07-024 (5) ifit W. al
PANICIPAIING
mass save COMASTON
Rrvn9+x•oNO crornrvy eN Iricncy
PERMIT AUTHORIZATION FORM
1, , owner of the property located at:
/ (Owner's Name, printed)
. iFr+t5 i'd , r/b re ore A-1 A •
(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.
Owner's 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:
(), Geoff cAAJ DSO) /a3/i3
Participating Contractor Date
Rev. 12132011
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.al 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. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g- ❑ Demolition
working Forme in any capacity- employees and have workers'
insurance.+
9. Building addition
[No workers' comp, insurance comp.
required.]ed-] 5- 0 We are a corporation and its MO Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I l.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]' c. 152,§1(4),and we have no
employees. [No workers' 13.Mi OtherinsUlation
comp. insurance required.]
_Airy 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. 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.�LLic. t� >?Li ) _ Expiration Date:4/29/2014
Job Site Address: "1 N , f vlrtr‘ City/State/Zip: 19'N'trxe, ,AAA
J X1)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 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 certify tinder the pai�nsn and penalties of perjue*r that the information provided above is true and correct.
Signature: \�1► Y 1l. �—V Date: \C),431 3
Phone#:(4-13)-774-36171
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 --
NYt-i =r'C?�r • 4;5 s;i
Massachusetts
",---ter; DEPARTMENT OF BUILDING INSPECTIONS ,• t• ',
s.- %:�' 212 Main Street • Municipal Building 4
.-rte Northampton, MA 01060 s _ �'
Property Address: 4' 9 N , ^r r5 Roc,(h F\Or?nce i' 11 'O Oa
Contractor
Name: 3oSeFI, &?.ol, f a,P. G€otele wuk Son, inc.
Address: 0 $ o+\twooa Sire$i
City, State: &r2e r c-litl A M A 01301
Phone: (Lt13)'77413L°4
Property Owner Dort- Roo i -,./q)
Name: 1
Address: $9 N' Futr S R^(4
City, State: F brfnct , MN
I, Jose( ‘ (OPiQ (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 \ , /L
Date al
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: r(�` Not Applicable ❑
Name of License Holder: 3-030 G of f. c53101°131 a
}
License Number
_ (tt HDIr4/OOd Sttee'c AlA 130 A`_ao11
Address Expiration Date
M,
413)-77%1 Vti
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
S, Q. Geary 0,4 son, ant, 15665
Company Name Registration Number
CLI liolv,i31 Sire-6 6-reer f\e ld+i MA .ol3O\ 7—S-/:old
Addres , Expiration Date
`d Telephone\'tl '774-36oy
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 Dwelliriis 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,von 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) I I Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs (O] Decks EP Siding[0] Other(tit
InSfn Ia4tor■
Brief Description pf Proposed a . Hi JjJ(�,
Work:,
;{ )dot � �It, (And Pts '`tN) ,Ins�o�: ett6o( .wolfs wit% ei\SC p k
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga.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
I,_ Urr-M R Afin 1-'"1 ,as Owner of the subject
property { r
hereby authorize Sa�tk\ 6-eint
to act on my behalf,in all matters relative ro work authorized by this building permit application.
See kk\v‘c\,6 10 /IV/ 1;
Signature of Owner Date
30 seP\\ C-@arty, ,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.
OOSeP\\ Geortv..
Print Name
0113/I
Signature of Owner/Agent Date
Department use only
i l'City of Northampton Status of Permit:
,Building Department Curb Cut/Driveway Permit
, 212 Main Street Sewer/Septic Availability
_
Room 100 WaterlWeu Availability
Electric, Piiimbir g&G zs Inspectior5shamptOn, MA 01060 Two Sets of Structural Plans
Northampton. MA phone 41 587-1240 Fax 413-587-1272 Plot/Site Plans
1-• 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: 4 Q[^ (�( _17,111,s Po iii d‘
7"l ! t Map Lot Unit
F\-"eML, MIS
Zone Overlay District
A)s Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
j` y
c. R()'Nt� 1 . Fermi 11%4 (IiIrt)A.e�MA 0\O P
Name(Print) Current Mailing Address: `14!1) -53 C V - 4��o
Ste, N 3`044 Telephone J J
r Signature
2.2 Authorized Agent:
3-0SepV\ (Tent 69 Hoywoon\ s', Green{z1r\,M.A oi3c
Name(Pri t Current Mailing Address:
�f-77ii —360'
irots).1.404,6
.C\10-y-Alk
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) rip ,Q Check Number • t� •
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings
Date
File#BP-2014-0524
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 489 NORTH FARMS RD
MAP 07 PARCEL 024 001 ZONE RR(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / ^
Fee Paid �[, 'P
Typeof Construction: INSTALL WALL INSULATION,AIR SEAL ATTICBASEMENT
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
INFORMATION PRESENTED:
oved 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
•
/ J
', : r-dar B ficia 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.
489 NORTH FARMS RD BP-2014-0524
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 07-024 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-2014-0524
Project# JS-2014-000898
Est.Cost: $4102.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq.ft.): 250034.40 Owner: ROTHENBERG BARRY C&AMY S WOLPIN TRUSTEES
Zoning:RR(100)/WSP(100)/ Applicant: JOSEPH GEORGE
AT: 489 NORTH FARMS RD
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON:11/4/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WALL 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 11/4/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner