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31A-304 (.b - 2- ` Customer ID Lstomer Name € ( \` l l"r-, Address 6c4 t'\ KNOB & TUBE WIRING During the Energy Survey of your home, indications of "knob and tube" wiring were found. This old style of wiring involves individual wires that are run through walls and ceilings in a house, with ceramic "knobs" and "tubes" to prevent contact with wood framing. The knob and tube wiring that has been noted may or may not appear to be active. Even if the observed wiring appears to be inactive, there may still be active knob and tube circuits hidden inside walls or other inaccessible areas of the house. The Mass Save Program requirements require that you have the home checked by a licensed electrician and certified as being free of all active knob & tube wiring where needed, before insulation and/or air sealing work can be done. Your electrician should fill out and submit a copy of this document to the Center for EcoTechnology (CET) in order to verify the absence or inactivity of the knob and tube wiring in the areas of your home where we are proposing insulation to be installed. Due to the liability involved in signing such a form, we suggest you show or describe this form to your electrician before hiring him to inspect your home to be sure he /she is willing to sign it. The Center for EcoTechnology (CET) and the Mass Save program will rely on the electrician determination and certification below and will not be liable if inaccurate. Your home could benefit from ' ulation and/or air sealing in the: ❑ Attic Slope Exterior ❑ Basement Attic Floor ❑ Kneewall Floor a ** Only after this certification is received by CET can a Contract be issued for energy saving insulation and/or air sealing work. ** Electrician's Certification (This form is invalid when any qualifications or alterations are added.) Company Name & Address /1'lfld 1e7 Electrician's Name/CO f'/ Z-(747 License # Ek.5 1 have performed an inspection of the wiring at the home of: 76 e/lt e / Ve. _ at 2 41.02. i ?"'WLce rr oTZ ' tl'-)LL7 t (Owner's Name) (Street Address) (City) Upon completion of my inspection I have found that there is no active knob and tube wiring in the area(s) noted below. ❑ Attic Slope Exterior ❑ Basement Attic Floor O Kneewall Floor Walls f Electrician's Signature Z , �-/ .. Date /-7 Please mail this certification letter to: enter for. coTechnology 320 Riverside Drive 1 -A Florence, MA 01062 Or fax to: 413-586-7351 Rev. 5/24/2012 Please call 800- 238 -1221 with any questions or concerns. Customer (mail -in when completed) - White Customer Copy - Yellow Auditor - Pink ..er," PARTICIPATING ' mass save CONTRACTOR Savings t !Inman 1011110Y Of filSWCY PERMIT AUTHORIZATION FORM 4 -- frey/ , fJ I, , owner of the property located at: (Ow 's Name, printed) • 10A1U,4 A-14. (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. .C./4 , 1‘2- Owner's Signature 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 The Commonwealth of Massachusetts I PrititfOttn Department of Industrial Accidents = Office of Investigations 1 1 Congress Street, Suite 100 Boston, MA 02114 -2017 4 �'w ' * www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � �ov Address: / : City /State /Zip: _ Phone #: Are yo n employer? Che .1 the appropriate box: Type of project (required): 1, am a employer with 4. ❑ I am a general contractor and 1 employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in capacity. employees and have workers' g any P ty 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I 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 insurance required.] t c. 152, §I(4), and we have no 12 �, R re p � employees. [No workers' 13 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1 Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state w hether 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: Policy # or Self -ins. Lic. #: 6 4C / - - � � c� t I Expiration Date: 03 3 Job Site Address: City/State /Zip: 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 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 the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi the pa' - d penalties of perjury that the information provided above is true and correct. Signatures Aar _ = — - - -_:__ Date j 7 Phone #: / y/3 + � - 7 /C 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: /� / J Not Applicable ❑ Name of License Holder : 1 �„ T ar, / Sha ( A.) L S ' 3 c r ( 73z1 License Number n l ' 1 u 1Iv�C � �ZIy ch (cc J4 /0 (3 Address Expiration Date ..t+r '115 Ef Z 5 1 Signature Telephone S. Regittered'.HOme.improvement Contractor Not Applicable ❑ 14 f a (er�%1 "t SCE Lt. C f �P (,, 0 Company Name Registration Number P6 6 X 2 3 - 42 Y - Z./ — �y Address Expiration Date 2 6 A ° f - e- /l 0 /02 t Telephone ` Lj - ( 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 ip No ❑ 116 - 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 6- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs D] ppcIts [Q Siding [D] Other [iE Brief Description of Proposed - ) t� (' Work: ii/ /a �+ 415kkfrit.*� /1 G 1 4ti Jetitt5i 6( Alteration of existing bedroom Yes No Adding new bedroom Yes N o S'64(3 Attached Narrative Renovating unfinished basement Yes No 4-,/e Plans Attached Roll - Sheet sa. 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 I, , as Owner of the subject property j; hereby authorize J �� , /C C^L k ! L`"' act on my behalf, in all matters relative to work authorized by this building permit application. S ignature of Owner Date I, � .(S �� "--/' , as #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 u .: r the . ns and •e - ties of perjury. & 1 thi►.a -' An. Print Name i► Antliir: ,-.' ( " Signature oFAwRer /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 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW YES IF YES: enter Book Page and /or Document #'' B. Does the site contain a brook, body of water or wetlands? NO (J DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES NO 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 0 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. �P C-----ii-7-r\117 - Department use only City of Northampton Status of Permit: 4 2013 \ BwIthnDePartment Curb Cut/Driveway Fermat 1 212 Main Street �rlSeptic Availability a Room 100 Watr/Well Availability I __ _ _ uE , rthampton, MA 01060 Twcr Sets of Structural Plans _ ___ �' - =.' — phone 413 587 - 1240 Fax 413 587 - 1272 Plot/Site Plane` Other Specify, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: n This section to be completed by office ( 9(40 ;etail�S A Ve, Map Lot Unit NO r i GI mp k n M A 01000 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: /� 010 1 -- 1 1 60x /b CiliCa ee /n Name (Print) Current Mailing Address: ic;-1:::___N..........,,..._____ t13 2 -- 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 Check Number 1167 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0796 APPLICANT /CONTACT PERSON JEFFREY BRADSHAW ADDRESS/PHONE P 0 BOX 1276 CHICOPEE (413) 427 -5481 PROPERTY LOCATION 26 JAMES AVE MAP 31A PARCEL 304 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out l /� Fee Paid Tvpeof Construction: INSULATE ATTIC New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 094734 3 sets of Plans / Plot Ply THE FOL ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 - olition De • . e p, 3 Si... - s B " ding 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. 26 JAMES AVE BP- 2013 -0796 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 304 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 -0796 Project # JS- 2013- 001361 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEFFREY BRADSHAW 094734 Lot Size(sq. ft.): 13939.20 Owner: BOND FLORENCE R & HOWARD BOND & JUDITH POGANY Zoning: URA(1001/ Applicant: JEFFREY BRADSHAW AT: 26 JAMES AVE Applicant Address: Phone: Insurance: P 0 BOX 1276 (413) 427 - 5481 CHICOPEEMA01201 ISSUED ON:3/6/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: I NSULATE ATTIC 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 3/6/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner