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24D-172 (3) mass save• j RR S"bWUML-Shenewaftlerty PERMIT AUTHORIZATION FORM 1 (( ,t A 4 I, Yosh Shulman &Cd4UA ��k ,owner of the property located at: (Owners Name,print ) 210 State st 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 Owne Signature V/3/1 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: v�5 Participating Contractor Date Off 'For Office Use Only Rev.12132011 City of Northampton Massachusetts ,.A DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building Jas 4�a \y r. Northampton, MA 01060 Property Address: Contractor �'4 �eor)t Gr 1 Sm,-soL. Name: U1 Address: City, State: Phone: 413) I -A04 Property Owner V©S� C CI`���Gn Name: 1 J Address: 'a w *Ac S\, City, State: ���y►rhd�on, MA 01�b� I, 3©fie Q� (seo�e. (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: a\O 5* S� The debris will be transported by: &Oft(, ynA SDn) Inc. The debris will be received by: Building permit number: Name of Permit Applicant 30o\ Geory Date Signature of Permit Applicant =n,=Fbrm TIze Co,,r?wzo,,r?weaPdz qfMassadzzisetts -zaI ccidezts Of- a List, y; , =77 01 fice of-nvesti 17, a,ations 7 colwj•ess street,silite-7 0 0 017 3ovo.n..AL 1 027114-2'7 ;2 2 ass-go,o,.,/ilia su R&7�--_';t: Bu der lCon ac-LorslEice;.riciaE.s[-Piut—i.bers com-aensa on_r_I -g-an-ce Aff S U -tr f1lease Print Legibly. Nlanae(BusinessfOreaniz-,6o,-v7ndi,.•idual):J-P- George and Son.. Inc-I Joseph George Addrcss:64 Haywood Street Ci�/SiateIZ-ip:GreenzIiPld/MA/0 1301 Phone--(413)-774-3604 you an empioyei*Che&the appropriate bo--- Type general of project(required): 1.17V 1 am--- empl over with g have hi�_red the sub-contractors 6- ❑INev.,construction employees(full and/or part-time).` I - listed on attached sheer -.71 1 art a sole proprietor or partner- 7- ❑ Rem odeLinz These sub-cozi-,,actors have ship and have no employees S. E] Demolition __MPIq,yees and have.workers- working nor me in any capacity- 9. ❑Buildin_g addition [No workers!comp.insurance comb_p- insurance_— 1 0_FJ F-leettical.repairs or additions we are a Corporation and it Cequired-i 5 1 ,- ot-ficers have exercised their repairs or additions ani a homeov.rner doing all work H_E1 Plumb] right a faxemption per NdGL myself [No v.•orkers' comp- 12.❑ Roar repairs C- i __. §1(4),and we have no employees.[moo workers: BE otherinsulation Como-insurance required.] "I must a i comoensation polio} information- iw-ipplicwir that cbec.L:s box also fill out the section below sholving timir worl.cr i-Ioni-cowners who submit thisaffida%-4 indicating they are doin2 all v:aril anti,!hen hire outside contractors milstsub.-nit a new.-M.davirindicatinz such_ _.-OlItnictors that cbecl,This box must attached an additional shoot showing we name of the sub-contractors and state wlictlicrormithose eatities have if the sub-contractors have employees_wet/must provide their i1rorkers-comp.Poliev number- Beloit/lstlzepolli!illajitl job sife Insurance Company Name:Arbellp -3 D 1. Ic- =."-or Self-ing-Lic-=: -6 i 0 4 (13 01' v �i 1 13% on Dare:412912016 job Site Address: citVistate/zip: Nor h 0►00 ij A-tuicha con}of the worliers'compensation policjj deC.121-2z0n rage(shomin.-the policy number and expiration date)_ ailure to secure coverage as require d under Sect-on 2S o'"NIGL c. 152 can lead to the imposition of cerninal penalties ofa FI and/or one-year imprisonn,enL as v.,ell as civil penalties in the form of a STOP WORK ORDER rid -fin fine up to SI-500.00 a P a m7uo to S250.00 a day againstthe violator. Be advised that a copy o-LEtill's Statement maybe forwarded to the Off,ice of Invescisa6ons-of the DIA for insurance cove.-Pacre i-clohei-ebi-cei-t firii7tlez-the pizifisa,Fzdpeizaltiesofpe,rjr4r,-j=tlra,'the itTori7zatiigiiprovirief[aboiletstriieaticicoi,rect, Signature: Date: 1-3)-7741(-AO4 jiQfTicia1 use ojzIj:_ Do not wfirgin thus area,tobe completed bil Cki"Di-tow.-I OffIr-i'aL Permit/License--.** one): •I. Board of ifealth 2.3nildiiig Department 3-Giryl-I o,..n Clerk _!_Electrical inspector 3-plumbing inspector er SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction SupervisQor: (� Not Applicable Name of License Holder:- \ F' I/v�� 1 37,� License Number Y\A ; 0130 Address Expiration Date 131✓71 4 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ )� (ICO�h Vk Son, -PL. Companv Name ffl Registration Number 64 )in-v,04 W �[Qr) kj ") W301 7/MM Address Expiration Date Telephone R13) 771-304 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 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) ❑ Roofing ❑ Or Doors 171 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding[0] Other[`Q JMVIE 01 Brief Description of Proposed Work: AlF 'kµI (;*L 04 V(A)tM 4 I�}ad ��, Pt Q111414y, (0c. 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 existina 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 1, �(A- J4mAnw as Owner of the subject property (,p hereby authorize �QQ1� Jf'a to act on my behalf, in all matters reltative_t�work author ed by this building permit application. S6t- G C O WW-Xo1A 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. Print Name Signature of Owners ent U Date _ __-- Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit JAN _ 4 212 Main Street Sewer/Septic Availability Room 100 Water/VVell Availability oEE=r.c Northampton, MA 01060 Two Sets of Structural Plans rvo r..,,. hone 13-587-1240 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: ago SlU�t 5� This section to be completed by office . MR ^n Q Map Lot Unit Zone Overlay District Now Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: os� Scwl m" o Slot Yl - Name(Print) (( p 1 Current Mailing Address:(ruo- —73q " '16A A Telephone Signature 2.2 Authorized Agent: �rNka rho 64 "(Aj\u00,A S, �, �rleenfield,MA, 01301 Name(Print) \ • Current Mailing dress: Signature V Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building Q/ r' �r (a) Building Permit Fee 2. Electrical +✓ l� (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+5) , Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File# BP-2016-0851 APPLICANT/CONTACT PERSON JOSEPH GEORGE ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD01301 (413)774-3604 PROPERTY LOCATION 210 STATE ST MAP 24D PARCEL 172 001 ZONE URC000V THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvpeof Construction: INSTALL ATTIC&BASEMENT INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildin,,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 Demolition Delay Sig f ui in 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. 210 STATE ST BP-2016-0851 GIS 4: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D- 172 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-2016-0851 Project# JS-2016-001440 Est. Cost: $8611.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH GEORGE 99372 Lot Size(sq. ft.): 9234.72 Owner: SCHULMAN YOSH Zoning: URC(100)/ Applicant: JOSEPH GEORGE AT. 210 STATE ST Applicant Address: Phone: Insurance: 64 HAYWOOD ST (413) 774-3604 WC GREENFIELDMA01301 ISSUED ON.•11612 01 6 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: (413)587-1272 Louis Hasbrouck—Building Commissioner