14-006 e z
mass save GIIITRACTOM
Savings tMOUgh energy elryGCncy
PERMIT AUTHORIZATION FORM
t1�' !�5( , owner of the property located at:
(Owner's Name, printed)
3 / Cl, eedr
(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.
Owners Signature
/I /i
Date
FOR CET OFFICE USE ONLY
Center for EcoTechnology has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
Rev.5/24/2012
City of Northampton
tr• � (------\\_,,,...s rir C Massachusetts x :,y; 'DEPARTMENT OF BUILDING INSPECTIONS k f J
?Z� 212 Main Street • Municipal Building '<''-7 .
Northampton, MA 01060
Property Address: 3c KR"ail Aoon Leal i No
Contractor
Name: joSeo, Georg, /J.P, George 0,4 S,oi\ *Inc
Address: t Hiw0o(A Strtei
City, State: Genre Ci,21(c, mp, oUO1
Phone: 0113)-779-, 3604
Property Owner
Name: QzAer Der QS
Address: 3c10 kin iy K004 itPa5, Mfl
City, State: LeeckS i In
I 3ost(A, &Cor) (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 \iI\,
Date ,5'. Pl O
The Commonwealth of Massachusetts
`=a Department of Industrial Accidents
Q'—? Office of Investigations
l ! 600 Washington Street
"• Boston,MA 02111
'' ,-- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ( Please P rint Legibly
egibly
Name(Business/Organization/Individual): ` ' 1 or3t i r .∎ S "!A If)i,• f J's e c\\ (,t rt t
Address: `t ti01' l
S\ Cf\
City/State/Zip: b�-rtef e\&, MI\ 01301 Phone#: 0. i) 774 "331/
Are you an employer?Check the appropriate box: Type of project(required):
119 I am a employer with kt 4. 0 1 am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.0 1 am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
g Y P tY t 9. 0 Building addition
[No workers'comp.insurance comp.insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 12.0 Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.[N Other DIiL11A\-`s^^
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. nn l
Insurance Company Name: Clr D?ttl'\
Policy#or Self-ins.Lic.#: k 11,1 Expiration Date:
14 119 I' �Lt
Job Site Address: 3� R f M'i? C4 City/State/Zip: 1-eeti S 1 Wu 0163
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 c i 'under the pains a penalties of perjury that the information provided*y\ above is true and correct.
Signature: . ((,
Date: 5i"1 113
II
Phone#: ( 3) -119 36()
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#:
License or registration vatic for iint1ti•id l use 0,.,- �
before the expiration date. If found return to: Office ofConsumer A(farira&�n mess Reg .a`tioli
Office of Consumer Affairs and Bns:nes Regulation HOME IMPROVEMENT CONTRACTOR
10 Park Plaza-Suite 5170 = Registration: 15668E Type:
Boston,MA 02116 ="Z'' Expiration: 7/25/2013 Private Corporatio
JP--GEORGE&SON INC
� JOSEPH GEORGE
Not valid Without signature 64 HA
ST
GREENFIELD,MA 01301
Undersecretary
°.1:1..achu.ett. - 1)ep,,ti•tnicnt Of Public aicti
Board of Builtlin_ 1 ettilatinns and ,,tantlartlo
Corisc°_ .or, Supervisor Specialty L ice-:se
License: CS SL 99372
Restricted to WS,IC
JOSEPH GEORGE *gam
64 HAYWOOD STREET
GREENFIELD, MA 01301
Expiration: 2/11/2015
( nuni••i ncr
Tr--- 99372
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ��,, Not Applicable ❑
Name of License Holder: 3-03e f1\ Geor t cs31 9311,
License Number
11 Hni.,00dt 3 ttee't (ree,Ai thl Iv% 01301 a.-1l-aol�
Address Expiration Date
AlLik ' 413)-7741-3b04
77't-3boy
Signature II Telephone
9.Registered Home Improvement Contractor; Not Applicable ❑
9• 6eolQ [At SoN Tnc, 156(38‘
Company Name Registration Number
\'1U`w,o i Slte-e\ 6-fet.4\ It), MR o1301 7—JS-aoI
Addre ` - 2 Expiration Date
�4 j 1 Telephoned 13 -774-3604
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) n Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[D] Other[PA
Jn5tn baton
Brief Description of Proposed \ iikt � (��)�°,y �0 iv,n1 Ih)�(��'s0,,, n (A< set �} it fMi �(/, ' 4)
Work: *�F/"
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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
X12 r bef at ,as Owner of the subject
property
hereby authorize Sale ek\ George
to act on my behalf,in all matters relative?o work authorized by this b uilding permit application.
See M-kCnG.\,4 C / / 1;
Signature of Owner Date
I 3.0 s ep\ CjQotty, ,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.
U0Se PA\ GeOrtitt
Print Nam: 1 ;4,
Signature of• r/Ag- t Date
a! f tJ Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
MAY 1 3 2013 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability INSPECTIONS rthampton, MA 01060 Two Sets of Structural Plans
-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
39 j (ent\eGki o(A41
Map Lot Unit
Zone Overlay District
0 1 OS
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
(?e\ r pegs 300 0 \01 p) Lee(11, MI; 010c3
Name(Print) Current Mailing Address:
See, �'�k�ctie� C�t131 (/‘ 1443
Telephone
Signature
2.2 Authorized Agent:
SoSepl\ GewAt 64 HUy ood\ St. Gseer{ite gift\ 013'31
Name(Pri Current Mailing Address:
' • (413)-77 -3604
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) a,60( ,'3.t Check Number L67, 9 c 63-
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-1092
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 390 KENNEDY RD
MAP 14 PARCEL 006 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid G�
Building Permit Filled out 0—/ ! f s
Fee Paid
Typeof Construction: ADD ATTIC INSULATION&AIR SEAL
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 FOLLO • •• ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN O' TION 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
1
AOIX7/ S-/Y-7_3
Sig . re of tuilding 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.
390 KENNEDY RD BP-2013-1092
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 14-006 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-2013-1092
Project# JS-2013-001803
Est. Cost: $2696.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): Owner: DEROSE PETER L
Zoning: Applicant: JOSEPH GEORGE
AT: 390 KENNEDY RD
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON:5/14/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD ATTIC INSULATION & AIR SEAL
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 5/14/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner