17C-143 (4) 122 HIGH ST BP-2017-0272
GIS#: COMMONWEALTH OF MASSACHUSETTS
hawk: 17C- 143 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-2017-0272
Project# JS-2017-000461
Est.Cost:$2948.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 11891.88 Owner: KLEINBERG NINA
Zoning:URB(100)/ Applicant: JOSEPH GEORGE
AT: 122 HIGH ST
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 Liability
GREENFI ELDMA01301 ISSUED ON:9/6/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL ATTIC & BASEMENT, ADD 10"OF
CELLULOSE TO ATTIC
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:
FeeTvpe: Date Paid: Amount:
Building 9/6/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File is BP-2017-0272
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774-3604
PROPERTY LOCATION 122 HIGH ST
MAP 17C PARCEL 143 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM .,LLE P OUT
Fee Paid 'Ie
Building Permit Fil ed out
Fee Paid
Typeof Construction: AIR SEAL ATTIC&BASEMENT,ADD 10"OF CELLULOSE TO ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 99372
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:$
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
",r.Eela
/ 7 a-/6
Siena • e of Building 0 �cia Date
Note: Issuance ofa 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
ti: 0 City of Northampton Statue of Permit:
�1,U „cv a�a Building Department Curb
cgdumeway Permit_._... _
212 Main Street SewaoSeptic Availability- —
�p > Room 100 Water/Well Availability_
tl �'a Northampton, M,4 01064 Two sets of Structural Plans_,_,
kl phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
S� 0lher spacRY_ _ ....
•r w AT)ON TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I
SECTION 1 •SITE INFORMATION
This section to be completed by office
1.1 Property Address:
oda w11‘ st
Map Lot_ Unit
Ff7?ACe7 M fl
1
Zone Overlay District
OW?
Etna St.pismM
__
Ck bsv a_
SECTION 2-PROPERTY OWNERSHIPtAUTHORIZED AGENT •
2.1 Owner of Record::p ;NA pq 1 �]
,N be
Name(Pent) Current Mailing Address. 031'.).1ta_ t
SEL AA t} l{PLh� Telephone t O` a !n
Signature I
y.2 Authorized Agent:
YOSePT, G-Euest 64 {lrnywoorlt Si. GTteM t13 013'31
Name(Pno l Gwent Mailing Address: j
` 1 (py' aittl ( (31-77it-364`k 1
Signature " Telephone _
LES. ION 3- STI LA ElCONSTRU,TIO!_ C'$TS
Item Estimated Cost(Dollars)to be Official Use Only ^�
coaudeted by permit applicant
Ai(�9 , Building
1. Building � a) Permit Fee
2. Electrical1
(b)Estimated Total Cost of
Construction from(6)
h —•3. Plumbing Suitdins Permit Fee I
i
4. Mechanical(HVAC)
5.Are Prateetlan
6. Total=(1 +2+3+4+5) a, 6l b44',o0 /915
This Section For Official UCheckse OnlyNumbkr —
X06'
6
Building Permit Number: 1 Date
Issued: _
Signature:
Building Commissioner/inspector of Buildings
--. .... Date i
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House D Addition Q Replacement Windows Alteationis) n Roofing fl
Or Doors O
Accessory Bldg. ❑ Demolition E New Signs [0] Decks [CI Siding[C] Other[EO
/nit() on
Brief Description of Proposed A( - Spv wit. imi ��))�� (� 1� (, rD _?t
Work: 1,3010*( A)d h `�1 LE�N1ole
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet '..
sa.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 stades?
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
Kirin i b2d
I. ( J ,as Owner of the subject
property /�,,
hereby authorize 5t�fi1`, &gory
to act on my behalf,in all matters relative 1tto work authorized by this building permit application.
See &crncveI . 81a,E,//E
Signature of Owner Date
I, 3'oSe0, & ry. ,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. i,
JoSeph GenrO,e
Print Name I ) C - „- _ vvvi 6
Iir
Signature of OwnarlAg nt Date
SECTION 8-CONSTRUCTION SERVICES.
8.1 Licensed Construction Supervisor. Not Applicable ❑
5 Sepk Geargt
` name of License welder- D cSsi GIG131
License Number
6w Hmy�..00d, Scree\ cretnkct41 0301a-1i - aoii
Address '(� Expiration Date
Signature L `r�r�l �` ephone ._
9.Registered Home Improvement Contractor: Not Applicable 0
S e• ()for w,1 Son,Int, IS6686
Company Name Registration Number
Sot tipnbw.tadl Street refA;telel MA 01$41 -?3 -`)oi.7
Address\ LL �(/� Expiration Date
.�jr-'' t ` Telephone�9Ifl 77y-36 4
SECTION 10•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G-L c.152,§25C(S))
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 a No ❑
11. - Home Owner Exemption
The current exemption for"homeowners'was extended to include Owner-occupied Dwell;its of one(i) or two(2)families
and to allow such homeowner to engage an individual for hue who does not possess a license,provided that the owner acts
as supervisor.CMR 780. Stith Edition Section 10833.1.
Definition of Homeowner:Ferson(s)who own a parcel of land on which hefshe 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 Othcialstjlak he/she shall be
responsible for all such work performed under the buildion permit.
As acting acting cktistnafed S tyispr your presence on the job site will be required from time to time,during and upon
completion of the work for which this pent 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,von may be liable for person(s)
you hire to perfwm,work for you under this permit_
The undersigned`tomeowner"'certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Otdinaoces,State and Local Zoning Laws and State of Massachusetts General Laws Annotated,
Homeowner Signature _
II
s
City o£ Northampton
;if! Massachusetts if
( �� DEPARTMENT OF BUILDING INSPECTIONS <
?/
212 Hain Street • Municipal Building t
D.‘;
Northampton, MA 01060` J
Property Address: '�'�" Hl \ 4 _
Contractor
Name: SoSe \N Creon e. /d,P• G2ot�g w 11 Sgi int.
Address: 0 HoWood Stree
City, State: Greeni,el&t, MA 01301
Phone: ('IM-771i- 304
Property Owner [V'N K
Name- Ni no le!Rbe'�
Address: l ;.). tli
)ft St
City, State: j lorertitr MA
I. 3o5e9' torr f (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.1
Contractor signature \ ) 1 , \t 1 Rept
Date g ' � .,Oib {`,i ']l\'u `OV`-'
Rina Form
The Commonwealth qy Massackusett -
•
Deparhnent offrtnusi+aI Accidents
- - _•
Office of Investigations
1 Congress Segel,Suite 100
Boston PTA 02114-291 7
:muw,nrss..goviriite
Workers' Compeasatioa insnraace Affidavit Ba tiersICo_tractors(E+ectrkciaresR13 hers
I
:pan€ eent Information --
_ Please?Tease_Prsht Legibly
MIT
r omindhiduet):J R George and Son,. Inc. !Joseph Geor e
\$vLZS[3usinc�4)r�eei>•;. i
_dei WS=HC Haywood Street .— I
li
LilyiState/Gip:Greenfield/MA/01301
_,,,,, Phone#:(4139-794-3604—_ h
'Are you an employer?Check the appropriate boxo
Type of project(required): jIl
t.i✓ I am a employer c nilaro z_en contactor and
P . ` 6. I New coasauc[ion II•
employees(full and/or pas:-time).` have Hired the sub-contracmrs
listed on the attached sheet. i. 9 Remodeling !
230 I am aside proprietor or partner- y'
ship aand have no employs
These sub-contractors haveS. ❑ Demolition
workingforme in any capacity_ employees and have workers '
p comp.insurance.- 4. []Building addition III
[So`workers coop.insurance n - IOUElectrical repairs or additions ii
required.] I l dte era 2 corporation and its _ P
I 'am a homeowner doing all work officers have exercised their i 1_U piumbm¢repairs or additions I,
3,Lri h ofmpiion perMGE Vii,
myself_[)Vo comp. 12.[] Roof repairs
insurance required] e. 1_ ye I(:),and we have no ;� Ii
` l3 L7 Otherinsuiaiion
employees-[No workers'
comp_insurance required) _— !!,,
pours*hat ghees Moll.:I must also till out the section below shovins der workers'comoa6auon poUer inronnatmn
innitownets who submit this amdmit enmeall they uzebing an wom and hen hire outside conlnemrc nmstsubmn a new affidavit Indication such,
rryninuctors than check this hoe must attached an additional shoot slroain_um name a:ncc sub-conrructors miasmic whethcror nottose thanes have
cntplo'C2i if the subconimpors have cmpiovecs they mail pmvvide Meir:tome comp policy number
font rot employer titer is providing Workers'COnroelrsaihOn DISII71112E2fOr MP el?lpoyeec. Below is the polity ant!job Sire
riljor/natio&, 1
Insurance Compare Name_ArbeQlla r"� ( (�j�{ Il ;
Policy€or Self-ins.Lie_iii: flit 1p(]" 0 1 " l l• Expiration Dace4/29/2Ut-"j p [ 1
Job Site Address; l t tl1 Si• City/StateJup: flounce/ M , ,oIo6 ii
4,t—tacit 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 o. 1 52 can deed to the imposition of criminal penalties of a
rine up to si500.00 andfor one-year imprisonmenc as well as civil penalties in the loom Ofa STOP WORK ORDER and a fine
niitio to 9250.00 a day against the violator. Be advised that a copy of this statement may be fox evarded m the Orme of ,
tnves[i&a lues of the Dir, yor insurance coverage,war cc k�n. "
1 do hereby carrj'anter the pi ins and penalties el-pet-jug that Ike it jarmmion provide[!above is true and correct.
+ 1
S!armoire: _ Ca�AJ. ._ Date:
t
Ione#4.13)-774- c14. ._
(l oliicta!use ash% Do not mire az this area,to be completed by chh.Or lawn Official —�
It
ICity as'Town:!„ __Permit/License= !
o Au:ho-fn:/circle onek,
' I. Board of Health 2.Building Department 3_City/TawClerk 4.Electrical inspector 5.Plumbing Inspector
Ii 1 D.^Cher. 11
j1
it ^.Oliatt i mon: Phone m:
19 Massachusetts -Department of Public saie*y
:Card of Sanding Rcgmauro:and Stito thou
:mho octon Suoun Hui
cease '
C9e3-099372
JOSEPH P GEORfl zer.,
64 HAYWOOD STREET re
GREENFIELD NFA 01301
Sri.- rxhoo,.oh
commissioner 02/11/2017
-/4r 6rmi.,nee.e76cf //
r. Office of Consumer*Affairs&Business Regulation License or registration valid for individul use only
":HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
3 RegIstration: 156686 Type: Office of Consumer Affairs and Business Regulation
Etplratwu: 7/251201? Private Corporation 10 Park Plaza-Suite 5170 }�
Boston,MA 02116
JP GEORGE&SON INC
JOSEPH GEORGE {
Ii
sa HarwooD sr e ` `- \r� q)1,20-7-71711-'
GREENFIELD.MAOt301
Undersecretary N
valid without signature
I
III
I.
RISE' 80 Shewmut Road,Un0 21 Canton,MA 02027 1339-5024335
ENGINEERING vninvRISEenglneering•eom
OWNER AUTHORIZATION FORM
I, t9. OtitJ _� _.
(Owners Name)
owner of the property located at: /
i Vi .. t‘ 1A 57 .
(Property Address)
Flt, re' e , Cr. MR- 471.017 ?---
(Properly
`L(Properly Address)
Z
hereby authorize r 1)"r1, (Mseri) Inc rip �n 2
(Subcontractor) C L IS u v [ 1,
an authorized subcontractor for RISE Engineering, to act on my behalf to ob ID=(building :1
;1 A'J„ S V CA ` j
permit and to perform work on my property. This form is only valid with a sign.1. • i tract. IL'
Owner's rs Signature
t.b
Date