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23A-187 WAP Work Order: Job Number: 13-194 Glass replacement per ui over 64 0 $1.50 $0.00 Glass replacement to 64 ui 0 $44.00 $0.00 Other 0 $0.00 $0.00 Side Press Lock 0 $9.50 $0.00 Storm Windows 0 $0.00 $0.00 Top Sash Lock 0 $9.50 $0.00 Weatherstrip Window/Schlegal or 0 $6.00 $0.00 equivalent Total $5,499.28 Contractor Instructions: Before Starting the Job: During the Job: 1.Please notify us 24 hours before starting or scheduling a job. 1.Incorporate lead safe practices as applicable. 2.Obtain required building permit. 2.Total for Heath&Safety and Repairs cannot exceed$2500.00. 3.Davis Bacon time sheets required for ARRA work on US Department of Labor Certified Payroll Report Form WH-347. 4.Photograph any air sealing or other work to be covered by insulation. Your Invoice Must Include: 1.Client name,client address and job number. 2. Signed and dated copy of the work order. 3.Pre and post blower door test results. 4.Attic inspection form. 5.Copy of certificate of insulation. 6.Copy of building permit. 7.Manufacture labels from replacement doors and windows. 8.Photographs of air sealing or other work covered by insulation. Certificate of Insulation posted? Yes No (Circle One) Attic Inspection form attached? Yes N/A (Circle One) Where Posted: Contractor: Date: WAP Auditor: Date: Page 7 WAP Work Order: Job Number: 13-194 Spray Foam Walls-CDC ONLY 0 $1.12 $0.00 Test drill 4 sides 0 $60.00 $0.00 Vinyl over asbestos(dense pack) 0 $2.31 $0.00 Window Weight Voids(pair) 0 $12.00 $0.00 Wood clapboard/shakes/shings or 1440 $1.79 $2,577.60 vinyl(dense pack) Window&Door Replacements 32-36 in Steel pre-hung 0 $640.50 $0.00 replacement door w/lite 32-36 in Wood pre-hung 0 $609.00 $0.00 replacement door w/lite Basement window replacement 0 $250.00 $0.00 (awning/hopper) Basement window replacement 0 $250.00 $0.00 with a frame CDC Windows 2 0 $357.43 $0.00 Other 0 $0.00 $0.00 Prime window replacement w/low-e 0 $350.00 $0.00 to 73 ui Prime window replacement w/low-e 0 $350.00 $0.00 to 74-83 ui Prime window replacement w/low-e 0 $350.00 $0.00 to 84-93 ui Prime window replacement w/low-e 0 $350.00 $0.00 to 94-101 ui Replacement Grids(per window) 0 $42.00 $0.00 Replacement window per 12/29/10 0 $350.00 $0.00 Tech Manual revision Sliding door replacement per WAP- 0 $1,100. $0.00 IM-2011-009 00 Sliding exterior door replacement 0 $1,100. $0.00 per WAP-IM-2011-009 00 zCDC Door 0 $490.00 $0.00 zCDC Window Replacement 1 0 $312.00 $0.00 Windows Deadlights 0 I$0.00 I$0.00 I I Page 6 WAP Work Order: Job Number: 13-194 Interior Air Sealing&Caulking 0 $75.00 $0.00 Labor only charge 0 $60.00 $0.00 Other 0 $0.00 $0.00 Replace Clothes Dryer Transition 0 $40.00 $0.00 Duct only Seal ducts with mastic or butyl 0 $65.00 $0.00 backed tape Weatherstrip(Q-Ion or equal)& 0 $33.50 $0.00 R-30 attic hatch Weatherstrip(Q-lon or equal)attic 0 $31.50 $0.00 hatch zCDC Airsealing 0 $62.46 $0.00 Other Other 0 I$0.00 I$0.00 I I Permit Building permit 0 $1.00 $0.00 Other 0 $0.00 '$0.00 Permit$50 0 $50.00 $0.00 Permit$35 0 $35.00 $0.00 Wail Insulation Bay Window insulate above*below 0 $100.00 $0.00 -your option as to method and Brick/Stucco(dense pack) 0 $2.89 $0.00 Double nailed asbestos/aluminum 0 $2.31 $0.00 (dense pack) Drill fmish patch plaster(dense 0 $1.90 $0.00 pack) Drill rough plaster patch or finish 0 $1.82 $0.00 wood plug(dense pack) Other 0 $0.00 $0.00 Single nailed asbestos/asphalt 0 $2.21 $0.00 (dense pack) Page 5 WAP Work Order: Job Number: 13-194 Health&Safety Basement window w/framing- 0 $250.00 $0.00 building code compliance(non- Clothes dryer vent including 0 $89.00 $0.00 Exhaust Duct Gutter Replacement(includes down 0 $6.50 $0.00 spouts) Knob&Tube Inspection,fuses, 0 $175.00 $0.00 wiring Other 0 $0.00 $0.00 Vent kit/bath fan 0 $89.00 $0.00 Misc Insulation 2"Foam Board on Door 0 $54.00 $0.00 Domestic water pipe wrap 0 $2.63 $0.00 Duct insulation R-5 0 $3.10 $0.00 Hydronic pipe insulation 1.25-1.5 0 $3.68 $0.00 in.copper pipe R-5 Hydronic pipe insulation to 1 in. 0 $3.41 $0.00 copper pipe R-5 Other 0 $0.00 $0.00 Steampipe insulation 3 in.iron pipe 0 $7.61 $0.00 R-5 Steampipe insulation to 1.5-2 in. 0 $6.35 $0.00 iron pipe R-5 Steampipe insulation up to 1.25 in. 0 $5.51 $0.00 iron pipe R-5 Misc Measures Attic sealing with two-part foam 0 $75.00 $0.00 Basement sealing with two-part 0 $75.00 $0.00 foam Blower door set-up with pre&post 0 $45.00 $0.00 tests Cut/close attic-kneewall access 0 $78.75 $0.00 Cut/finish attic-kneewall access 0 $105.00 $0.00 Page 4 WAP Work Order: Job Number: 13-194 Basement overhead insulation R19 0 $1.58 $0.00 Fiberglass Basement overhead insulation R30 0 $1.82 $0.00 Fiberglass Belly repairs-foam board 0 $2.00 $0.00 Belly repairs-labor 0 $60.00 $0.00 Crawlspace overhead insulation 4 ft 0 $1.87 $0.00 high or less R-19 Crawlspace overhead insulation 4 ft 0 $1.96 $0.00 high or less R-30 Garage ceiling cavity filled with 0 $2.10 $0.00 blown cellulose Other 0 $0.00 $0.00 Perimeter 2 in.foam board 0 $2.50 $0.00 Perimeter Wrap R-5 reinforced foil 0 $1.91 $0.00 or vinyl faced ductwrap Sill insulation Faced R-19 0 $1.58 $0.00 Sill two-part foam w/fiberglass batt 0 $2.20 $0.00 Doors 28-32 in interior solid core door 0 $315.00 $0.00 Automatic Sweep 2 $23.00 $46.00 Basement/outside door-door only 0 $367.50 $0.00 Basement/outside door-w/jambs 0 $435.75 $0.00 Fixed Sweep 0 $15.75 $0.00 Lockset/Schlage or equal 0 $73.00 $0.00 Other 0 $0.00 $0.00 R-5 Ductwrap or R max on door 1 $51.00 $51.00 Repair Striker Plate(WMECO 0 $8.75 $0.00 only) Repair/Refit Door 3 $52.00 $156.00 Slide Bolt 0 $9.25 $0.00 Weatherstrip s/Q-lon or equal 2 $45.50 $91.00 Page 3 WAP Work Order: Job Number: 13-194 R-30 restricted-slopes/floored fill 10 $1.48 $0.00 w/cellulose R-30 unrestricted-settled cellulose 664 $1.37 $909.68 R-38 unrestricted-settled cellulose 0 $1.47 $0.00 R-49 unrestricted-settled cellulose 0 $1.61 $0.00 Reinforced poly/R-20 cellulose open 0 $1.84 $0.00 rafters Reinforced poly/R-30 cellulose open 0 $2.05 $0.00 rafters Site Built pull down stair insulation 0 $180.00 $0.00 2 in foam box Spray Foam&Mesh&Blow CDC 0 $1.39 $0.00 ONLY Tenmat Recessed Can Cover- 0 $30.00 $0.00 pending approval Thermodome or Magnetic pull 0 $180.00 $0.00 down stairway box Attic Ventilation 1/2 Window Gable Vent 0 $118.00 $0.00 Other 0 $0.00 $0.00 Propa Vent 0 $4.00 $0.00 Rectangular gable vent 0 $92.00 $0.00 Rectangular soffit vent 0 $27.00 $0.00 Ridge vent 0 $23.00 $0.00 Roof vent 135(1 sq ft NFV)large ,0 $95.00 $0.00 Roof vent 865(.4 sq ft NFV)small 0 $80.00 $0.00 Stack Vent 0 $152.00 $0.00 Turbine Vent 0 $168.00 $0.00 Varipitch vent 0 $114.00 $0.00 Basement Insulation 6 ml poly on ground fo I$0.75 I I Page 2 WAP Work Order Community Action of the Franklin,Hampshire and North Job Number: 13-194 Quabbin Regions,Inc. Work Order Date:6/13/2013 P.O.Box 1432 Ownership:Renter Greenfield,MA 01302 Phone:413-774-2310 Eastern Weatherization Auditor:Joseph Rosenburg PO Box 249 Email:jrosenburg@communityaction.us Montague MA 01351 Cell:413-325-3229 Email:easternweatherization @yahoo.com Phone:413-376-1135 Phone:413-863-5215 Cell:413-426-8768 Octavia James-Gentles / Bay State Gas $5,499.28 154 S Main St Total $5,499.28 Apt.3 Florence MA 01062 413-923-4661 Landlord Name:William&Mary Jo Nagle Landlord Phone:413-531-5511 Safety Issue(s):Asbestos:No BL.DR. Additional Contractor Instructions: Authorized Actual Measure Description Qty price Total Qty Total Comments Attic Insulation Attic stairs-fill with cellulose 1 $135.00 $135.00 Attic/Kneewall Floor Transition 0 $2.52 $0.00 Dense Pack w/cellulose Kneewalls R-12 cellulose behind 0 $1.73 $0.00 permeable membrane Other 0 $0.00 $0.00 R-10-12 restricted-slopes/floored 360 $1.30 $468.00 fill w/cellulose R-10-12 unrestricted-settled 0 $1.21 $0.00 cellulose R-11 FGB in open rafters/walls/ 0 $1.31 $0.00 kneewalls R-18-20 restricted-slopes/floored 750 $1.42 $1,065.00 fill w/cellulose R-18-20 unrestricted-settled 0 $1.29 $0.00 cellulose R-19 FGB in open rafters/walls/ 0 $1.47 $0.00 kneewalls Page 1 „ • 5145753 oit't6 3,04-05,15$1:1 kj CLAN HG X DM 5-11 M a:=4, qt'• SMITH PATON:KG 79 Man ST MONTAGUE,MA 3* ” 01351 so,s,Ten .Ativir;e2 . . - Stipt:r1,Nur`)1/vcialt...k. CSSL-100236 1 PATRICK G SMITH 79 CENTER ST. Montague M 01351 04/05/2014 e 0 fi c e Weo 111 ds(tiegg tailitreolP 7HOME IMPROVEMENT CONTRACTOR Alt1-4-e=17 Registration: 134741 Type: r`f E ==, xpiratton: 1/11/2014 DBA EieERN WEATHERIZATION PATRICK SMITH 79 CENTER ST MONTAGUE,MA 01351 Undersecretary n� CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYY) l ns/1FU2013 FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER.AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). `_ t \,� PRODUCER CONTACT,,,.1} C ■ S--l^G'c7 Q( V) s ` KNIGHT DIK INS AGCY INC PHONE 5G(-6 -75Z FAX FAX 5 -7 s Q.--. 17 , 440 MAIN ST (NC,No,Ext): (A/C,No): E-MAIL WORCESTER,MA 01608 ADDRESS: Q C.■ 1"4‘1\t");c.al-Vc \V\ , Cot V 77R3D INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: ACE AMERICAN INSURANCE COMPANY SMITH,PATRICK G DBA EASTERN WEATHERIZATION INSURER B: INSURER C: INSURER D: PO BOX 249 INSURER E: MONTAGUE,MA 01351 INSURER F: COVERAGES CERTIFICATE NUMBER REVISION NUMBER: THIS IS TO CERTFY THAT THE POUCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDmON3 OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIDDIYYYY) (MMtDDIYYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE i$ I COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ CLAIMS MADE a OCCUR. PREMISES(Ea occurrence) MED EXP(Any one person) I$ - PERSONAL&ADV INJURY $ GENII AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE r$ - POLICY 0 PROJECT p LOC PRODUCTS-COMP/OP AGG j$ AUTOMOBILE LIABILITY COMBINED SINGLE '$ - ANY AUTO LIMIT(Ea accident) - ALL OWNED AUTOS BODILY INJURY i$ - SCHEDULE AUTOS (Per person) - HIRED AUTOS BODILY INJURY 15 NON-OWNED AUTOS (Per accident) III PROPERTY DAMAGE I5 - {Per accident) S - UMBRELLA LIAB E OCCUR EACH OCCURRENCE j$ EXCESS LIAB C CLAIMS-MADE AGGREGATE j$ DEDUCTIBLE 1$ ill RETENTION $ I$ A WORKER'S COMPENSATION AND x WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-5884761A 13 03/01/2013 03/01/2014 LIMITS ANY PROPERITORIPARTNER/EXECUTIVE © N/A E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMSER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 1$ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT i$ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR SMITH,PATRICK G. ACTION INC NATIONAL GRID USA AND IT SUBSIDIARIES AND KEYSPAN ENERGY DELIVERY AND ITS SUBSIDIARIES MTC G.LC.A.C.INC CERTIFICATE HOLDER CANCELLATION SPRINGFIELD COMMUNITY ACTION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 721 STATE ST BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL B DE 0 IN ACCORDANCE WITH THE POLICY PRO •• AUTHORIZED REPRESENTATIVE SPRINGFIELD,MA 01109 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 1988-2010 ACORD CORP•- •lidie A f glh4i reserved. The Cominottwealth of Massachusetts f_ Department of Industrial Accidents =1,„„4-1...._,Et Office of Investigations �.'��", 600 Washington Street =vim. Boston, MA 02111 iti '�'- „„0,0, R'wtu.mass.bovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly , ,.L P eat C k C.K Name i Business,'()rganizationilndividuai _� Y% ec In-1 2Ct t\(�e CYt t r� Address: W 1 ci F'c-1 es a..1 f-i-j rq_._Sc.t.; a . - _ • t.ti 9 CitviStateiZip:i1 iO1n 4- c,,ui-._.M—i ct l Phone #: `'1I'? 6'5-3l) 15 - 913 ?.-7a_9' 5o Are you an employer. Check the appropriate box: Type of project(required): I.X I am a employ=er with _ to 4. ' '• I am a general contractor and 1 t ti. D New construction employees(full andlor pan tun.).' have hired the sub-contractors t 2 listed on the attached sheet. . . Remodeling E 1 am a Sole proprietor or partner- _ I ship and have no employees These sub-connactors have ( g- 7 Demolition vyorking for me in in t 'pity. employees and have workers p- ' 1 9. r! Building addition [No workers' comp_ insurance camp tnsnranct.t required.] We a corporation and its 10.5 Electrical repairs or additions f 3. 1 am a homeowner doing all work officers have exercised their I I. j Plumbing repairs or additions right of exemption per MU myself. [To workers comp. ! 12.^ loot repairs insurance required.]' c. I I(-I).and we have no employees. [No workers' 1 13.X Other Weal."'her t Zino ni 1 comp. insurance required.] 1 1 fC 1,•(5uICL]'iot') "An} applicant that checks hex::I must also fill out the sect i m i•cle w sit iwrng their workers'compensation policy irttotntatiun 'Homeowners who submit this affidavit indicating the\ are donut all ts-ott and then hire outside contractors must submit a ness affidavit indicating such :Contractors that check this box mast attadied an additional sheet show•mg the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employee;,they must provide their workers'comp.policy number. I am an employer thar is providint,workers'compensation insurance for tart employees. Below is the policy and fob site information. . PiL'."-1 C-1 Insurance Company Name: AGt= prole:_t_co_cy s-„` v:.-a.C:,.:,'�G t of va —/—('q. ht -U 1-13ex--) j Policy or Self-ins. Lie. =: 5 ►j5 :j_(Ci( A t.}_ _.._—.—_ —_— Expiration Date:_�1 1 !:2+^ ! y �,/ C� Job Site Address:/S / SOUT4 ,n'IOa* S�_---_- —_-CitviState.Zip: �'”%(P/vice �D6, Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required tinder Section 25A of N161._ c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 anti 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 coverace verification. A. I do hereby cif,t/der t, ants an a enalties of l'that the information provided ahoy s Ito and correct. Signature: ( ��,�� - —-- Date: -,d /7 P h o n e / `l/ 3 3/0-3 2 i 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. CitytTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION-SERVICES- 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 09 7. ent Contractor ____ W ___,07_w_. . _ y__. _,._.' Not Applicable ❑ Company Name Registration Number _ Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G L c.'152,-§-25C(6)Y:':-( - 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 El Replacement Windows Alteration(s) n Roofing n Or Doors 0 Accessory Bldg. El Demolition ❑ New Signs [D] Decks [E] Siding[D] Other Brief D !c iption of Proposed Work: A westrA€ , i.4Tlo4 c /OSt /fr$ 41/•A/ '9/714 *`l/4//$ Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa !f_NeW house and or addition to existing` _.__. � g 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 Al eiT/erlz,.T ID A/ 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, Vt/ill 4..n So /t14 4' , as Owner of the subject property -�+v hereby authorize /O�//S(Gam" C / to act on my behalf, in all matters relative to work aut 7Z' ized by this building permit plicati n. Y Y 9P P ►�� / /3/ 3 Signature of Owner Date o ` ( 1 /fr / , 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_u := the pains and penalties of perjury. .41 Pnn A . i irif,r '.ignature of Owner/•rent 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 ' I _ _ f � I Frontage : 1 Setbacks Front 1 t i f f i r---i I F Side L:,-----1 R: _i L:L_._._..; R:t t i 3 Rear ■ I Building Height i ; i i i Bldg. Square Footage i I % ∎ i € I Open Space Footage /o (Lot area minus bldg&paved 1 i 1 f I parking) - #of Parking Spaces s 1 Fill: i (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 DONT KNOW (0 YES 0 IF YES: enter Book Page; Document#I j B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ) Obtained , Date Issued: ! � C. Do any signs exist on the property? YES 0 NO l 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: ' I 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 0- IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • . rt-ex.s, 64., ( 4„,.,7 -6 ci,,,,T,,,L,..7-6,— . , ,, . ..., . , .,. ..„ Department use only ' i F City of Northampton Status of Permit CI E s "r is {/,yr — Building Department Curb Cut/Driveway Permit , CI' 6="' `"==-- 212 Main Street Sewer/Septic Availability .. =--,ii Room 100 Water/Well Availability JUN f 2013 N orthampton, MA 01060 Two Sets of Structural Plans ,. 1 `. phon 413-587-1240 Fax 413-587-1272 Plot/Site-Plans - '. DEPT.OF BUILDING INSPECTIONS Other:Specify`: NOrITI IAMPTAN,MA 01068 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: Map Lot Unit Zone 'i Overlay District Elm St f Distpct CB District - SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT - 2.1 Owner of Record: W//I/A,•? ,/-'In ar—Y _ So NA /5Y 5, ni4t.t. 5 ( ,4PT 3 Name(Print) '`✓ Current Mailing Address: Signature )-1-4(,,,4- Telephone/ c 2.2 Authorized Agent: .yam/ y, sOV Y/► �v4 Sr l-a�? eh Sm i / k 77 p,-,t/ec s ,w//s „/,# 0/576 Nam rint) Current Mailing Address: S nature Telephone SECTION 3--ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant . 1. Building (a) Building rm Peit Fee 2. Electrical (b) Estimated-Total'Cost of -.Construction from (6) 3. Plumbing BuildingliPermit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) / 9 q, A.$ Check Number 1 =,f. - -. ,This Section For Official Use Only Date Building Permit Number. - Issued. ': Signature. Building Commissioner/Inspector of Buildings; Date - • File#BP-2013-1213 APPLICANT/CONTACT PERSON PATRICK SMITH ADDRESS/PHONE 79 CENTER ST MONTAGUE (413)367-2228 PROPERTY LOCATION 154 SOUTH MAIN ST MAP 23A PARCEL 187 001 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 /01 $ 6-( Fee Paid O` Y� Typeof Construction: INSULATE ATTIC,WALLS&WEATHERIZATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 100236 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Demolition Delay i UC A' r (.0`-/4 43 Signature of uil g Of is 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. 154 SOUTH MAIN ST BP-2013-1213 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A- 187 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-2013-1213 Project# JS-2013-001985 Est.Cost: $5500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PATRICK SMITH 100236 Lot Size(sq.ft.): 59241.60 Owner: NAGLE WILLIAM P JR&MARY JO Zoning:URB(100)/ Applicant: PATRICK SMITH AT: 154 SOUTH MAIN ST Applicant Address: Phone: Insurance: 79 CENTER ST (413) 367-2228 WC MONTAGUEMA01351 ISSUED ON:6/19/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC, WALLS & WEATHERIZATION 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 6/19/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner