12C-031 a, an
i i I
07 Y F'A 111CIPATIHt,CONTHAUTUH
PERMIT AUTHORIZATION FORM
I, Kenneth Maiuri ,owner of the property located at:
(Owner's Name,printed)
237 Spring Grove Ave 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. 1
Owner's Signature
-�; 1,441y-
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:
6 YLJ V &P ly)�-9 - J)/ -) // � ,
Participating C tractor Date
D{fCi
For Offica use Only
Rev. 12132011
The Commonwealth of Massachusetts
1
Department of Industrial Accidents
Office of Invesdgations
600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Amlicant Information Please Print LeLnWx
Name(easiness torgw3j=tion/tnaividua4: Bryan G.Hobbs Remodeling
Conway St.
Address: Greenfield,MA 011301
City/State/Zip: Phone#:_ `rte .�7- 17q L �(
G C.. C!
Are you an employer?Check the appropriate box: Type of project(required):
1.EQ I am a employer with—(-- 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(fall and/or part-time).* have bored the sub-contractors
2.El am a sole proprietor or partner- listed on the attached sbeet t ? ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for mein any capacity workers'comp.insurance. 9. []Building addition
(No workers' comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.E]Plumbing repairs or additions
myself:[No workers' comp. c. 152,§1(4),and we have no 12.F] Roof repairs
insurance roquired.]t employees. (No workers'
13.[0 Other I f 1 S�..'rrt-�G�;1
comp.insurance required.] ✓ t t n
*Amy applicant flat checks box#1 must also fill out the sec don below abowing their workers'c on4maabon policy infonmtIon
t Homeowners wbo aubM Ibis aff davit indicating they are doing all work and then biro outside contractors must suta dt a new affidavit indicating;sock
IContwims that check firs box mmtst attwbed an additional sheet showing the name of the sub-ovmiactors and their workers'camp.policy mforrrmtiom
lain an employer that Is providing workers'compensation insurance for my employees. Below Is the polky and fob site
Information.
Insurance Company Name: A l l l G L I I L-b (t--
Policy#or Self-ins.Lic.#: 2 Z LA-1 0 -� ?�C� `� Expiration Date:
Job Site Address: City/State/Zip: �/
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 imnprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 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 certtfy1 sunder the pains andp)enakies ofper,Jury that the information provided above k true and correct
Siva e: i` l V`J l-is Drie: /
n M L4 j — C C
Official use only. Do not write in this area,to be completed by city or town gfileial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.C1ty/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Bryan G.Hobbs Remodeling C3 _ U,-�;r'a61,� 2-
License Number
Greenfield,MA 01301
Address Exp ration Date
to
Signature Telephone
9 Registered'Home'lmprovement Contractor Not Applicable ❑
Bryan I3 1s [�
B an G.Hobbs Remnrlelinn
Company Name 346 Conway St. Registration Number
Greenfield,MA 01301
Address
,.f 5, Exp7i ationF ate
Telephone
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 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[o] Other[ 1]
Brief Description of Proposed
'6 {{ fF � � # t
u ! f Y"[
Work: „ C at
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
/` (" (',(
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I to " m1 as Owner/Authorized
Agent hereby de blare 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.
Print Nam
-7 / s'
Signature of Owner gent Date
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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW Q YES C)
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW � YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
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.
C1=1V D City of Northampton d
AU
Building Department j'
g �� 212 Main Street � �
Zj"Room 100 Vft-
oE�r............I orthampton MA 01060 '`
au
"cR7"^�"' QN,1MAO �e 4 3-587-1240 Fax 413-587-1272
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:
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing A dress:
Telephone
Signature
2.2 Authorized A-gent:
. t , �. .
Name(Print) Current Mailing Address: I q 7 „
� 41 ,, . 1 S rio
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 3 ) ! (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) �' r Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0887
APPLICANT/CONTACT PERSON BRYAN HOBBS
ADDRESS/PHONE 346 CONWAY ST GREENFIELD01301 (413)775-9006
PROPERTY LOCATION 237 SPRING GROVE AVE
MAP 12C PARCEL 031 001 ZONE RIO 00)/URA000)/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 ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 83982
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
la qr
Sigma it ng fficial 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.
237 SPRING GROVE AVE BP-2015-0887
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 12C-031 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-2015-0887
Project# JS-2015-001724
Est. Cost: $3172.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BRYAN HOBBS 83982
Lot Size(sq.ft.): 19253.52 Owner: MAIURI KENNETH
Zoning: RI(100)/UFA(100)/WSP(100)L/ Applicant: BRYAN HOBBS
AT: 237 SPRING GROVE AVE
Applicant Address: Phone: Insurance:
346 CONWAY ST (413) 775-9006 WC
GREENFIELDMA01301 ISSUED ON:3125120I5 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC 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 3/25/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner