /State /Zip :A G 1/4 /1/ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal 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 WORK ORDE R 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 the Office of Investigations of the DIA for insurance coverage verification. I do hereb certify under the pains and Penalties of perjury that the information provided allow is tru' and correct. t_ Signature: / rV ,[ Date Phone #: qL' ,322-3//1 — Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # — Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ /l Name of License Holder : 7 i,9MS e o SS f) aSS /€ r f 2 5 0 ^ License N mber 2A2 SCZ@" \<, 1 c \--• \ko� ` a k e, A/0 1 o I o 46 9 2 (3 Addres t Expiration Date x(3-3 -3i1 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Nam / Regi tration Number o 0 14 e if / Address Expiratio / it J i t Telephone 3- 32.2,3 — 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 build g 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 ❑ New Signs [0] Decks [Q Siding [O then Brief Description of Proposed Work: �sT/ Alteration of existing bedroom Yes 0 Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes 0 <-_____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 Philip Mathews I, , as Owner of the subject property hereby authorize Energia, LLC to act on my behalf, in all matters relative to work authorized by this building permit application. January 29, 2013 S' nature o r 11--7 Date 1, Philip Mathews / 2 V SS Mats - 5 . , 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 f perjury. Philip Mathews #/1 l S'S s.CX Print a January 29, 2013 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 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 Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 © NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit JAW 3 I 2013 I 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability 3- 587 -ortham ton, MA 01060 Two Sets of Structural Plans EPT. OF BUILDING NORTHAMPTON,, MA 0 tint• _ orthampton, 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 Pro ert Ad /dress: This section to be completed by office 33 / /5N7 1 Map Lot Unit A/i fh /u v /66'0 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Philip Mathews 33 Allison St Northampton, MA 01060 Name (Print) Current Mailing Address: • r / �� 41'.923.8502 �C Telephone Signature 2.2 Authorized Agent: 2A 9- t,i /446 /./1 Name (Print) Current Mailing Address: ( P3 - 322-3111 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 J 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) 2oD . 00 Check Number J99a al 55 — This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0735 APPLICANT /CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111 PROPERTY LOCATION 33 ALLISON ST MAP 18C PARCEL 125 001 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 tik Fee Paid /� T � p e o f Construction: INSULATION 7 - / 1 S t New Construction `- Non Structural interior renovations � A /, 5 Addition to Existin • � G PL r/6 Accessory Structure 9 Building Plans Included: Owner/ Statement or License 92540 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 ature of Buildi g 0 ci• 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. 33 ALLISON ST BP- 2013 -0735 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C - 125 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 -0735 Project # JS- 2013- 001250 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 11151.36 Owner: MATHEWS PHILIP J & LORI H Zoning: URB(100)/ Applicant: ENERGIA LLC AT: 33 ALLISON ST Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322 -3111 WC HOLYOKEMA01040 ISSUED ON:2/7/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: INSULATION - OPEN BLOW R19,AIR SEAL KNEE WALL R11 &ISO DENSE PACK KNEEWALL FLR 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 2/7/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner