35-049 (2) r___1 �r. City of Northampton
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= Massachusetts
,'l j�?r DEPARTMENT OF BUILDING INSPECTIONS ,y
212 Main Street • Municipal Building �S
.=mot Northampton, MA 01060 _
Property Address: 61 63 Ryw, oc J Flo rtrte1 ps p 0)0 ka
Contractor
Name: JOSeth &earl, II?. (Rory 0"d S,o'\1 Ir\t.
'yw
Address: bLf H000a Stre2I J
City, State: Green Held(, MA o13O1
Phone: C113)-77't- 360'
Property Owner
Name: i\11crf)C hoover
Address: 0)63 ''iti,n orn ti
City, State: f-brt'te , ig\A
t, 3ose?1. ifsf (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 ..)nkik (l .k. ( 1/4,6j1At—'11,k
Date 04 ft).'13
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4001k
i l(
PARTICIPATING
mass save N
Savings IMG1Un'maw eNid4KY
PERMIT AUTHORIZATION FORM
I, �Y Gt,Y' b a��Y , owner of the property located at:
(Owner's Name, printed)
J r`�/ t�cg 2
(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.
wt, to.
Owner's Signatur- .
2
Date
FOR 080 OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
t
fit (reor)z av4 SDN 1 Inc.._ .... 0t Dajti
______
Participating Contractor Date
Rev. 12132011
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
i-s 1 Congress Street,Suite 100
Boston,MA 02114-2017
- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 11 l Please Print Legibly
Name (Business/Organization/Individual): 3.'t WiZ o J Sort,Ir ., ! Ia�P1` � "e _
Address: I.utWo0f51 SA,
City/State/Zip: lrtvfAlf ti1A , MP+ Oi0 Phone#: X13)-31'1-3144
Are you an employer?Check the appropriate box: Type of project(required):
1.121 I am a employer with I' 4. ❑ I am a general contractor and I
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 any capacity. employees and have workers'
g Y P h' 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 1 l.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.12S1 Other PhSti+lPl f oo
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: e-hN
Policy#or Self-ins. Lic.#: Wc3-7"151%4 Expiration Date: Lilal ta'oi3
Job Site Address: ( ■ itPc4A City/State/Zip: Of�C AAA Dio 6a
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 certify under the pains and I enalties of-peg u91 that the information provided above is true and correct.
Signature: ' ' Date. 0
Phone#: k3 y ((o 9
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 ❑
IT
Name of License Holder: 3-03t01 GOt . CS31 019131 a
License Number
(4 Hci' 00ck scree\ &ee,itelel MH oi301
Ad• ess Expiration Date
Signs r: Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
J• e• &eor5e 04 Son, Int, 1566$6
Company Name Registration Number
6y KuNIVAq d1 Sfief\ (rre f e Idl MA 01301 7—Z-aors
Add - s l 36°4 Expiration Date
acjitAik- Telephone)g)-779-
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 10833.1.
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) n Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [L7 Siding[C7] Other[IQ
In AA laxtm
Brief Description of Proposed 56A1 UkcC pfd
Work: V■14tM\tr ext-tior Poo , inMivve tAeriof w015 wi\ti d{ASefoGI, ct;llu\oSt
ofe men(
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 yOR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, t"t 1� t`ooler •as Owner of the subject
property rr����
hereby authorize NC O\ uforle
to act on my behalf,in all matters relative o work authorized by this building ermit application.
See {kkkoAct,edt �J'1/�a building
Signature of Owner Date
I 3.05 etA Georf3 , ,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.
OoSeON Gefant
Print Name
t . ()Li i
Signature of 0 /Agen Date
1 Department use only
i
City of Northampton Status of Permit:
IQR r� fit` Building Department Curb Cut/Driveway Permit
c"r"aNS 212 Main Street Sewer/Septic Availability
MA01U6° Room 100 Water/WellAvailabil'
Di PT r'�' N Availability
NC) THAi1PTv
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
1.1 Property Address: This section to be completed by office
Ivi
VI-
1.1 Noae� 0163 R7Nn Rik,
Map Lot Unit
tocer'el MI1
Zone Overlay District
olo(
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'WX t\01'31ltr 113 R.�w ?,_00a �o rfncc 1 Mt 0,0‘2.Name(Print) Current Maili g
Address:
See A\kaG1,eA (ill) �°�
Telephone
Signature
2.2 Authorized Agent_
3-0Se0, (rent 64 N,nr.00& s\-, Crreem.( ►IM,A O13,31
Name(Print) Current Mailing Address:
11. 1A.- (ii13)-77`t -3634
Signature Telephone
SECTION -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 f( pp
6. Total=(1 +2+3+4+5) _ a j�3 Li 66 Check Number 50 g l 055
This Section For Official Use Only
Building Permit Number: I sssuu
ed:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-1003
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 963 RYAN RD
MAP 35 PARCEL 049 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out LQ ,�? (�
Fee Paid d
Typeof Construction: INSULATE WALLS,AIR SEAL ATTIC&BESEMENT WEATHERSTRIP EXT DOORS
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 FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
di, • •• - ay
Sig "uil.ing 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.
963 RYAN RD BP-2013-1003
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-049 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-2013-1003
Project# JS-2013-001679
Est. Cost: $2936.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 19209.96 Owner: MCHUGH SUSAN A&MARK B HOOVER
Zoning: Applicant: JOSEPH GEORGE
AT: 963 RYAN RD
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON:5/1/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE WALLS, AIR SEAL ATTIC &
B 'SEMENT WEATHERSTRIP EXT DOORS
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 5/1/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner