22D-053 WAP Work Order: Job Number: 13-509
Wall Insulation
Double nailed asbestos/aluminum 885 $2.31 $2,044.35 check first this may be a 1 1/2 X 3"walls
(dense pack) with small bag insulation
Windows
Glass replacement to 64 ui 1 $44.00 $44.00 bed
Total $3,975.15
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 52500.00.
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.
Blower Door Test Results Pre Post
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 2
WAP Work Order
Community Action of the Franklin,Hampshire and North Job Number:13-509
Quabbin Regions,Inc. Work Order Date:11/18/2013
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
Margaret Welch Bay State Gas $3,975.15
24 Ryan Rd Total $3,975.15
Florence MA 01062
413-584-1482
Safety Issue(s):Lead Paint Possible
Additional Contractor Instructions:
Authorized Actual
Measure Description Qty Price Total Qty Total Comments
Attic Insulation
R-30 unrestricted-settled cellulose 840 $1.37 $1,150.80 has super large gable end vents
Doors
Automatic Sweep 2 $23.00 $46.00
Repair/Refit Door 2 $52.00 $104.00
Weatherstrip s/Q-lon or equal 2 $45.50 $91.00
Misc Measures
Attic sealing with two-part foam 6 $75.00 $450.00
Blower door set-up with pre&post 1 $45.00 $45.00
tests
Page 1
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rtazii II copy al the wurkers'compensation policy declaration tie(shard:4.5 the policy rattraber:and trs.Dir-.1tion date).
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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 I I I
Frontage I II I 1
Setbacks Front 1 ( I I
Side L: R: Li I R:C
Rear I I I I I
Building Height I 1 J I
Bldg.Square Footage I I % ! I 1 I I
Open Space Footage %
(Lot area minus bldg&paved 1 I J ( I 1
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT 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 and/or Document# 1
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued: 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 Q NO 0
IF YES, describe size, type and location: 1
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 ® NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
• SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House El Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors C
Accessory Bldg. El Demolition El New Signs [0] Decks [p Siding[0] Other
Brief Description ot Proposed v / 7- �7-�C /�s+ SAP '�"�C4
Work: WeetThelt 2.4TM�/ `i- �Cre /N5v a t tv k 1�Gt/�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
yT_r
sa.,If...New-.10iii ntl<oraddlfiaiiiiaxlStmAaiousina : fila to ifii asaikitiii
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 /I4r,q,' P f G(4 '/ 'j ,as Owner of the subject
property J
hereby authorize /a'77 L-4 ,S� /d�' "`
to act on my behal,in all matters relativ to work authorize y this building permit application. ,
// •C)//' 3
Sign re of 0 r Date
I, Q 7'7 f( K S/ 1 /� ,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 p d penalties of perjury.
( /
Print Name j die, II —A G_l 3
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
FAS1"FRN
Name of License Holder:
rw I . 1 T�ZA License Number
1 l 1 O l�. V N /
ck G Smith /Do A
Address f >Or 3 X p V I Expiration Date
i7 y ,'a, L�
Sig�` phone ' //S /
9.:Registeted.Nome_Improv rr]ent Corva- or ,: ,7 ._._,. .7: ,. _= Not Applicable £
l .tt
Company Name - Registr tion Number
1LA1IO\ / fr7yr
Address ` r7'lh Expiration Dat
T&eptonm t °'. ////
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�(.�wner.�zemption
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
Nii •
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P F-T--. - Building Department
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Wf-4175ii.:".0%-:
NOV 2 5 aii:-.,
I Room 100
Northampton, MA 01060 .i...1-..
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phone 413-587-1240 Fax 413-587-1272 Br_,.. ,pia!wel.s. .
Elect . klrrieit4r.'atYa.,,f'-*X
ric, Piurnbmc ,,, ,
-
APPLICATION i tl.)CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION - ::::: . :.
WRIC_W --Lit-AT,hittriratibittoWeVetkifOleftdilliOttiOV4-.-9)M.::f,L,:',
1.1 Property Address: i 4774 =1,7;_tV1---....,4-0:.---.,,. :,...,_- ;,,,,-- 7,,,.,:z.-f--- .W.,1cS,'.4..,.„,_,-,F,-...,.-s-eiz4n,---*77_,.:is.1:-.7-.:,,_,,,,r;‘,2
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SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: i
Marc-er we/c/ 21.1 4, - ei/ ./a.. r-,ce Avo- c /O 6
Name(PAU) Current'Mailing Address:
k/e le. /r1 Telephone 7 3 5 2.r 1 y 8..2_
Signatur TC' ,1. ii.RN
2.2 Authorized Agent:, \NT EAT 1 1F 1'7 i'''T 1 0 Ni
i _, IL,_ 1 _ . .5 6 V?•A t:/1.0gX C in
—
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NbiudrIVIVIrsvi Cuntt Mailing Address: ri,,e,-A/ _5' r--4/1 s 41.1 di 1 76
F.A. hi,.//f ‘1*,-,
Signature '
v.i oI nac-:l-uf e M I
As'-r T-,,A l4La-r.--t.-ig‘
ne
SECTION 3--ESTIMATED CONSTRUC,1A 4tAT
-
Item . Estimated Cost(Dollars)to be - Official Use Only
completed by permit applicant - : .
1. Building (a)Building Permit Fee -
2. Electrical (b)Eitimated Total Cost of
r.. COnstrUction from(6) -
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
.1
5. Fire Protection 44)LC
6. Total=(1 +2+3+4+5) 3/ 9' 7 Check Number /y 6,e/ .
_ , . :.: This oection For Offialif Use"Only ,
_ • Date :
-
Building Permit Number . Issued:
. .
.. .. .
. • "
. .
Signature:
- . . .
Building Commissioner/Inspector of Buildings . . .Date
•
• .
File#BP-2014-0672
APPLICANT/CONTACT PERSON PATRICK SMITH
ADDRESS/PHONE P 0 BOX 249 MONTAGUE (413)426-8768 0
PROPERTY LOCATION 24 RYAN RD
MAP 22D PARCEL 053 001 ZONE URA(100)/WSP(100)/WP(12)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ! ti/4 55
Fee Paid
Typeof Construction: INSTALL ATTIC&WALL INSULATION
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
INFORM ION PRESENTED:
pproved 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
emoliti Delay
, 4r%,
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.
24 RYAN RD BP-2014-0672
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D-053 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-2014-0672
Project# JS-2014-001147
Est.Cost: $3975.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PATRICK SMITH 100236
Lot Size(sq. ft.): 13590.72 Owner: WELCH EDWARD J&MARGARET A&PAUL KELLEY&TRACY
KELLEY
Zoning:URA(100)/WSP(100)/WP(12)/ Applicant: PATRICK SMITH
AT: 24 RYAN RD
Applicant Address: Phone: Insurance:
P 0 BOX 249 (413) 426-8768 0 WC
MONTAGUEMA01351 ISSUED ON:12/5/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC & WALL INSULATION
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 12/5/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner