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35-219 (9) `*P-0[44/py t0� A mass save PARTICIPATING S+ninip ihra,ph—VV aftKtarici CONTIPIACTOR PERMIT AUTHORIZATION FORM 1, JAIME CAPLAN ,owner of the property located at: (Owner's Name,printed) 26 Ladyslipper Ln 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. X O s Signature Ll �, 1 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: ap ��Cl 9e Chf)� Participating Contractor Date affo For Office usa Only Rev. 12132011 City of Northampton 15 Massachusetts 6-� DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Northampton, MA 01060 Property Address: V (lt S PPPl Lw)e, Pof('W,ffih ( i O a Contractor Name: jigeeh &eDrAt o,,\tk Sion, lie. Address: `�mywoof� S$r2�� City, State: Grier% MAC MA 01301 Phone: ( t D-17q` 304 Prerty Name: Owner �r ee Cy\pj&(\ Address: �V Vi S l'I P('eil- fL wN e City, State: t ��e I M� , 1� y� 1, josep� (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 1 have provided the property owner with a copy of this affidavit. Contractor signature "\�#VQ-0A Lt`Y--T� Date _�i_ 1'he Commonwealth of Massach usetts Print Form ✓ eparhnent of ndustrial Accidents _-- ©jf ICE Of Investigations _ - 1 �'otzaTess St.-ee' Suite 100 - ostalz,iZ 021_7e-?0I7 'VDV 1V.mass_;OVIdla Workers' Compensation insurance Af idaNdt: Builders/Contracto;rs/Elec>ricians/P1u;k-libears Anpiicant>!nsormailon Please Print.> etfibly Dante (Business/OreanizadorvTndividual):J-P. George and Son, Inc./Joseph George _,-ddress.64 Haywood Street City/State/Zip:Greenfield/MA/01301 Phone s:(413)-774-3604 Are You an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with L'- 4. ❑ I am a general contractor and I employees(full and/or-part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7- ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition -%vorlcing for me in any capacity. employees and have workers [No workers' comp.insurance comp. insurance.- 9. []Building addition 5. We are a corporation and its 10-E]Electrical repairs or additions required.] ❑ � ❑ I am a homeowner doing all work officers have exercised their l l-❑ Plumbing repairs or additions myself o workers' comp. right of e%emption per MGL y � p 12.❑ Roof repairs insurance required_] c_ 152:§1(A),and we have no employees. [No workers' 13.0 OtherinSUlation comp. insurance required.] ".1ny applicant that checks box'I must also till out the section below sho'vins their"•orkc&compensation police information- Homeowners who submit this affidavit indicadne they are doing all work and then hire outside contractors must submit a ne%v affidavit indicating such. -Contractors that check this box must attached an additional sheet showin_the name of the sub-contractors and state tvltcdter or not those entities have enmloye:s. if the sub-contractors have employees-they must provide their'workers-comp_policy number- I rrnr ttir etarployer tlrar is provitliirg worriers'conipeiisatloii IiisllYrliice for ia2y employees. Below is the policy and job site information. Insurance Company Name:Arbella _ Policy t or Self-ins.Lic. Expiration Dater/29/201 job Site Address: D16 LoA��(er Lo-A City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure eoveraee as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties ofa fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ofup 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 veri icatior I do hereby-certify under the pains andpenalties ofperjurl=that t/re itrforntation provirlerl above is tale and correct, 5lanature: j —�� �� Date: Phone=:(413)-774-3604 1 Gf?cial 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): 1. Board of i-iealth 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5-Plumbing Inspector o`.Gather 011LaCi Pei'�011: phone,,: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: n ,gyp Not Applicable ❑ Name of License Holder: ��Sl i UG�ryL U31 R�31 1 License Number 0130) Address ' Expiration Date M , (q[3) 77q-3(lo4 Signature elephone 9.Registered Home Improvement Contractor: Not Applicable ❑ I P, �orgQ fnnr� �anr ant, 15664 Company Name Registration Number �1 tiE--fv,,A dN 511,6-A P-e,\ kk wl MR o1301 7-2S Address `f } Expiration pate Y y Telephone 4 1;J'771'3 b D� 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 Ezemntion 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 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 near 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 wort:for which this pen-nit is issued. Also be advised that witb 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,von 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,Ciry 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 r_] Addition [] Replacement Windows Alterations) ❑ Roofing ❑ Or Doors Cl Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [0 Siding(p] Other(CA .InStA laillor, Brief Descriptio of Pro osed t` Work: N r �u1 is cM� �3wenc��. d� '7 p f ce llmwt to �z*t, rSu c*on in 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 folfowfncL 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 1. Is construction within 100 ft.of wetlands? Yes No. Is construction within 900 yr. floodp)ain 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 T_ OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ZGI Mf �n ,as Owner of the subject property hereby authorize St1se�i Glory to act on my behalf,in all matters relative fo work authorized by this building permit application. See )Vv-Lx'e_1 5-0-\1 r Signature of Owner Date I, 3osf- 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. Print Name Signature of Ow d gent Date Department use only 'of Northampton Status of Permit: j tiding Department Curb CutlDriveway Permit MAY 2 6 ''+� !9 12 Main Street SewerlSeptic Availability E ROOM 100 Water,MlellAvailabil--------- ampton, MA 01060 Two Sets of Structural Plans ~^ 3- 87-1240 Fax 413-587-1272 Plot/Site Plans ph9h 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: Uj 1 _ J�si'gPer �e U +� t� Map Lot Unit f o ceoce, I�H Zone Overlay District OI ) p, Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPlAUTHORIZED T7 2.1 Owner of Record: ��nitht C PI�n ab L Sid etr LU.ne F(oreltcej MA D1062 Name(Print) Current Mailing Address: (413) - � - (g 7 3 jO S$e, MkOtc,hPA Telephone d Signature 2.2 Authorized Agent: IDS 2P kor t 69 Hrn oo� S�, Gfe2n WdtI A 01301 Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only com leted 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) gQ t Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissionerlinspector of Buildings Date File#BP-2015-1177 APPLICANT/CONTACT PERSON JOSEPH GEORGE ADDRESSIPHONE 64 HAYWOOD ST GREENFIELD01301 (413)774-3604 PROPERTY LOCATION 26 LADYSLIPPER LN MAP 35 PARCEL 219 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid �>f �� ` l-' Building Permit Filled out Fee Paid Tyneof Construction: INSTALL ATTIC INSULATION 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: 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 D mo ' 'o la 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. 26 LADYSLIPPER LN BP-2015-1177 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma:Block: 35 -219 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-2015-1177 Project# JS-2015-002206 Est.Cost: $2888.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH GEORGE 99372 Lot Size(sq. ft.): 57499.20 Owner: CAPLAN JAMIE ANN Zoning: Applicant: JOSEPH GEORGE AT: 26 LADYSLIPPER LN Applicant Address: Phone: Insurance: 64 HAYWOOD ST (413) 774-3604 WC GREENFIELDMA01301 ISSUED ON.512812015 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 Shmature: FeeType: Date Paid: Amount: Building 5/28/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner