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PERMIT AUTHORIZATION FORM
I, Linda King owner of the property located at:
(Owner's Name,printed)
32 Bliss st 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
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:
(,AO
Participating Contractor Date
D�rO
For Office_Use Only
Rev. 12132011
City of Northampton
'r 3 Massachusetts %t
.. �• p� j _ nl a �1
i 3,= DEPARTMENT OF BUILDING INSPECTIONS
r 1
*- 212 Main Street • Munici. al Building
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F 9 rs..
Northampton, MA 01060
Property Address: 1' S l�r���� 0
Contractor
Name: JoSep� Greo!25t GeO!lt 0nn4 SOS, lR(,
Address: b �m��woof� �-f"Pi
City, State: GrRr\'1'. lAj MA 01301
Phone: ! � 3604
Property Owner j
Name: I n r^ +�i n
Address.-
City, State: w-�[\c i
f, Jos;fk (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 �7
�_
Date
4 The Conznzonwealth ofMassacltusetts Print Form
Department of industrial ACCidetits
- ®fjice of Investigations
ress 5tt get,S itite 100
1 Cong
Roston,M4 02 7114-2017
ii ww.mass-,bovIdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aniglicant information Please Print Legibly
Name (Business/Oreanization/Individ,al):J.P_ George and Son, Inc_ /Joseph George
address:64 Haywood Street
City/State/Zip:Greenfield/MA/01301 Phone j4:(413)-774-3604
Are you an employer?Check the appropriate box:
Type of project(required):
L❑✓ I am a employer with 4 4. ❑ I am a general contractor and I
employees(full and/or part-time)-x have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7_ ❑ Remodeling
ship nd have no employees These sub-contractors have
P P ii. ❑ Demolition
-working for me in an),capacity. employees and have workers'
comp- insurance. 9• ❑ Building addition
[No workers' comp. insurance
required-] 5- ❑ We are a corporation and its l0.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I L❑ Plumbing repairs or additions
myself. [No workers' comp. ri-ght of exemption per NIGL 1 ❑ Roof repairs
insurance required.]' c. 152, §1(4),and we have no
employees_ [Nfo workers' 110 Otherinsulation
comp. insurance required.]
_Any applicant that checks box fl must also till out the section below showing their workers'compensation policy information_
t-lomcowners w-ho submit this affidavit indicating the}°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
emplovees. If the sub-contractors have cmplovecs,dtey must provide their workers comp_policy number.
I am an employer that is providing workers'compensation insuFance for n:p errrployees. Below is the policy and job site
InjOrntation.
Insurance Company Name:Arbella
Policy 4L or Self-ins.Lie. vi -N b 104
]� Expiration Date:4/29/201,5
Job Site Address: °� V'it S St City/State/Zip: H yAc e, MA 010 6)
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 STOP WORK ORDER and a fine
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 DIA for insurance coverage verification.
1 do hereby certify u>xler tl:e prti>rs affil
en, •es ofperju{y,that the infornnation provided above is trtie aitd Correct.
Signature: /\ Date: / A
Phone=:(413)-774-3604
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):
I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 licensed Construction Supervisor: Not Applicable ❑
2ore, q`1311
Name of License Holder: O jep� �ss�
j License Number
4fh'1JW00 f( 5�tf e� �� �t 01301
Addre ' Expiration Data
Signatur Telephone
8.Registered Home Improvement Contractor: Not Applicable ❑
a. e. Mary f/4 �O!\, Tr%C, 15 60S
Company Name Registration Number
�� d} [re-e,4�W, MA DIM 7-2S-ao1-�
Addres { 1 Expiration Date
Telephone\���J-771-3604
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....... lA No...... ❑
11. -Dome Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwelliries 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-vear period shad not be considered a homeowner.
Such"homeowner"shalt 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 whicb 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 perrorm 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 Alterations) Roofing ❑
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs (p] Decks (p Siding[0] Other[EM
$nS1A lo,{ion
Brief Description of Pjo f ld;� �� A_^r, , � 1 / S( �i } SP j
Work: \Net-i- 1 , J�/}IC �t 'wWl( z II 10
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.
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, L t n�, N �i 1 h as Owner of the subject
property rt
hereby authorize arse t� &e0r;'!e
to act on my behalf,in all matters;relativero work authorized by this building permit application_
See h)AV"A,e4 I I/a!,/ N
Signature of Owner Date
+, '30Sf-6, 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.
Jose 6 1&e'0fA2
Print Name \t�4VQbw
Signature of Owner1A a Date
Department use only
1 - f Northampton Status of Permit:
( u ing Department
Curb Cut/Driveway Permit
5 2015 ±; 2 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
> iectric, Plumb n
mpton' MA 01060 Two Sets of Structural Plans
Northarnp&t � ,
s - 7-1240 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
This section to be completed by office
1.1 Property Address: ` (� i SJ S� Ma
p Lot Unit
� �R Zone Overlay District
f`)�r) �)— Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record;
Name(Print) Current Mailing Address:
13 k
S$ ��$o
P, tr'4 Telephone 1
Signature
2.2 Authorized Agent:
SoSg (Tezmt Hrn�artoo� S�, GTeen
Name(Print ' Current Mailing Address:
'7,71q Aolk
Signature i Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be OttiCial 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) S, —7 Check Number
This Saction For Official Use Only
Building Permit Number Date
Issued:
Signature:
Building Commissioner/Inspector or Buildings Date
File#BP-2015-0702
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 32 BLISS ST
MAP 23C PARCEL 079 001 ZONE URA(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
Typeof Construction: INSTALL WALL INSULATION.AIR SEAL&WEATHER STRIP DOOR
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:
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
Demolition Delay
Si re o uildmg Officik V 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.
32 BLISS ST BP-2015-0702
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23C-079 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-2015-0702
Project# JS-2015-001361
Est.Cost: $3486.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 6838.92 Owner: YARROWS LEONARD A&MARY L& STEPHEN M&JEFFREY R&
LINDA M KING&JULIANNE M TOUCH
zoning: URA(100,/WSP(100)/ Applicant: JOSEPH GEORGE
AT. 32 BLISS ST
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON.11712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WALL INSULATION,AIR SEAL &
WEATHER STRIP DOOR
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 1/7/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner