24A-029 (2) j;rrra- City of Northampton
r Massachusetts --�
DEPARTWNT OF BUILDING INSPECTIONS
212 Main Street a Municipal Buildings s
=Fr Northampton, MA 01060 =:
Property Address:
Contractor
Name: JflSePt• (Teo!)2 �,°, Ge-01V t�nrA Sin, 311t.
Address: r� ymywoDf� SsrZQ3
City, State: r��(� �$�(�, M o i 3o j
Phone: ` #3�-�7 �
Property Owner
Name: 'e' sw's
Address: �J� � i !�C � � rcAit
City, State:
I, SoSq� (contractor)attest and affirm that the building l 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 `��o QA�"
Date -)0
1
_&tam
PARIXVWM
COXTRACM
mass save
PERMIT AUTHORIZATION FORM
Q �o ��-�"^� owner of the property located at:
(Owner's Name, printed)
LJ P� y ^
(Property Street Address) (City/Town)
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.
0 4 --
Owner's Vgnature
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
G �rJ� CA,', soy, loo _ _�o I�
Participating Contractor Date
Rev. 12132011
Print Form
Tile Con-zrnamwealth of IYassaclzitsetts
DepaltMeHt a�`,ztzztstrial4ccidetzts
-
r^'a f eizvesti,-aiiotzs
--- �,��ice o
1 colag•ess i-reei,6ziite 100
-- - ostr�iz, i1,/l� 0�11d-201
tJb1/1 V_r32GSS-j ovl d it<
Voz-yers' Compensa+tiat?riser ace Afflidp_v;,?? dens/�ortz aetot sl��eetrase P bait Le ibl
�,..- ,- Tease�'ri�t�,eGia�l��
: 21_�.''__rtt 4niQrnaEiOL
NName(Business/Or!!anizadorvindn•idual):J-P. George and Son; Inc_I Joseph George
i
i
:;-ddress:6-• Haywood Street
Ci toiStaiefGip_Gre,eniieici/MA/01301 Phone":(413)-774-3604
Du an employer?Citecic the appropriate boy.: Type of project(required):
n ! I am a general contractor and I
l am a employer with_ " � 6. (r]New construction
` employees(Full andlor part-time). have hired the sub-contractors
-Q I am a sole proprietor or parmer- listed on the attached sheet_ 7_ Remodeling
e
Thes _ub-contractors have S
ship and have no employees These Q Demolition
v,,oilcins for me in any capacity.ca p employees and have,:vorkers-
_ 9_ ❑Building addition
[-No .vorlcers' coma. insurance comp. Insurance.°
_ required.] 5_ Q lAie are a corporation and its 10_Q Electrical repairs or additions
Q I am a homeowner doing all work
officers have exercised their I 1_❑ Plumbing repairs or additions
i right or e:,7em Eton per XIGL
yself[i�Io x orkers comp_ p p I2.❑ Rnot repairs
tnStlrartCZ rZ lliSad. c. 1,2: 5 l -'.},and��e have no
`� - 13.21 otherinsulation
employees- [itio���orkers-
comp. insurance required_]
``.d m?annlicant that checks box N I must also till out the section below shox% their worker compensation polio information.
i-lnmcowners who submit this affidavit indicalin_e they are doing all v;ork and i ien hire outside contractors mustsubmit a nen-of-davit indicating such-
CL
11tractors that check:this box must attached an additional sheet showing the name of the sub-contractorS and state whether or not those entities have
emnlot'es_ if the sub-contractors have employees.they must provide their troffer comp_policy number_
s aln an enlpinver that is providing Ivorliers'colullensation insurance for 1221'en2plo}gees_ Beloit,is the policy an-d job site
l i J 01721QIIOII.
Insurance Company Name:Arbetia _
Policy-or Self-ins.Lie__ . { L 3 Expiration Date: -12
� ! ��.���� l�f�a�' City/State/Zl NOr tk t%,f'�0 l,1 ,AI A 01060
sob Site Address. p= '
A-ttaen a cony of the i orkers' compensation polic}declaration page(showing the policy number and expiration datej.
a1ltu•a to secure coverage as required tinder Section?�A of i`,IGL c. 1�?can lead to the imposition of criminal penalties of a
fine up to S1;500.00 and/or one-year imprisonment:as ivell as civil penalties in the fiorm ofa STOP WORK ORDER and a-fine
or up ro S250.00 a day against the violator. Be advised that a copy of this statement may be Forwarded to the Office of
InyIsriEarions of the DIA for insurance coverage verinca:ion-
f do hereby cerfiif,under the pailrs and penalties of perjrrrt-drat the iirformation pruvirled above is true and Cigual,
S.i�nature: Date:
1'ijol,�e_:(-13)-7741-3604
vJj IClal use Qlll}L Do 170,Iurife ill this area,to be completed ov cir),or town offrciai
1
City Or 'own: = II
_ssuing tiuthority(eircie one)- ll
�) `?Dard of Health 2.Building Department 3_CityFfown Clerk -'_.Electrical inspector s-Plumbing inspector
o_Wither
D
,� '„�iltdCl 1?t'30P, Alone ,
t'
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable ❑
�os�Q1� �ssl �t�13'l a
Name of License Holder: Georg . —
Ucense Number
__��f_��►y�oo� 01301 x-11® �o1
Address Expiration Date
Signature Telephone
�4
9 Registered Home improvement Contractor: Not Applicable ❑
�• �, �aF� fMf� S0��r>c, �,JD�1$0
Company Name Registration Number
�q dN S+re-6 r re-e--,itwl rya 01301 7-)s ' - �ko1 7
Address }} Expiration Date
Telephone4l)-7/ -360
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 wi►I result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ® No...... 0
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 1083.5.1.
Definition of Homeowner:Person(s)who own a parcel of land an 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.Aperson 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 171
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [Q Siding[0] Other[CA
_
IlnO if v(i�
,on
Brief Description of Proposed e 4V01N w 11111 11A
Work:
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. flood plain Yes No
i
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. 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
SSA 1A
J-
1, (�n�� as Owner of the subject
property i
hereby authorize arise�
to act on my behalf,in ail matters relative fo work authorized by this building permit application.
Signature of Owner Date
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 0S d
�Wl 2
Print Name
Signature of Owne A nt Date
Department use only
QCi orthampton Status of Permit:
$Ui
V .� U `, jng apartment Curb Cut/Driveway Permit
5� in Street SewerlSeptic Availability
pir►g& p 100 WaterMell Availability
j am` ortharftpton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION L - This section to be completed by office
1.1 Property Address: 3 4 �.�'� �e r r(A Ma
'J p Lot Unit
Oft K(A M PF')r' Zone Overlay District
01 f) or) Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: c Itrrc,c
Name(Print) A Current Mailing Address:
j$� AAOCI A Telephone
Signature
2.2 Authorized Agent:
�oS2P Cs2-��'� b� �U��,roo� S�. Gseenf�e�J�s�IA 0132►
Name(Print) Current Mailing Address-
h13)-71q _No k
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
complete 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) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissionerllnspector of Buildings Date
File#BP-2016-0437
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD01301 (413)774-3604
PROPERTY LOCATION 84 RIDGEWOOD TER
MAP 24A PARCEL 029 001 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
Fee Paid
Typeof Construction: INSTALL WALL 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
INFO ATION 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
Delay
u ing O cia 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.
84 RIDGEWOOD TER BP-2016-0437
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24A-029 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-2016-0437
Project# JS-2016-000722
Est. Cost: $3884.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 7492.32 Owner: JAMES JOANNA IRENE&JOANNE E SALUS
Zoning: URA(100)/ Applicant. JOSEPH GEORGE
AT. 84 RIDGEWOOD TER
Applicant Address: Phone: Insurance:
6414AYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON.913012015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WALL 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 9/30/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner