18C-073 (4) Property Address: 7 7 7
Contractor
Name:
Address:
City, State: Ac
Phone: S'C - lG S`
Property Owner � //
Name: ! �6 l
Address: ? 1,2 'f s
City, State:
I, (contractor) attest and affirm that the building I intend
to insulate does of 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 sign re
Date _
/� 17
OWNER AUTHORIZATION FORM
(owner's Name)
owner of the property located at
r-7 7 -7 A-Q, �Ld
t
(Property Addr6is)
VC)k,
(Property Address)
hereby authorke /li Z-ti rWrfim �rr� zj,
(Suboo ')/
an authorized subaor actor for RISE Engineering,to ad on my behalf to obtain a bull ft
Permit and to perfomt work on my propedy.
j r�,�- 0
ownws Signahare
c -- L
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
m Offce of Investigations
'p 1 Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): The Energy Specialists
Address:212 Ames Road
City/State/Zip: Hampden, MA 01036 _ Phone 4:413-566-1058
Are you an employer? Check the appropriate box: Type of project(required):
1.F011 I am a employer with 3 4. ❑ I am a general contractor and 1
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 8. ❑ Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance.$ 9. E] Building addition
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers Have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑■ Other Insulation
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
7 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:Associated Employers Group
Policy#or Self-ins. Lic. #:WCC5009547012014 Expiration Date: 10-16-2016
Job Site Address: 4"",//r el Z^ _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 imprisonment, 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.
do hereby certi er the an allies of perjury that the information provided above is true and correct.
Si na�ie: Date: A4',Y/
Phone#: 413-566-105
Official 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 Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
--1
r 8.1 Licensed Construction Supervis or: / /► Not Applicable ❑
Name of License Holder: /,)"14C t ` Crne i.,�uc� � /c J k
License Number
Address Expiration Date
�-
Siqnaf6e Telephone
9. Registered Home Improvement Contractor; Not Applicable ❑ j!
rompany Name � Registration Number i
lAddress Expiration Date
—_-----Telephone
r 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 resLilt i
in the denial of the issuance of the building ermit.
Signed Affidavit Attached Yes....... No...... ❑ I
el
11. - Home Owner Exemption
The current exemption for"homeoevrn rs" was cxccnd,,d to include Owner-occupied Dwellings of one(1) or two(2) iarnilic_
and to allow such homeowner to erigatc an individual for hire ,vho does riot possess a license; provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.;3.5.1.
Definition of Nomeowner. .Person(s)who own a parccl of lam!on which he/she resides or intends to reside,on which there
is. or is intended to be,a one or two famil} dwcliing,a-Ltached or detached structures accessory to such use and/or farm
structures. A person who constructs more than one home in a two-ycar period shall not be considered_a_homeowner.
Such"homeowner-shall submit to the Building Otficz 1,on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building pert-nit.
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 lvlassachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this penrMit
The undersigned-homeoNI,Tner"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Loczl Loniq-,,Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 0-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows I Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Others
Brief Descr,ijption of PrrXosed J�
Work: i5/,�� /f-d ee-11, 3 c XI 4Tl'�
Alteration of existing bedroom Yes_ No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X 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 /
jhereby authorize �Nr ��'r"'f y
to act on my behalf, in all matters relative t work autKorized by this building permit application.
Signature of Owner Date
`n1r-f , ��'<< (� `J�f __ _, as Owner/Authorized
Agent hereby declare t the stat6ments 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 N -
Signature of Owner/Agent — -_ _ Date
� l
Section 4. ZONING Ail 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 1,:' R:
Rear
Building Height
Bldg. Square Footage ---T`
Open Space Footage °a,
(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 0 DON'T KNOW 1 YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW YES Q
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO cr� DON'T KNOW Q YES 0
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 0 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 0 NO
IF YES, then a Northampton Storm VVater Management Permit from the DPW is required.
- Department use only
ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
DEC _ 7 212 Main Street Sewer/Septic Availability,
201 Room 100 Water/Well Availability
N rthampton, MA 01060 Two Sets of Structural Plans'
oENOR rfUrsFr'cN�M'F,Q e 41 587-1240 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
1.1 Property Address:
This section to be completed by office
7 -7 7 `,�i�s �t- Map Lot Unit
Zone Overlay District 1
Elm St.District CB District j
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i
Name(Print) Current Mailing Address:
�r� vY5�7
Telephone
Signature
2.2 Authorized Agent:
Na in Current Mailing Address::
5G A) 5-
Signature Telephone 1
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical s (b) Estimated Total Cost of
/U �T Construction from 6
3. Plumbing Building Permit Fee
-- I
4. Mechanical (HVAC)
5. Fire Protection .✓� !I!
n. rotal = 0 + 2+ 3+4 + 5) tj) C�0,C- -- Check Number J __
l This Section For Official Use Only _1
Building Permit Number: Date
issued:
Signature: _
Building Commissioner/inspector of Buildings Date
File#BP-2016-0764
APPLICANT/CONTACT PERSON THE ENERGY SPECIALISTS
ADDRESS/PHONE 212 AMES RD HAMPDEN01036(413)566-1058
PROPERTY LOCATION 777 BRIDGE RD
MAP 18C PARCEL 073 001 ZONE URB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT _
Fee Paid o Q
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existina
Accessory Structure
Building Plans Included: -
Owner/Statement or License 99381
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
)proved 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 olition Delay
Signature of Buil mg 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.
777 BRIDGE RD BP-2016-0764
GIs#: COMMONWEALTH OF MASSACHUSETTS
MaL:Block: 18C-073 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Cate-ory: INSULATION BUILDING PERMIT
Permit# BP-2016-0764
Project# JS-2016-001277
Est. Cost: $3500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Coast. Class: Contractor: License:
Use Group: THE ENERGY SPECIALISTS 99381
Lot Size(sq. ft.): 23391.72 Owner: NOEL WILLIAM
Zoning URB(100)/ Applicant: THE ENERGY SPECIALISTS
AT: 777 BRIDGE RD
Applicant Address: Phone: Insurance:
212 AMES RD (413) 566-1058 WC
HAMPDENMA01036 ISSUED ON.121912015 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 12/9/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner