24D-239 own 41
Permit Authorization
Form ,� `�►
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Site ID: 50129638 Customer: Katheryn Brown
1, Katheryn Brown ,owner of the property located at:
(Owner's Name,printed)
162 Prospect Ave#5 Nothampton
(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.
Owner's Signature:
Date: t Z 1-9,
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
cl�-OY J�q
Participating Contractor Date
i7s`o
Di
For Office Use Only
Conservation Services Group • 50 Washington Street,Suite 3000 • Westborough,MA 01581 • 1800-480-7472
Rev.062015
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS yv a
212 MaiNorthampton, ici uilding
01060 EjsNW7�1,�
Property Address:
Contractor 1 �,,, L
Name: �,Q GeD3 (4 30R, ln�,
Address: Vol h ('1WgoA S1 .
City, State:
Phone:
Property Owner
Name:
Address: �� Q�OS�e C✓� A��
City, State:
C*y (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
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 16�
The debris will be transported by: �'Q� '�� G'^� 5M, lnt.
The debris will be received by: D(VSWt6qrj
Building permit number:
Name of Permit Applicant �05� ('e0f't
Date Signature of Permit Applicant
., -- - print Form I
=lie Conzrzonivealth o�Massachusetts
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Niame(Busines_!Orean_izatiorv7ndiriduat):J-P- George and Son, Inc_1 Joseph George i
i
_,-ddress:6" Haywood Street
C tZ; StatefLip_Greenfield/MA/01301 Alone
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction
Supervisor: , Not Applicable ❑
Name of License Holder: �Cog C �( TD
License Number
6y �"OOIA 5�, WeAMAIIAA , onpn oa/ I&M17
Address Expiration Date
Signature elephone
9. Reaistered Home Improvement Contractor: Not Applicable ❑
a t P �►� G�1� son, il►�. NU 6
Company Name Registration Number
61 H(A wool+ S}, &reeoite /Ah, ()uo l 7/aVad7
Address Expiration Date
Telephone 13 J�771-30 4
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....... Q No...... ❑
11. - 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 10835.1.
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 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) E] Roofing 0
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0) Other[JU
TQJ'4 �?
Brief Description of Proposed �1f S'L41 N\® ,-_.1 4 b ,
Work: I5 1 0 D 1 l iv'(� q tALkj (& CeIlul(k 0 O IL
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, � �ry as Owner of the subject
property `
hereby authorize (�p�1� �(hie-
to act on my behalf, in all matters r lahtive to work authorized by this building permit application.
Signature of Owner Date
I, �flxpV., 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 Owner/ g nt Date
Department use only
City of Northampton Status of Permit:
JAS — Q Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, 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
1.1 Property Address:
This section to be completed by office
10 P rq M W T p}
3 Map Lot Unit
No f!�(AMO()), Mp Zone Overlay District
Q 1 o v o Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
L Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
N3) 771-3 bey
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Gi (a) Building Permit Fee
2. Electrical 0 V (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+ Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File 9 BP-2016-0850
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD01301 (413)774-3604
PROPERTY LOCATION 162 PROSPECT ST-APT 5
MAP 24D PARCEL 239 001 ZONE URC(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 ATTIC& BASEMENT 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" ION 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
Demol' 'o clay
Sig ure of Building fici 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.
162 PROSPECT ST-APT 5 BP-2016-0850
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D-239 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0850
Project# JS-2016-001439
Est. Cost: $1855.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 6795.36 Owner: BROWN KATHERYN
zoninz: URC(100)/ Applicant: JOSEPH GEORGE
AT. 162 PROSPECT ST -APT 5
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREEN FIELDMA01301 ISSUED ON.11612016 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC& BASEMENT 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 1/6/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (4 13))587-1272
Louis Hasbrouck—Building Commissioner