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ENERGY CONSERVATION APPL1CATlON FORM FOR
LOW'RISE RESIDENTIAL NEW CONSTRUCTION AND ADDITIONS
780 PMR Appendix J{effective 3/1/98)
Applicant Name: Site Address:
Applicant Address: City/Town:
Use Group_
Date of Application:
ContpbiAnce Path(check one)r
❑ Prescriptive '•'a:kage (Limited to 7- or 2- family wood frame buildings heated witn ossil fuels only)
Package (A through KK from Table J5.2. lb): ____ Heating Degree Days (HDD,�_S) from Table J5.2 la:
(For items d. throug;l i., fill in all values that apply from Table J5.2)
a. Bross Wall Auer sq. fl f. Walt R-aaf= �-
b. Glazing Areal __.. __--=4• ft E. Floor ° .Wal:;s
c. Glazing%(100 z b+a) g� h. Basement wall g-
d, Glazing I I-vali
Slab Forlmeier li
e. Ceiling R-value �3_ j. Heating AFUE
Q C.-mponet i Performance: 'Manual Trade Of (Limited to wood or metal framed buildings only)
Climate Zone(from Figure J6.2.2) ❑ Zone 12 [) Zone 13 ❑ Zone 14
Attach Trade-Off ft(kshee,from Appendix J, (2nd nVAC Trade-Off Worksheet, if applicable)
❑ �AAScheck Software
Attach Compliance Rapc4 and-Inspection Checklist printouts.
❑ Syster`is Analysis OR ❑ Renewable Energy Sources
Attach Mass Registered Architect or Engin—_,r Analysis
ALTERNATIVE FOR ADDITIONS ONLY:
a. Gross Wall + Ceiling Area / 36sq. ft. b. Glazing Area, / ,577sq.ft. c_ Glazing %(100 x b+a)
ADDITION with Glaring% (c.)up to 40% may use 780 CMR Table J1.1.2.3.1 below:
MAXIML M U-valuz Minimum R•vaJues
F&*stration Ceiling Wall I Floor Basement Wy ll Slab Perimeter, Dept
039- R-37 R-13 R-19 ' R 10 R•10,4 ft.
❑ "SUNROOM-addition (greater than 40% glazing-to-wall and ceiling gross area)
Attach Consumer information Form" from 789 CMR-Appendir B.
Official's NkOrrte: Official's Signature:
Appficsti in Approved ❑ Denied ❑ Date of Apxovab'Denial:
Rzason(s) tvr Denial: (rarW- 'de additional details as needed on back side)
Gl -az Ma awry be ek 3aovttk Opening or Unh Dmvnsions
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m DEPARTMENT OF BUIL.DDT G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE AF t AVTT
(li a;rlsez'/penni tree}
with a principal place of business/residence a/t�
(strc�ticity/naie/ap)
do hereby certify, under the pains and penalties of perjl]_ry that
( ) I am an employer providing the following worker's compensation coverage for my
employees wor4dng on this job.
(Insurance Company) (Polio tvtumber) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the fonov,flLng workers compensation policies:
(Name of Contractor) (Insurance Company/Policy Numbcr) (Expiration Date)
(Name of Contractor) (Insurance Comnauy/Pohcy Number) (Exoirann Date)
(Name of Conti-actor) (Insuram-- CompanyiPolicy Ntmllxr) (Expiration Date)
(Name of Contractor) (Instirance, Company/Policy Number) (Expiration Date)
(attach adclitioazl 21xc t if to include infor na oa pertaining to al]oxi1x c or.)
i
�) I Mn a sole proprietor and have no one wor4;-ilig for me_
O I am a home owner performing all the wort:myself.
NOTE:please be aware that tv[iile han a tirm wbo c:Iplay z :s to d c r repair�4mk an a d«cll ng of
not mote thna throo units in tcivch the hrncoavcr n=icks or oa the ups appurtensn!llk 0 arc rkt Ccmrally 00clickmd to be
cmployc13 under the wockru's axe ctatica Act(GL152,.s 1(5)),np tication by a homcom-na for t l cuisc oc permit may cvidcaoc tttc
legx1 ctnhu of an employct undor tho Workcla CocupcnsaLion Act_
I undcritxad th:i a copy of thin rutcmcai may bo forwarded to tbo Dcparta� of Industrial Acc,6cn&Offioo of Inscui oa for tho
oovtragc verification and tlut fuiurc to_v:atrt covcm v urkz scaioa 25A of bML 152 can lm to tha imposition of aiminal pcnalLcs
oomistutg of a fine of up to S 1,500.00¢ndlor imrgisouman of up to one}'.ar en3 civil penalties in the fcxcn of a Step WoTk O dG and a
fino of S 100.00 a day i{ inst me
Y
Foc deal uio only
Permit Nttmbcr
= / 0 443 Lot 9
tare o iccnserlPermiace --
SECTION 8-:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : _J�,\" L6�—_
License Number
3 s S — -- bl t6 Z 6'Y _
Address Expiratiof Date
Sig r Telephone
;:rr»rRr�°c v e +rnpau�x w .. ..»_,w.
Rgisfered�Hom�e Irnprbvement Contractor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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......\il No...... ❑
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 fe-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
SECTION35 DES�R'IPTiION OF PROPOSED WORK(check,all applicable
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:_CIA d r c7 n
Alteration of existing bedroom Yes V q, o Adding new bedroom Yes N�
Attached Narrative❑ � Renovating unfinished basement Yes \i No
Plans Attached Roll ❑ Sheet`s
sa:If N6- frdiP Sand``6K!! ddition�--to'dxistin -housin com I6b&Ahgj611dwii"
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: '" _ Number of Bathrooms e
c. Is there a garage attached?—ho �Y f
d. Proposed Square footage of new construction._ Dimensions CIP
e. Number of stories? 6)A k
f. Method of heating? Fireplaces or Woodstoves Y)G Number of each
--* g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction _WQJ _ \
i. Is construction within 100 ft. of wetlands? Yes - V No. Is construction within 100 yr. floodplain Yes \J_No
i. 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
OWNER'S AGENTbR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, Fr<�e_LAAZLAA.- `��•( 1 L� as Owner of the subject property
hereby authorize 1t _ to ac; on
my behalf, in all matters relative to work authorized by this building permit application.
Si ature of Owner Date
r
i, Re sci a , as Owner/Authorized A ent
hereby declare that the statements and information on the foregoing application are true and accurate, to the—bes of my
knowledge and belief.
Signed under the pains an enalties of perjury.
e ---- — — --
Print Name
Signat e o wner/AVgent Date /AQ3
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size bib 0 0
Frontage 7S
Setbacks Front 2-0 r J s
Side L: 11s L:� R: S
Rear
Building Height
3S't
Bldg. Square Footage % 3W a /
O
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
I j
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? N0�N— DON'T KNOW _
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained _ Date Is ued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF-YES, describe size, type and location:
City of Northampton S atus.c, F
Building Department Curb"Cu /D&
s�
212 Main Street Sewe. S
►� ! — ' 4x03 Roo 100 WrlWe
m ll va I
Northampton, MA 01060 TWO Sets .of
phone 413-,587-1240 Fax 413-587-1272 Plo/Site P
Other Specify r _= �
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section.to,be,,completetl by office
1.1 Property Address.
Lot
Map � Lot
Zone Overlay.,D�stnct '?
Elm St. District CB,Distr�ict
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ICU kv,
Name(Print) —trent Address:
Signature -- —qA3 ---
2.2 Authorized A ent:
Name(Print) Cr.rrent Vai!ing Address:
Signa re - �ephnr
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant l _
1 Building (a) Building Permit Fee —
2 Ele(-',rica Gv b) tiro Total Cost of -
Construction from 6
3 Plumbing Building Permit Fee
4- Mechanical (HVAC)
5 Fire Protection tr l =_ (i ?_ ; 3 + 4 + 5) `�Q0 00 Check Nui Aber d — —
This Section For Official Use Only-
Building Permit Number: Date Issued: _—
Signature: ---- ----- — -----
1 Building Commissioner/Inspector of Buildings Date
File#BP- 003-0615
APPLICANT/CONTACT PERSON Kim Rescia
ADDRESS/PHONE 311 Locust St (413)584-5816
PROPERTY LOCATION 27 FAIRFIELD AVE
MAP 17C PARCEL 172 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid G ,650
Typeof Construction: ENLARGE SUNROOM 26 X 12
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 022464
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 C mmission
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.
BP-2003-0615
GIs#.
COMMONWEALTH OF MASSACHUSETTS
. ._«
r CITY OF NORTHAMPTON
Lot: -001
Pennit: Building
Cate or : BUILDING PERMIT
Permit# BP-2003-0615
Project# JS-2003-1016
Est. Cost: $40980.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Kim Rescia 022464
Lot Size(sq. ft.)_ 5619.24 Owner: STEIN FREEMAN&WENDY S
Zoning:URB J-pplicant: Kim Rescia
AT: 27 FAIRFIELD AVE
Applicant Address: Phone: Insurance:
311 Locust St (413) 584-5816
FLORENCEMA01062 ISSUED ON:119103 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENLARGE SUNROOM 26 X 12
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:
Fee Type: Receipt No: Date Paid: Check No: Amount:
Building 1/9/03 0:00:00 790 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
---�-
27 FAIRFIELD AVE BP-2003.0615,..-- —�-��
GIs#: I,ioMMONWEALTH OF MASSACHUSETTS
MU-.Block: 17C- 172 CITY OF NORTHAMPTON
Lot: -001
Permit: B U i l d l n>7
BUILDING PERMIT
Category:
Permit# BP-2003-0615
Project# JS-2003.1016
Est $Cost: $40980.00
Fee: $o t: PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Const. Class: 022464
UseGroun: Kim Rescia
Lot Size(sq. £t.): 5619.24 Owner: STEIN FREEMAN&WENDY S
Zonin : URB Applicant• Kim Rescia
AT. 27 FAIRFIELD AVE
Phone: Insurance:
Applicant Address: (4131 584-5816
311 Locust St
FLORENCEMA01062 ISSUED ON:119103 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENLARGE SUNROOM 26 X 12
POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector
Inspector of Plumbing Inspector of Wiring D.P.W. g p
Underground: Service: Meter:
Footings:
g
Rough:
Rough: House# Foundation: l�/� —(3 3 :� ✓
Driveway Final:
Final: Final: J5 R
g
ou h Frame:
11-71
�/�� Fire Department
Gas: Fireplace/Chimney:
Oil:
Insulation:®k
Rough:
Final: Smoke:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. ``
Certificate of Occu anc si nature:
Ce Check No: Amount:
Fee T t e: Recei No: Date Paid:
Building
1/9/03 0:00:00 790 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo