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32C-250 r .. WAP Work Order: Job Number: 13-228 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 $1,570.12 Contractor Instructions: Before Starting the Job: During the Job: 1.Please notify us 24 hours before starting or scheduling a job. 1.This residence was built before 1978.Lead safe practices are 2.Obtain required building permit. required. 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: ' i Contractor j ,,/�.�.% �/,/ Date:, / WAP Auditor: Date: Air Page 7 , WAP Work Order: Job Number: 13-228 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 0 $1.79 $0.00 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 white 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 $0.00 I I Page 6 I l l WAP Work Order: Job Number: 13-228 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-lon 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 Wall 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: 13-228 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: 13-228 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 bait 0 $2.20 $0.00 Doors 28-32 in interior solid core door 0 $315.00 $0.00 L Basement/outside door-door only 0 $36750 $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 0 $51.00 $0.00 Repair Striker Plate(WMECO 0 $8.75 $0.00 only) Slide Bolt 0 $9.25 $0.00 Page 3 WAP Work Order: Job Number: 13-228 R-30 restricted-slopes/floored fill 0 $1.48 $0.00 w/cellulose R-30 unrestricted-settled cellulose 0 $1.37 $0.00 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 10 I$0.75 I$0.00 ( I Page 2 WAP Work Order Community Action of the Franklin,Hampshire and North Job Number: 13-228 Quabbin Regions,Inc. Work Order Date:7/29/2013 P.O.Box 1432 Ownership:Renter Greenfield,MA 01302 Phone:413-774-2310 Eastern Weatherization Auditor:Joseph Rosenburg PO Box 249 Email:josenburg@communityaction.us Montague MA 01351 Cell:413-325-3229 Email:easternweatherization @yahoo.com Phone:413-376-1135 Phone:413-772-9950 Cell:413-426-8768 Phillip Bascomb NGRID Electric $1,570.12 52 Holyoke St Total $1,570.12 Northampton MA 01060 Safety Issue(s):Vermiculite Present/Lead Paint Possible Additional Contractor Instructions: Authorized Actual Measure Description Comments Qty Price Total Qty Total Attic Insulation Attic stairs-fill with cellulose 0 $135.00 $0.00 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 0 $1.30 $0.00 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 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 1 Page 1 CC) O N I eT101 oar of-the-Frar rkfm. Hare shrrc,..�nd North fY Cjuabbin Rer>iotzs ENERGY ASSISTANCE DEPARTMENT 393 Main Street Greenfield MA 01301 413-376-1140 or 800-370-0940 ext 140 July 29,2013 Hannah Richards 52 Holyoke St Apt 1 Northampton MA 01060 Re: Weatherization Job Number: 13-223 Dear Hannah Richards, Your energy audit has been approved and processed. The next step is to schedule the work: -Air seal Door(s)(1) -Insulate Attic -Insulate Basement -Repair Door(s)(2) -Replace Door Sweep(s) (5) -Replace Dryer Duct -Weatherstrip Door(s)(5) You should hear shortly from the following contractor. Please coordinate with the contractor to find a date that works for you both. Pat Smith Eastern Weatherization PO Box 249 Montague MA 01351 413-772-9950 When the contractor bills us for the work, I will call you to make an appointment for the final inspection. Community Action does not pay for work until passed by an inspection. Please call me at 413-376-1135 or 800-370-0940 ext 135 if you have any questions. Joseph Rosenburg(Auditor) WAP Work Order: Job Number: 13-223 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 $1,079.98 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: A �,.W41, Contractor ,� ,, Date: WAP Auditor: Date: �( ,, Pr,l' Page 7 WAP Work Order: Job Number: 13-223 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 0 $1.79 $0.00 vinyl(dense pack) Window&Door Replacements 32-36 in Steel pre-hung 0 $640.50 $0.00 replacement door white 32-36 in Wood pre-hung 0 $609.00 $0.00 replacement door white 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 $0.00 I I Page 6 5 WAP Work Order: Job Number: 13-223 Interior Air Sealing&Caulking 0 $75.00 $0.00 Labor only charge 0 $60.00 $0.00 Other 0 $0.00 $0.00 Duct only _ Seal ducts with mastic or butyl 0 $65.00 $0.00 backed tape Weatherstrip(Q-lon 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 Wall 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 $231 $0.00 (dense pack) Drill finish 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: 13-223 Health&Safety I 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 n 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: 13-223 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 ■- .■-■ r e overhead insulation 4 ft 0 $1.87 $0.00 high o less ■- ■ high or ls R-19 high Craw'space ss R-30 insulation 4 ft 0 $1.96 $0.00 ■--■-■., high or less R-30 Garage uing cavity filled with 0 $2.10 $0.00 ■-- ■., blown wn cellulose Other 0 $0.00 $0.00 ■-- .,■ Perimeter 2 in.foam board 0 $2.50 $0.00 ■- --■ or vinyl a Wrap R-5 reinforced foil 0 $1.91 $0.00 ■-or vinyl faced ductwrap Sill insulation Faced R-19 0 $1.58 $0.00 ■- ' � ,�� wherever you can Doors 28-32 in interior solid core door 0 $315.00 $0.00 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 ■- , Repair Striker Plate(WMECO 0 $8.75 $0.00 ■- - only) Slide Bolt 0 $9.25 $0.00 ■- - Page 3 WAP Work Order: Job Number: 13-223 R-19 FGB in open rafters/walls/ 0 $1.47 $0.00 kneewalls R-30 restricted-slopes/floored fill 0 $1.48 $0.00 w/cellulose R-30 unrestricted-settled cellulose 0 $1.37 $0.00 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 $139 $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 0 l$0.75 I$0.00 I I Page 2 WAP Work Order Community Action of the Franklin,Hampshire and North Job Number: 13-223 Quabbin Regions,Inc. Work Order Date:7/29/2013 P.O.Box 1432 Ownership:Owner Greenfield,MA 01302 Phone:413-774-2310 Eastern Weatherization Auditor:Joseph Rosenburg PO Box 249 Email:;josenburg @communityaction.us Montague MA 01351 Cell:413-325-3229 Email:easternweatherization @yahoo.com Phone:413-376-1135 Phone:413-772-9950 Cell:413-426-8768 Hannah Richards NGRID Electric $1,079.98 52 Holyoke St Total $1,079.98 Apt.1 Northampton MA 01060 413-320-7965 Contact Person:Cell Contact Phone:413-587-0729 Safety Issue(s):Vermiculite Present Additional Contractor Instructions: Authorized Actual Measure Description Qty Price Total Qty Total Comments Attic Insulation Attic stairs-fill with cellulose 0 $135.00 $0.00 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 0 $1.30 $0.00 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 0 $1.42 $0.00 fill w/cellulose - 192 $119 $2474: for new addition Page 1 3 - Me C.omin on wealth of frausach zisetts Department of Inausirlai_-_,:cclaen.., Office of_TH37 esti:gallons 600 i'l--ilskin.----5.zon toe "-Jost, ,14-4 02111 -..-- www_ma.52,-.govidia Vi o r ke Ts' Co - t ion Insu.raucc Affichz-v-It: .3ciliclers/C,.)ritrf..,ctorsiEl,T.::rir.iarisP-'iun-Z1- -s '.r•-t-,,t C. r,l 5•-0;,-.1-.-“1-:-;, , 4-..4.;:al...-4,41.--,:. 2.Z.14131:4,1:::::4.4i..0:: 'Please Print = PaSbly 7 Name t-BusinesstorgzunzationlIndividuair.. —a. -g —,-, 1..\:::::....,?-ili2a...-11 ‘ ,',c',..C) . e"--)r.--,It‘.--‘ Address: -Li-- ci -Fa d.e-—-' k -=--y:t. ''-` r' ''') --L' '-' - \_..g..... . ".. i c-N r inj t...11yiSlateiZip: Y)oll . __ Phone 4: If? 6- 5 3 7 - 5c Are...,ou an employer? Check the appropriate boy: ! 1 ! I Type of project(required): I ;...-- - . si. '—: 1 am a uenerillcoinractor and . I.1...,t1 i am a employer with fc.. -• _ employees i full and,:or pari-iiniei.'' have hired the sub-contractors li n- LI 'New c"stni"ri'm 2.[j 1 am a sole proprietor or parmer- listed on the artaehed sheet. i i 7. 2: Rentodelin . Ship and have no employee.s , ' ;— These sub-contractors have ; ( s. Li Demoihion workinu for me ill art Capadiy enipttlYetE and have workers- i i Building,-addition comp.insurance. ! ! w..:Irkers- comp. insurance I , ,-- 7. 77 We are a corporation and its ; 10.L..) Electrical repairs or additions required.] , , 1.1 i I am a homeowner doing all work officers have exercised their I 1 11.fl pi t.”..., o-ns repairs or.o•-,j- :o n s inyself. [No workers' comp. riuln of exemptim per:via ! i Roof repairs 12. 15-,.§ii--1).and We have no I i insurance required.1 t employees. [No workers I i --- r e coin)).insurance required.] 1 i 1/a -1_---16L-tct.ti n “An; applicant that t:hectes has Ft I illUSI'ASO filt:7■1:1:111:Secti;,:i below Ai:wine.their%...orl:cr.F eomptnniation policy information ''.Ilornesawners who suhma this affidavit:min:aline they ate&ma all woal:and:hen lut. ntSide cc,ntraztt-tts must submit a ii ev.affidavit indica:me,inch :Contractors that che..:1;tins box must anazited art acitl a.,,.::::::sait ; : : sor. ttwing.the name of the su:1-contraeloni and staie whether or not th -e e.mines hare etnployets. lithe sub-eontractt.et ha.::cma-.111,:y mu:a prAt-rde then- tt.orkets'zomp policy number. I am CM employer thar is providing workers compensation insurance for my employees. Below is the polii).and fob site information_ iCi...o tri,c2..f ., Insurance Company Name: PI c,..,...1 pi-n,,-...t Cc-,7-1 -r.--,, ,....-....ac. ....f. orr--?c --I , )," 1 Lil't Ckht — U■kt..._1:43e.Anc — --,a)-- Policy:*41 or Self-ins. Lic.:F:_._ W-3 1:111.rd R .1,3 rO___._ _ _____ Expiration Date: -5. i i 1010 I,,`-i Job Site Address: .<2 I/01 I 0 1.—A. › -T-- city,,s-tate:7 in.77W/49.71-1.-1(11/1" 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 NIGL. c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.0()andior one-year imprisonment.as well as civil penalties in the form of a STOP WORK CIRDER and a iine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the Cfi.-k for insurance coverace‘-erification. ...., Ida hereby cl,1/41_,',pier rid pains au 4enalties al t ?..that the information provided oh ye is in 'and correct. Au --...N C - iv Simature: if i, 0 l Date: e /3 ---- — Phone#: L113-11 7 6.-:6 / Official use only. Do not write in this area.at be completed hr city or town official. City or Town: Permit/Lieense 4 1 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityrrown Clerk 4- Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 1 A ) J ■ SECTION 8-CONSTRUCTION SERVICES - a 8.1 Licensed Construction pervisor: Not Applicable ❑ Name of License Holder: 4i � ��/ 7� /019 c 3C License N ber G , o 11�i �4 $ l'� �X � / Andres r/ Ex it tion ate _ v ti rS (( c �I l371 .natur ,., - • • e 9 is tered Home Improvement Contractor _ h__, , ___ ._ __ _ Not Applicable ❑ 'a 5 re/14/ r vrp7X-ter 24yrip4/* / 3 V ? Company Name Registr ion mber 5 iq _e //y Address /�� , Efcpiration Date Telephone 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 • J SECTION 5-DESCRIPTION OF PROPOSED-WORK(check-all-applicable) New House n Addition ❑ Replacement Windows Alteration(s) i l Roofing n Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [la] Decks [D Siding[El] Other[0] Brief Description of Proposed d� f/(6,76 �$dare � f ,fir � Work: f�t'w�/i,�r"/Z.d��/ � / l � � �l7 � '�-.' GIJeti�!�° > Alteration of existing bedroom Yes fro Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa If Nevi 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 . OWN ERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, /`/A /]/J¢ c /t LI> p ,as Owner of the subject property hereby authorize CI / r C-h • ;, to act n my behalf, in all matters rel tive to rk authorized by this building per t appl// 3 n. i ig ature of Owner Date 1, 77 (-( 544/ 7Z-k , 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_un•- • pains and penalties of perjury. Prin/t S.,:in.•''re of Own 1k'g-t Date • d r 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 j Side L; R: L:+- R:° . Rear I , , Building Height s I Bldg. Square Footage 1 I F.----7 % 1 s ; Open Space Footage (Lot area minus bldg&paved I I € parking) #of Parking Spaces Fill: i (volume&Location) A. Has a See, at Permit/Variance/Finding ever been issued for/on the site? NO ffi DON'T KNOW 0 YES 0 IF YES, date issued:, IF YES: Was th ermit recorded at the Registry of Deeds? NO DON'T KNOW 0 YES 0 IF YES: enter Book Page; I a d/or Document#1 B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW Q YES I IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date ued: i C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES NO Q IF YES, describe size, type and location: { E. Will the construction activity disturb(clea ' g,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. i - Department use only ---\ . City of Northampton Status of Permit Building Department Curb Cut/Dnveway Permit AUG 9 2013 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability — Northampton, MA 01060 E NORTHAMPTON MAC1060NS• one 413-587-1240 Fax 413-587-1272 P ot/S te-Plansructural Plans Other Specify = 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: ``-- Ird l y d K� 7 r `Map Lot Unit Zone ' Overlay District Vv -TTG,4.„,,,To4s rrA 0/© 6p Elrn St..Distnct CB:Distract =SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT = 2.1 Owner of Record: fin .4%.t.--4X I! C, Jc �� Name(Print) / Current MailingAddre � �` 7/ 3 ?Y Iifll�Lfs;`/ ,.,4 Telephone ignature . 2.2 Authorized Agent: _ 1 .i/ /A sou // - 57- • /itl f} Na C went Mailing Address: �A .,,//,�� �/„,i/�i-S' g_t/if' D/3 '2 6• .ignat Mr Telephone 1-i/ 3 yz j F 7e”W' SECTION 3--=-ESTIMATED CONSTRUCTION'COSTS Item Estimated Cost(Dollars)to be Of icial-Use Only completed by permit applicant =_ _ ._- - 1. Building 5/� (a);;Building Permit".Fee _ 2. Electrical �(/ (l r (b)'Estimated Total Cost of _ .Construction from (6):.`. _ = 3. Plumbing Building Permit Fee = 4. Mechanical(HVAC) = - 5. Fire Protection .- 6. tal=(1 +2+3+4+5) See) Check Number ._ .. - _ . _ This Section For?Official Use Only __ __ . _.. ..- Date Building Permit Number Issued. Signature - - . :. — - !Building Commissioner/Inspectorof.Buildings - Date : File#BP-2014-0190 APPLICANT/CONTACT PERSON PATRICK SMITH ADDRESS/PHONE 79 CENTER ST MONTAGUE (413)367-2228 PROPERTY LOCATION 52 HOLYOKE ST MAP 32C PARCEL 250 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /33!Z3 gd{5C Fee Paid / Typeof Construction: INSTALL WALL&ATTIC INSULATION&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 FO ING 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 Sig e of Build ng •fficial 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. 52 HOLYOKE ST BP-2014-0190 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C-250 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-2014-0190 Project# JS-2014-000324 Est.Cost: $2650.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PATRICK SMITH 100236 Lot Size(sq. ft.): 7492.32 Owner: ADAM JAMES M&HANNAH RICHARDS Zoning: URC(100)/ Applicant: PATRICK SMITH AT: 52 HOLYOKE ST Applicant Address: Phone: Insurance: 79 CENTER ST (413) 367-2228 WC MONTAGUEMA01351 ISSUED ON:8/22/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL WALL & ATTIC INSULATION & WEATHERIZATION PO ST 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 8/22/2013 0:00:00 $55.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner