25C-016 (2) fret
Orst PARTICIPATING
mass save CONTRACTOR
PERMIT AUTHORIZATION FORM
1, -Devoid CT Jot(-r ; owner of the property located at:
(Owner's Name, printed)
1 T y - i 4-119 NA J+. (1,o r.-4Z.aiiv -�/L
(Property Street Address) (City/Town) I
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.
Owner'ignature
e/3///
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:
, Ge��ty, SOr 1 71003
Participating Contractor Date
Rev. 12132011
License or registration va ik!for iqn-sq:Jut
l'eoizatea (VaCcia..k
before the expiration date. If found return to: Office of ConsumciAttarrs guSiness czu.a Ito,'
Office of Consumer Affairs and 0usines3 Rectulation - = HOME IMPROVEMENT CONTRACTOR
Registration: 156688
10 Park Plaza-Suite 51-70 Type:
Boston,MA 02116 Expiration: 7/25/2013 Private Corporatio
-
JP'GEORGE&SON INC
/
\ 11 JOSEPH GEORGE
„
64 HA'.'WOOD ST
— .
\Not valid without signature GREENFIELD,MA 01301
Undersecretary
1 ii--
- - .
— - - -
-- - 7
LIP■27'.
7: E CSSL-099372
JOSEPH P GEORGE
64 HAYWOOD STREET
GREENFIELD MA 01301
- = 02/11/2015
The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
_ Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):J.P. George and Son, Inc. /Joseph George
Address:64 Haywood Street
City/State/Zip:Greenfield/MA/01301 Phone#:(413)-774-3604
Are you an employer?Check the appropriate box: Type of project(required):
1.MI I am a employer with 4 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
These sub-contractors have
ship and have no employees 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. E] We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.9 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.9 Roof repairs
insurance required.]' c. 152,§I(4),and we have no
employees. [No workers' 13.SI OtherinSUlatiOn
comp. insurance required.]
Any applicant that checks box#I must also till out the section below showing their workers'compensation policy information.
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. lithe 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:Arbella
Policy#or Self-ins.Lic.#: "! • I°I 1 Expiration Date:4/29/2014
Job Site Address: ,l 1— ti 11i31 A\ City/State/Zip: tiOr\‘`(Ain , 4P• D I0 b 0
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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
do hereby certi under the pains nd pe Ities of perjury that the information provided above is true and correct.
Sienature: Y` Date: O 71 o3 1
Phone#:(413)-774-36e,
Official use only. Do not write in this urea,to be completed by city or town official.
City or Town: Permit/License#
issuing Authority(circle one):
I. Board of Health 2_Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
; rTrs� . City of Northampton
(--
I : Massachusetts
1?-114� .l, 17 DEPARTMENT OF BUILDING INSPECTIONS `v`al "6
212 Main Street • Municipal Building f
s Northampton, MA 01060 „'
Property Address: \ 1 -11 k Nr"O‘ StVttt
Contractor
Name: SoSe0, Geary, jai ?. G2ot e (,,,,d, Sion, Tnc,
Address: 1.1 HoI\wDoC -tree?
City, State: Greeoc io\ MA
01 301
Phone: C113)-774- 304
Property Owner
Name: i
Address: -1 — 1710 N rk1 9c '
City, State: ND f�hUr Q\',cwt,
I, Jose (eorf Q (contractor)attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
)r_ek.\\
Contractor signature pc
Date 0.7 f c)-3 i,-C
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: JOSON Geer . C53) c 9.31'1
License Number
_ (:1t �$� �,00d Siren.\ Green Ctt ) /t/A 0130\
Addres Expiration Data
OA rt. 413)-771t-313°4
Signature elephone
9.Registered Home Improvement Contractor: Not Applicable ❑
J. P. Creole G4 Son, Tnt, 1SVA
Company Name Registration Number
1-10yw')q d\ 5'fr e fre-enfte Ids, MR 03o1 7-2s-aor
Addre ' Expiration Date
,1 • / OVRIA_Alik 3 6 0 4 1;1-774
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 he 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) I I Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[IX
Irtsvi la}ion
Brief Description of Proposed vtiit Q�C1k «`1 Ott ;^ tr\'r+.. floor. Att 5etAl P tt- f Bowles
Work: �l�
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
b�\A\ t 6(ANN5 ,as Owner of the subject
property
hereby authorize 3bSe Qk‘ Gtorcr
to act on my behalf,in all matters relative fo work authorized by this building permit application.
See tAVACX,e1 °7/01/ 1;
Signature of Owner Date
50Se91\ c3eor> t ,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.
JoSeo, &bone.
Print Name Nih1/4 i , 0W01 III)ICOstrli1/4441/4_•
Signature of Own -a ent Date
06'`k621 IS 55
Department use only
ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
_ _� 212 Main Street Sewer/Septic Availability
DEFT. G h' ''1 GTiUNS
NOFTI;AMPTON,MA C1060 Room 100 Water/Well Availability
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
Map Lot Unit
k 74 `DrtWAmoton/ Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
btfm;) \-1e1 r".4 UVf th1,th Slteee q1 Mr1rY\,fAlt
Name(Print) Current Mailing Address:0 13, t q
See A ) u4 -5
Telephone
Signature
2.2 Authorized Agent_:
JOSe?\ (&e,nt 64 No,Yv,00j■ S}, Gfeen#;e Ap, 013131
Name(-rint) Current Mailing Address:
\ '' • ( t3)-77`t -36out
Signature s 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) C( .�% • 00 Check Number
r This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
174 NORTH ST BP-2014-0046
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-016 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-2014-0046
Project# JS-2014-000115
Est.Cost: $9268.00
Fee:$55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq.ft.): 11891.88 Owner: HELMUS DENNIS
Zoning:URB(100)/ Applicant: JOSEPH GEORGE
AT: 174 NORTH ST
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON:7/18/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 7/18/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner