12C-100 �7I�tTtp
0 Le
mass save ��, �
Wafer" �
PERMIT AUTHORIZATION FORM
I, Mark Mccormick ' ,owner of the property located at:
(Owner's Name,printed)
53 Morningside Dr Florence
(Property Street Address) (City)
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
S�zf/i y
T
Date
FOR CSG OFFICE USE ONLY
Conservations Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
D, GNT Wd Sin, ant 7-PM
Participating Contractor Date
For Office Us.E Only
Rev. 12132011
vv�` ro City of Northampton
JY - �
Massachusetts
;y DEPARTMENT OF BUILDING INSPECTIONS ��'g xWa� � 1
. _? .. 212 Main Street • Municipal Building wry r
Northampton, MA 01060
Property Address:
Contractor
Name: JIDRF� _&N-At / G2ot jt c,,4 S�or,, Tr1t.
Address: lr� �rn�woo� S'tre2
City, State: t7Y22(� �Z-1�� MA o34�
Phone: 1 �7 ! - 3604
Property Owner ML�y mcorm L K
Name: 1�
Address:
City, State:
(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
Date 7 ! 1
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor; ,vp Not ApplicabGle ❑
Name of License Holder: ��SQ � G2or CSS 11 `3�1`�
License Number
�,� �G,�e�..DO� S'�r�e'c �ee��+�'�► 0��01 a-1�-2,013
Address Expiration Date
Signature lephone
9 Registered Home Improvement Contractor: Not Applicable ❑
J- e. orate crnr� ion,Into Jsw6
Company Name Registration Number
C� �� a d� S�i��� &fe-e,R 41 MR .01301 7-3S-101r
Addres 1 Expiration Date
Telephone 4' J'774'3604
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 Dwelluls*s 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 aaplicable)
New House Addition Replacement Windows Alterations) Roofing El
Or Doors 0 7P7
Accessory Bldg. ❑ Demolition ❑ New Signs [ice] Decks [C] Siding[0] Other(CQ
$n AA lajton
Brief Description of Proposed f� f �eU� �� '` F I ()�ta�� [��� t` 0� L�f(N(p� �g 00if))J
Work: 1111 W1fi U J� j1 ��lv.ia�ton �n
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.
L 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 ��Kt���r�►�K
as Owner of the subject
property
hereby authorize atsepE Crecirs
to act on my behalf,in all matters relative To work authorized by this building ermit application.
See �fi fnx,e1 7 / 1
Signature of Owner Date
JoS% George ,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.&Q0171-019— —
Print Name 7/a/N
Signature of O er/ gent \y� Date
{. ..
3 '•j
�:
,�
�....,
4
Department use only
City of Northampton Status of Permit:
• Building Department Curb CutlDriveway Permit
212 Main Street Sewer/Septic Availability
L ICATIO Room 100 WaterMell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
N N TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION L - This section to be completed by office
1.1 Property Address. 53 ��Itan�Sl(�e 4�i�e
U Map Lot Unit
Zone Overlay District
Elm St.District Ca District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MKW r\tcorpyj we Florew /m OPQ
Name((P�rint) Current Mailing Address: Oslo
Telephone
Signature
2.2 Authorized Agent:
3-IDS &2orAt 64 Hn;roodl S-�, Green{off ,MA oi3o\
Name(PH Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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) 70, Check Number
This Section For Official Use Only
Building Permit Number: IIsssued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0054
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 53 MORNINGSIDE DR
MAP 12C PARCEL 100 001 ZONE SR(118)/WSP(118)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out (o l a► 65
Fee Paid
Tyneof Construction:_AIR SEAL IN ATTIC AND BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building-Plans Included:
Owner/Statement or License 156686
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
emolition Delay
Signa ure of Building O icial 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.
53 MORNINGSIDE DR BP-2015-0054
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C- 100 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateyorv: INSULATION BUILDING PERMIT
Permit# BP-2015-0054
Project# JS-2015-000096
Est.Cost: $2760.89
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: JOSEPH GEORGE 156686
Lot Size(sq. ft.): 22476.96 Owner: MCCORMICK MARK C&MARTHA E
Zoning-: SRO 18)/WSP(l18) Applicant: JOSEPH GEORGE
AT. 53 MORNINGSIDE DR
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 Liability
GREENFIELDMA01301 ISSUED ON.711512014 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL IN ATTIC AND 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 Sianature:
FeeType: Date Paid: Amount:
Building 7/14/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner