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PERMIT AUTHORIZATION FORM
i, JEANNE COMEAU ,owner of the property located at:
(Owner's Name,printed)
46 Pilgrim Dr NORTHAMPTON
(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 /�r
Owner's Signature
Jun 12,2015
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:
Participating Contractor Date
0�`l7
For Office Use Only
Rev.12132011
t o
Massachusetts -Department
�Public� J Sa;e c
eense: CSSL-099372 _..
JOSEPH P GEORGE
64 HAYWOOD STREET' _
GREENFIELD KA 01301
fl \�
02/1112017
Cornmissioner
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
'HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 156686 Type: Office of Consumer Affairs and Business Regulation
l Expiration: 7/25/2017 Private Corporation 10 Park Plaza-Suite 5170 j
Boston,MA 02116
JP GEORGE&SON INC
i
JOSEPH GEORGE2
64 HAYWOOD ST
GREENFIELD,MA 01301 Undersecretary
No valid without signature
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The Coilzrzai7wealth of lVassachzfsea[s Print Form
epa3•ttrze.F2 of�.ztlztsV-ial caceldeuts
--- - 0fjzce of lfzvestigatioizs
-- 1 �'oti�,•ess.�treei 3 iaite 700
- >tJfviv.f:zcss_�ov/ilia
to
/�r♦er-s' Corn pe-Sa>ion nsur al?ee rfida e3I Cd2t s/�Lo F'a+ �o rs/RIeeirlcla�zs/ �r1pi bb's
_zR U I:nsar aE=o;3 Tease Print- el=ibli•
Name(Business/OreanizaLiorvIndividua[):J-P' George and Son. Inc_I Joseph George
_;ddre5S:o4 Haywood Street
G( iStatetZip-Green field/MA/01301 Phone 4':(413)-77a-3604
_re you an employer?Cbeek the appropriate boy.:- Type of project(required)_
1.(� l am a employer w ith'' '`-- F] I am a general contractor and I
j employees(null and/or part-time).; have hired the sub-contractors 6_ ❑lievr construction
?_Q 1 am a sole proprietor or partner- listed on the attached sheet_ i. ❑ Remodeling
i ship and have no employees These sub-contractors have
1 p S. Demolition
NvoricinQ for me in any capacity_ employees and have workers` 9_ ❑ BuiIding addition
i
[tio WOI_kerS' coma. insurance comp. insurance.=
j recuirzd_]
5. 0 We are a corporation and its 10.0 Electrical repairs or additions
1 am a homeowner doing all work
officers have exercised their 11.❑ Plumbing repairs or additions
rnnyself. [No workers' comp. right of exemption per MGL 1? Root repairs
( insurance required-] c- 151, §1(—'.),and we have no
i
employees_ ( io«orkers• 13_[] Otherinsulation
comp_ insurance required.]
'.a nv annlicanr that cheeks bog El must also fill out the section below sihowins their wort c&compensation policy inforination.
1-innicowners who submit this affidavit indicatine the%-are doing all work and then faire outside contractors must submit a new affidavit indicating such.
'r,ntractoris that check-this box must attached an additionni shcet shOlcin-a diC name of the sub-contractors and staic Ivlicdicr or not those entities have
employees. if the sub-conlractor5 have cmployccs.tits v must provide their norlers•cetnp_policy number-
1 ant an einplgver that is providing ivorker5 compensation insurance for inP ezzzploj+ees_ Below is ilzepolict=and job site
<<j brr7raiion.
Insurance Company Name:Arbelia
Policy or Self-ins.Lie-_ �! ti _-�4 I
' Expiration Date:"=/29/201 )
job Sre:',ddress: —I � Pt 13r V'rVe Citv/Strafe%ip: Ortk (A �Q'1 M11�`) o��
A-tacit a copy of the workers- compensation polic,r declaration page(showing the policy number and eY iratinn datej.
-P lu-a,to secure coverage as required under Section 2SA o1 LIGL c. 152 can lead to die imposition of crminal penalties of a
file up to S1,500.00 and/or one-year imprisonment_as«tell as civil penalties in the rorm ofa STOP WORK ORDER and a 5ne
or up io S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
IIIVCStt garionS of the DIA-mr insurance covera$i'veri=Caii�n_
11-10 11erebjt certify tinder the pains azzd enalFZes ofperjrtn-tizat the infonnariorr provided above Is h Ile r1T1f1 COl'CeCI.
5i�natU1'e: - — � f
Date:
Phone_:( 1 3)-774-360.
O lclal rise nnlj+. Do not write in this area,to be complered bji CID:or tohvn official.
E
wit,=or T own: Perinit/License
issuing Authorit_.(eircie one):
!1 _. Board of-Health 2.Building Department 3-(2ity/-own Clerk -_t.Electrical inspector 5-Plurnbing inspector
jo`_¢3tiier
I
Phone Y.
City of Northampton
f ', 1�
'r Massachusetts
J, c JZ _ _!
<< �, ; DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building •�s•. -;'_ .
Northampton, MA 01060
Property Address: � �
Contractor
Name: JDWD. Cybn Geotle o Atk S'qf\, lr\c.
Address:
City, State: l�Ct� t�1► M A oi3oll
Phone: `� '174- 3604
Property Owner r uu
Name_ e�Rr ��
> L C�r�ll.
Address:
City, State: �� lA 8
1, 30&q� for,.9 (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 � ,� ,��•�-
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ,,tg Not Applicable.ry❑
Name of License Holder: �OSe r� �or
License Number
Addres Expiration Date
(413) TN-3bo'l
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
J'. q, ISW
Company Name Registration Number
(A d\ S+r'e-6 &m-el,t W I N (A30 7-23 _),0i7
Addres Expiration Date
Telephone�� i)-7/?1-3 olj
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_.._.__ 9 No...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dweliitiz 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 andt 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 hermit.
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 I53(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,City of
Northampton Ordinances,Stag 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 F-1 Or Doors F-1
Accessory Bldg_ ❑ Demolition ❑ New Signs [p] Decks [0 Siding[C1j Other(to
i ` ,,r 1 $nStAiajion
work iofn°f�C tr, �Proposed T�St�+ll (1 n v) Q)\� ���� �V��i / �l�L�^�l�f l e ��`�� �,)r-3
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a_If New house and or addition to existing housing COMPlete the following:
a_ Use of building.One Family Two Family Other
b. Number of rooms in each family unit Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h_ Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k_ Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, V� � ,as Owner of the subject
property LL
hereby authorize �0sepl1 UeOrs
to act on my behalf,in all matters relative fo work authorized by this building permit application.
Signature of Owner Date
1, �O$QL11\ (Tpor�c ,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.
u0se \\ Geor�2
Print Name G
LY � ?�
Signature or Owned Date
1 Department use only
SEPaoi5 �.:e
ty of Northampton Status of Permit:
�' B ilding Department Curb of P'
Permit
ur bina&U, Insueclions 12 Main Street SewerlSeptic Availability
Electric Pi
Northampton, ��-�atoo Room 100 WaterlWeA Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PloVSite 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:
N yIm V Q Map Lot Unit
NI-0 CAft/} �A Zone Overlay District
ii YY prrt� G� Elm St.District ca District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
21 Owner of Record;� P)',Vjrj^ Df,
Name(Print) Current Mailing Address:
JLV Telephone ` ~l
Signature
2.2 Authorized Agent: O���t
_ SOSeP3� �t"A� ' Cn oo[Ir S � ��i�,MA - - -
Name(Pri " Current Mailing Address:
A' 13)'T7`t_3��1 ti
Signature Telephone
�SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 5 �;� (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 S ='� Check Number ° i �.5
This Section For Official Use Only
Building Permit!Number: Date
Issued;
Signature:
Building Commissioner/inspector of Buildings Date
File 4 BP-2016-0343
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD01301 (413)774-3604
PROPERTY LOCATION 46 PILGRIM DR
MAP 24A PARCEL 228 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out yo y b
Fee Paid
Typeof Construction: INSTAL VAPOR BARRIER AIR SEAL&WEATHER STRIP DOORS
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:
_1,,!!!�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
Delay
1s-
Si r4513ut
ld i icia 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.
46 PILGRIM DR BP-2016-0343
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A-228 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2016-0343
Project# JS-2016-000552
Est. Cost: $2656.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 29620.80 Owner: COMEAU JEANNE
zoning:URA000)/ Applicant. JOSEPH GEORGE
AT: 46 PILGRIM DR
Applicant Address: Phone: Insurance:
6414AYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON.911512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTAL VAPOR BARRIER, AIR SEAL &
WEATHER STRIP DOORS
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:
FeeTvpe: Date Paid: Amount:
Building 9/15/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner