23A-008 (4) 38 PARK ST BP-2016-1270
GIS #: COMMONWEALTH OF MASSACHUSETTS
Ma :Block:23A-008 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate,,ory: INSULATION BUILDING PERMIT
Permit# BP-2016-1270
Project# JS-2016-002181
Est. Cost: $2304.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin POTENTIAL ENERGY LLC 106184
Lot Size(sq. ft.): 12458.16 Owner: BUCKLEY JEMIFER B
Zoning:_URB(100)/ Applicant: POTENTIAL ENERGY LLC
AT. 38 PARK ST
Applicant Address: Phone: Insurance:
4D QUEEN TERR (860) 620-4433 WC
SOUTH INGTONCT06489 ISSUED ON:5/3/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL PLASTIC GROUND COVER & RIGID
INSULATION - IGNITION BARRIER MAY BE REQUIRED
POST THIS CARD SO IT IS VISIBLE FROM THE NTREET
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 5/3/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1270
APPLICANT/CONTACT PERSON POTENTIAL ENERGY LLC
ADDRESS/PHONE 4D QUEEN TERR SOUTHINGTON06489(860)620-4433
PROPERTY LOCATION 38 PARK ST
MAP 23A PARCEL 008 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid _
Buildin Permit Filled out
Fee Paid
Typeof Construction: INSTALL PLASTIC GROUND COVER&RIGID INSULATION
New Construction J
Non Structural interior renovations xrio
Addition to Existing
Accesso Structure
BuildinIZ Plans Included:
Owner/Statement or License 106184
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON TRIS APPLICATION BASED ON
INFORMATION PRESENTED:
proved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDEIR:§
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 goof 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
Demoliti n Delav
j ;J 497f /
Sig eof Bui ding ficial 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.
Department use only
C of Northampton Status of Permit:
l B (ding Department Curb Cut/Driveway Permit
APR ? 'n16 i 312 Main Street Sewer/Septic Availability
�1 Room 100 Water/Well Availability.
G En forthmpton, MA 01060 Two Sets of Structural Plans
ne X587-1240 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
Map Lot Unit
[oy I ►c e ` 4 of�r�j/n Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
EL
Name(Print) 'Curre tes'ling
'g ' (055
Telephone
Signature
2.2 Authorized Agent:
Name(Print) 'Current ailiinjg�Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit 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 T2 �S
This Section For ficial Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING All 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: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(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 O DONT KNOW ® YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW ® YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained O , 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 O 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 O NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement,Windows Alteration(s) ❑ Roofing ❑
Or Doors Q
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [0 Siding[p] Other
e r
Brief Description of Proposedrl I J /I,i, ,
Work:
P p // �' °� � �`I �I
/ V. � ,
4 1J
Alteration of existing bedroom Yes No Adding now 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 I 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 Na. 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 PEI MIT
01f,
Ij/K I,,AA S! � e„ as Owner of the subject
property
hereby authorize f V�T/►' l I I Is( i 1 } I lel. 1 �.�
to act on my behalf,in all matters relative to work auth6rizdd by this building permit application.
Signature of Owner Date
felr 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/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Sup�erv/i�so/r�:C t Not Applicable ❑
Name of License Holder: p��[,��r(J ��lr� o FA- 10W4
License Number
4D@1&"6T:erK ,5Wfhvrt-n&T0W9q 412-7/xtq
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
MJLMOA&I° U . LLC'./ Ct21` r 1A10 1
Company Name Registration Number
Address ✓ Expir tion Dat
Telephone
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 buil ing 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 108.344.
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
The Commonwealth of Massachusetts
=moi Department of In4ustrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:;Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PtRMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/individual):,� , �(}�.�, �L 00L
/�01 i01 NA S-r({�
Address: 4 !p L u Le-o T,t rrC(-C. e_
City/State/Zip:, CTr 4-fl Phone#:
Are you an employer?Check the appropriate box:
Type of project(required):
II am a employer with_—d—employees(full and/or part-time).* 7. New construction
2 I am a sole proprietor or partnership and have no employees working for in 8. Remodeling
any capacity-f No workers'comp.insurance required.]
9. El Demolition
3.[J 1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10[]Building addition
4.[—][am a homeowner and will be hiring contractors to conduct all work on qly property. 1 will
ensure that all contractors either have workers'compensation insurance of are sole 1 I.[]Electrical repairs or additions
proprietors with no employees. 12.E]Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurancc.t .P
h.❑We are a corporation and its officers have exercised their right of cxcmptipn per MGL c.
14. Other vy1sulaboyl
152.§1(4),and we have no employees.[No workers'comp.insurance rewired.)
*Any applicant that checks box#1 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.
*C:ontractors 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 work[;rs'comp.policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information.
Insurance Company Name: C
Policy#or Self-ins.Lic.#. ; j � Y' 1t.1 Expiration Date: )
Job Site Address:,-�s K `'s � ,� ,City/State/Zip:
IVA 01Wz,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expir tion date).
Failure to secure coverage as required under MGL c. 152,§25A i�a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido hereby certify under the pains and penaldes of perjury that,the information provided above is true and correct
Signature: �''�l ( `-_'� / � Date: 4125JIW
Phone#
Official use only. Do not write in this area,to be completed Y 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#:
Owner Authorization Form
I, Jennifer Basile & John Barlett ,
(Owner's Name)
Owner of the property located at
38 Park Street
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize _Potential Energy LLC , a certified Mass Save Home
Performance Contractor, to act on my behalf to obtain a building permit and
to perform work on my property.
Owner Signature
10/26/15
Date