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44-009 mass save: PERMIT AUTHORIZATION FORM i, iw► • as e • ,owner of the property located at: (Owners Name, nted) r . r 10.1--t • 1rCa- t. u.G r .d 4a c� {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. as Signature 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: (5enry, (MA 5O , I'\c, Participating Contractor Date Rev.12132011 — - '7I%(''6 01111110 le/MUNI(/ 7r17.;;(1(11(6(14. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only _ _ •ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: If.k.Registration: 156886 Type: Office of Consumer Affairs and Business Regulation fl) 74Expiration: 7/25/2015 Private Corporatio 10 Park Plaza-Suite 5170 Boston,MA 02116 JP GEORGE&SON INC JOSEPH GEORGE i2A1. Y-17k. 64 HAYWOOD ST GREENFIELD,MA 01301 Undersecretary N t vali t without s 'nature 11Ip 7:- 7- ~"- \ Board a: Constructilm Super _c :38 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): 1.12 I am a employer with 4 4• ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction listed on the attached sheet. 7. El Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have s. ❑ Demolition working for me in any capacity. employees and have workers' comp. insurance:: 9. ❑Building addition [No workers' comp. insurance P required.] 5. ❑ We are a corporation and its I0.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their i 1.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.]' c. 152, §1(4),and we have no employees. [No workers' 13.12 Otherinsulation comp. insurance required.] Any applicant that checks box#1 must also fill 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. 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:Arbella Policy#or Self-ins. Lic.#: I b In-115 Expiration Date:4/29/2014 Job Site Address: 1 1\flLrc-1 "'" ``o�t� City/State/Zip: �� fnt M 61° 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certf'under the pains and penalties of perjury that the information provided above is true and correct. Signature: °A ,il� -=1�' Date: 0 11S/1 Phone##:(413)-774-3604 1 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: City of Northampton i itil rr4� n\-:-Massachusetts l..-t 1 (r 1;_ '_. f,P DEPARTMENT OF BUILDING INSPECTIONS s. ;-?:`--._ 212 Main Street • Municipal Building P 4 mss,:. ._.i .%'c.' Northampton, MA 01060 "', Property Address: 451 (' ')bK l )4 fo�i Flo rerieet w\j} q\Ot? Contractor Name: Jp$epIN Game /a,P. Geory &AA Set\1 Ti-N(.. Address: ,bcl �a+./woo(j r ei City, State: G rP($'e 1dk, M A 01301 Phone: ( 1(3)--17,i- 304 Property Owner ,. Name: �.c��`t Address: 45 \ .oc(1 WiA RG)4 VbffiVi �PI 0IOCA City, State: f I I, Jost?t (arl 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. Contractor signature ` 4 �1/4A Date �/ 1Vi5 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: 0SeQ1\ G2Oto t CS31 `10131 License Number (" Hc"p"o00t st-e\ (.ceenvelo‘t Mq 0130\ Addres Expiration Date 413)-771/10b°4 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ J. Q, Berea- Cnnd■ San, 'tnt 15664, Company Name Registration Number Cy Vtol a S re-e\ (yrffrtf e id, MR .01101 Addr Expiration Date Telephone�I;)-774-36°‘1 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 1083.5.1. 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) ❑ Roofing Or Doors 1] Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding[D] Other[till Irtivt h 4ion Brief Des nption Qf Propo ed + Rd $ 6 Iff , Work: r )ecotl kt tiA)e etili (roe INA4 $ Of �� InoJ; �Sln J coo t, 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. ftoodplain 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 L��l C71 1�l ,as Owner of the subject property hereby authorize SOS I &fOr % to act on my behalf,in all matters relative fo work authorized by this building/permit application. Set 1\ o, e1 4c / 1; Signature of Owner Date 3.0 St \ Create, ,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. UOSe Gepr- t Print Name � T JIMA Signature of Owner!, Date C:Cgi‘4745 Department use only City of Northampton Status of Permit: AUG 2013 Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability DEF iF 131.111,AG INBFECTONS OFTHAtv'TON,MA01060 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 � ��sky H;'�� � Q Map Lot Unit \OT el)C e l C'^1 t Zone Overlay District \ Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: A\■1 451 R,ut.i H►11 Fo0A 1nfe+ite 1NIP' 0106. Name(Print) l f� ed�1rn Current Mailing Address: ] -5)p 7 �`3o 3 See AVolG Telephone Signature 2.2 Authorized Agent: /OSeW Ge r 64 HoIN.Noa S Green{;eIWA.A ofto Name(• Current Mailing Address: ' t IIVIA N{3)-77 -360 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) , hn°Y.5 Check Number .536 / 0v5s This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0201 APPLICANT/CONTACT PERSON JOSEPH GEORGE ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604 PROPERTY LOCATION 451 ROCKY HILL RD MAP 44 PARCEL 009 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out h%� 6 Fee Paid Typeof Construction: INSTALL ATTIC INSULATION&AIR SEAL ATTIC&BASEMENT 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION 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 n Delay Signature of Building 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. 451 ROCKY HILL RD BP-2014-0201 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 44-009 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-2014-0201 Project# JS-2014-000337 Est. Cost: $2750.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH GEORGE 99372 Lot Size(sq.ft.): 10541.52 Owner: MAURER KYLE P Zoning: Applicant: JOSEPH GEORGE AT: 451 ROCKY HILL RD Applicant Address: Phone: Insurance: 64 HAYWOOD ST (413) 774-3604 WC GREENFIELDMA01301 ISSUED ON:8/21/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION & AIR SEAL ATTIC & BASEMENT 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 8/21/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner