38D-042 (4) City of Northampton
l Massachusetts :n * , v
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. t DEPARTMENT OF BUILDING INSPECTIONS
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�,�� fi .�; 212 Main Street • Building s s ��,
": :4 7 " -- « Northampton, MA 01060 f '
Property Address: -HO VI ' Abe Northr MP o\Ob°
Contractor
Name So$ep1• &eory l J, P. (Rory st t& Son, Im,
Address: U Hoywooa S} 1"ee}
City, State: G ree 0f Ie lo\, M A 01301
Phone: (4 13) 304
Property Owner C 1(e11
Name:
Address: 4o H(/`flow Pte'
City, State: Nor'CAwrl'S on ) MR
I 3oSe fl\ (ar5 $ (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 wLiii\i, ,4e
Date \ 'II
License or registration valid for individul use only of //r dznazzaT ut ea: ' onsumcr .f!acrs & t� 3Lam c h ��, ,
� ess Kcgula
before the expiration date. If found return to: _ HOME IMPROVEMENT CONTRACTOR
Office of Consumer Affairs and Business Regulation ; `� '
i 10 Park Plaza - Suite 5170 Registration: 156686 Type:
Boston, MA 02116 - 4W � Expiration: 7/25/2013 Private Corporat,o
JP & SON INC
r . i + , ) ,, ' k rz . JOSEPH GEORGE
'\ 4 ,,,, ✓ � r 64 HAl'WOOD ST - �
Not valid 4 itho • signature GREENFIELD, MA 01301 undersecretary
31i sachu,ctt, - Department of Public NafctP
9 Board of Buildua�4 Rc ulatiuns and et aatlard'
_ C s rucLinn. ::5! cQ F_< -
Restricted to WS,IC
JOSEPH GORGE ;; , ;
64 HAYWOOD STREET
GREENFIEI_D, MAO'' 301
--‘-- --- Expiration: 2/11/2013
1 , „inner Tr=: 99372
+- ; f Offzeg ofInvestfgations
7:-........7:0K1,—. 600 Washington Street
‘ek viitt;_ Boston, M4 112111
t sF ivwmumasx ovfdia
Workers' Compensation InsnraiceAffidavit Builders /Comtrartors/Electrieimasi. l ers
ApplGcalit Inforxmatiop — _.�,s P ._. ; �Please 'riot Legibly
Maine (BusizessfOrgarization /Individual): _ P. '+J� ,-' � — F
Address: -C` i - = k t0 3 c _
- (-_ ift_ IN 4\ 3 (
—
Are you an employer? Check the appropriate box: Type of project required)_
1- n I am a employer with 14 4 ❑ 1 am a genera] contractor and 1 5. 0 New consinlction
nzployees (full a;Itd/or paxt firno)_"-t have 11ACd The sub - contractors -
2. 0 z am a sole ptupaietor or partner-
listed on the attached sheet 7. 0 ResuodelLg
ship and have no employees These sub- tmtractoTS have 8- ❑ Demolitio '
working for me in any capacity. worket5' comp. insurance. 9. 0 Banding addition
iN4 tivexrkess' comp_ insurance - 5. 0 We area corporation and its 30.0 Electrical - epahs or additions
_J
requz officers have exercised lheir .
3. ❑ 1 a z. a homeowner doing all work ` ;right Ofesemptiin pew /4GL 1 i .❑ Plenhirmr r Taus or additions
myself [No workers' mop. = •-c. 3:52, §3(4). -91teiloyt no 12.0 Roof reps iS
insurance requiTed } t etoployf,es [No ?varl p' 13. OtltE inicliOi i
. corm. irisnriece i -tlsed.J - ,
- Any applicant checks b .41 mat also fill oat the section belnisr savrina their wazkets' convensehon polity s
Fiwaeowaers was submit thin a da* indicating they are aloitsg 871 worketid then ltireoutside tnutractoisisust subnut anew &Ede -ht lad:in t ng suck
=Com:motors that clack. lilisboa-Ixnat attecbed an additional sheer showing the wane aftba ealreantraetorsand flair workers' comp policy iofotni Ih n-
C affirm employer tbat is providing workers' compensation aaswaxee far my employees Below is Ihepa anklet she
in orrreation. {• ' ° E ,
insuran Company Name: k....._ \ACk( tt S
�` T [ q ° ` L— ' B uatiou Date: L t --) y��- .1 t 3
Policy t� ox ;self -ins. sic. 7. d
Policy xp
Job Site Address: 4 VI v r 1m^, Pv e city/shoe/zip: (V o rfil\u" on A , (A ow O 0
Attacia a copy of the workers' compensation policy deciaratioa page (showing the policy timber and expiration date).
Fallow 133 secure coverage as required under Section 25A of MGT.; c: 152 can lead to the topositian o= criminal penalties of a
Roe up to $ 1,500.00 and/or tine -year ft prisonmeut as well as'civlpe aalties in the form of a STOP WORT: ORDER and a flue
of up to $250.00 a day against the violator_ Be advisedlbat-a opy-ofthis statement maybe forwarded to tie Office of
Invesigations of the DIA for i:u3urance covcxage verification. -
r d. o hereby eertryv undertke pains d penalties ofpeduly'thatte information prodded above is twee and correct
Siznatttre: .• i ' 1 = Date: t —1 `1- 1
Phone ( 4 k. `1 t t- i ` )-) 0-i _ .
Official use only. Do not ?wile in this area, JO be complete t by city orMon o, ccial
City or TOWEL: - -- -- - - - - - -- Pertilftaieert§e ri -
Issuing Authority (circle one)' " _ - . - -- - --
I- Board of Health 2_ Building Department 3 - Cttyfrowu Clerk 4_ Electrical Inspector 5. Plumbing Inspector .
6- Other
COMaCt Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 30sePA\ George. (S3) 0 1'131 a
License Number
by Ho, Ytty &ree,Aiw. 4 l AAA 0 O a- 11-A011
Addres Expiration Date
1 ‘,',1 11 i- l c. 40
Signature 00 Telephone
9. Registered Home improvement Contractor: Not Applicable ❑
J. e, &Pore &44 or ant, jS 66S6
Com pany Name Registration Number
6y Ha1W,q d Stre e\ (Greer f e Ie, MA .o1301 7 -)S ao13
Addre / t1� 2 Expiration Date
FL em
S. :� '�� Telephone \'13, -3 6 °4
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 0 Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other [IA
In Jtn la }ton
Brief Description of Proposed ,
Work: Atr seal A\‘ 9. 4 Ptnseri,e,:i f 31 dlfnse rex cellolthe tr. IMeeierwr^N
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 .
1. 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
1, _ Cynk1\t 1011465 , as Owner of the subject
property
hereby authorize 3Str P r. Geor i
to act on my behalf, in all matters relative o work authoriz d by this building ermit application.
r 4 CO ' ( vf
Signature of Owner Date
JO e l, Corlt, , 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.
JoS • AN Ge,or • e.
Print Name
N . io bli, ' ik.
Signature of 411 e Agent Date
■
e `! Department use only
City of Northampton Status of Permit:
jp 2 4 2 °13 Building Department Curb Cut/Driveway Permit
■
L , 212 Main Street Sewer /Septic Availability
Zs - � 1 _
Room 100 Water/Well Availability
°E ' "N Northampton, 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: 40 14. IOW Nit
Map Lot Unit
NO NVPMereils i PAN
A,p bo Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Cyr}laln keholi yO Hfrr iQ w Aire
Name (Print) Current Mailing Addres 0 ^ r o4 - %7C 4 b D
.; li ( � - Telephone
Signature f
2.2 Authorized Agent:
soS 1 (TP.oc, t 64 Hrnywood\ s3, Greer` {z4)N\ o130k
Name (Prin \ Current Mailing Address:
.:Jll:b'� ■gtAl 'Ilk (413) -7N -364A
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) ea-1151,30c, Check Number 7 a
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0717
APPLICANT /CONTACT PERSON JOSEPH GEORGE
ADDRESS /PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604
PROPERTY LOCATION 40 HARLOW AVE
MAP 38D PARCEL 042 001 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 JJQ4
Fee Paid 7 `Z v
Typeof Construction: INSULATE EXT WALLS,AIR SEAL ATTIC /BASMENT
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 • 1 LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF t RMATION 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
D e j,. o el. y
5- t?
Si:.. - •re of Buils g tticial 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.
40 HARLOW AVE BP- 2013 -0717
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D - 042 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Peru lt: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2013 -0717
Project # JS- 2013- 001203
Est. Cost: $2256.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 5706.36 Owner: KELLOGG CYNTHIA
Zoning: URB(100)/ Applicant: JOSEPH GEORGE
AT: 40 HARLOW AVE
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774 -3604 WC
GREENFIELDMA01301 ISSUED ON:1/28/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE EXT WALLS,AIR SEAL
ATTIC /BASMENT
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 1/28/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner