25C-173 (3) 125 NORTH ST BP-2017-0915
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 25C- 173 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLc.1144/2�A)
Category: INSULATION BUILDING PFI 11T1IT
Permit# BP-2017-0915
Project# JS-2017-001563
Est.Cost:$3420.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
const.Class: Contractor: License:
Use Group: POTENTIAL ENERGY LLC 106184
Lot Size(sq. ft.): 6098.40 Owner: SIRECI STEPHEN G&
Zoning: URC(IOU)! Applicant: POTENTIAL ENERGY LLC
AT: 125 NORTH ST
Applicant Address: Phone: Insurance:
61 EAST MAIN ST (860) 620-4433 WC
BRISTOLCT06489 ISSUED ON:2/7/201 7 0:00:00
TO PERFORM THE FOLLOWING WORK:DENSE PACK & OPEN CELLULOSE
INSULATION, VENT BATH FAN THRU SOFFIT, AIR SEALING AND WEATHERIZATION
POST THIS CARL)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 2/7/20170:00:00 $65.00
212 Main Street,Phone(415)587-1240, Fae: (413)587-1272
Louis I lasbrouck - Building Commissioner
File# BP-2017-0915
APPLICANT/CONTACT PERSON POTENTIAL ENERGY LLC
ADDRESS/PHONE 61 EAST MAIN ST BRISTOL (860)620-4433
PROPERTY LOCATION 125 NORTH ST
MAP 25C PARCEL 173 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PEC:• APPLI • ION CHECKLIST
(ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: DENSE PACK&\Q.PtEAKLLULOSE INSULATION,VENT BATH FAN THRU
SOFFIT,AIR SEALING AND WEATHERIZATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 106184
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
Demolition Delay
Signature of Building 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.
Department use only
a City of Northampton Status of Permit
17
Building Department Curb CuUOriveway Permit
212 Main Street Sewer/Septic Availability
<((<3. 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
125 NuriTh Stree+ Map Lot Unit
Nwthptor , MA CI 0.90 Zone Overlay District
Elm St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Stepp er Sirert / 25 North Street Northampton,
Name p(Printowner
)� y� v/� v +!' Current Mailin Address: _ LI MAC Cly/
-See owner aVfhC/ l?oh e l okm Telephone} to
Signature
2.2 Authorized Agent:
Putential PMergij (Nichnlas IVc ter) [DI E Maim St_, ,CToC
Name(Print) �7 / / Current Mailing Address:
Or
Li li SOIL 42Llc
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building/I ns ti tui-o h �3 4 20 -- (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 Q �
6. Total=(1 +2+3+4+5) $3 420 -- Check Number /321 L�/l
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs ]C] -n:°�uDecIs a[t] OYk, Siding 10] Other[0
i
Brief Description of Pro osed
Werk: (knee �ereneeluIOSe .)ver+bah fan tHvuco-fit,air seal irc , � _
Alteration of existing bedroom Yes No Adding new bedroom Yes No hQ�I �at)1�✓(
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.If New ho s- and or addition to existi a housin, corn•lets the foil•win•:
a. Use of building:On- amily Two Family Other
b. Number of rooms in each fa nit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimen s
e. Number of stories?
f. Method of heating? ire• -ces or Woodstoves Number of each
g. Energy Conservation Compliance. Masschec' nergy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. • • etlands? Yes No. Is construction withi 100 yr. floodplain Yes No
j. Depth of basement o eller floor below finished grade
k. Will buildin• .•nform to the Building and Zoning regulations? _ Yes No.
I. Sept ank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTORAPPLIESFOR BUILDING PERMIT
I, r��.f. LI,-I-tar;hectoi»ne V , as Owner of the subject
property p J�,
hereby authorize el l*ThCYI I C /4 .16 r144,7
—
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner9 /, ,(p� p�� /�}p ./� Date`,'�1
I, Nicholas M sfeJ' P len jt/ Eno-icy ,asOwner/Authorized
Agent hereby declare that the statem nts and information on the foregoing a li tion are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Nicholas Merstei-
Print Name
• 31/) 7
Signature of Owner/Agent Dais
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
p • p Not Applicable 0 p
Name of License Holder: NIhChol (IS e,Ster ccFA - iOL: I84
License Number
4DQUeepTerr. South(ngtorr, CTo4gq /z-7 /20i q
Address Expiration Date
�"_ 81D0IG2G4y33
Signature Telephone
9.Replstered Home Improvement Contractor: Not Applicable 0
PG\ent1al EriercCj i7g401
Company Name Registration Number
y D Queen Te Scttthincyfon C-f C(o4$3q - / zR/zoi g
Address p�� In I'IIq Expiation Date
�--- .-.. Telephone/ (f 22 `t93,
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I.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 0
11. — Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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 108.3.5.1.
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
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 byMGL c 111 , S 150A.
Address of the work: I Z 5 N01+hst. t NOrt "corritYI, NIA 0 CAC'
The debris will be transported by: POtev1flo J Enel'Cy
The debris will be received by: PuHerSVVI Ente{'rrf Skc — EVISt) ,CT 0(QCI C
Building permit number:
Name of Permit Applicant Peterhal Energ j / Nickolas MEI Eder
1/31 /17
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
11.=;s� OM(1 Office of Investigations
, =ice to ii / Congress Street, Suite 100
t `' '�_,` Boston,MA 02114-2017
.r•' www.mass.gov/tlia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information '7 Please Print Le¢iblx
Name(Business/Organixatiionnfndividual): ;��'�}f'.1t11,d {—ntrIS�� ���./ \lI �11l'�I b �, �.�_) CK
Address: (c7 L N'10.111 )ttee
r� 5 ( I , � U1 �City/State/Zip: _ tTh7 x�� il. L
LI
Areou an employer?Check the appropriate box: Type of project(required):
I. l am a employerwith 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
listed on the attached sheet. 7. ❑Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑Demolition
working for mc in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp. insurance comp, insurance.:
required.] 5. ❑ We are a corporation and its 10.9 Electrical repairs or additions
3.❑ I am a homeowner doing all work olTiccrs have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12,D Roof repairs
insurance required.] ' c. 152,81(4),and we have no - I
employees. [No workers' 13.. Other Thu i 0t•
I C'r.
comp. insurance required.]
'Any applicant that cheek box dl must also till out the action below showing their workers compensation policy in formation.
t Homeowners who submit this affidavit indicating they are doing all pork and then hire outside contractors must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sleet showing the name of the sub-contranun and stale whether or not those entities have
employees. If the sub-contnelon have employees,they must provide their porkers'comp.policy number.
I am an employer that is providing workers'compensation Laurance for my employees. Below Is the policy and job site
inforumtimn
Insurance Company Name: 'N(1(tfCIfl l(t'X41Y��f 'Ce x,CtiAi
1 p
Policy if or Self-ins. hie.h: 0' L. 1Ii t 0 C �.,�j 7 _� Expiration Date: p�.)// LV; I
Job Site Address: 5 Nie v.-1-h S-f-kee} City/State/Zip:NuyTamptQ IM4 0 to W0
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.
Ido hereby certify undfr the pains and penalties of perjury that the information provided above is true and correct.
Signature: � —� Date k l '3 /
Phoned: SISr ' - 11-2,9U
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Permit/License ft
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.011ier
Contact Person: Phone N:
Owner Authorization Form
Stephen Sireo
(Owner's Name)
Owner of the property located at:
125 North Street
(Property Address)
Northampton, MA 01060
(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's Signature)
1-24-17
(Date)
City of Northampton
sicx
Massachusetts
ti 4
q {t„+£ hS DEPARTMENT OF t "ffBUILDINGINSPECTIONS
212 Nadu Street • Municipal Building
Northampton, NA 01060
...:..:S.T.,
Property Address: IZS �l(,Y7�` cute.} N i.)Yfk(lYtrft V?1 MA (;IG 'C
Contractor
Name: {G't,))1;t C,L 1, rYV-�f' -suU
Address: 4)(, E MC; SIV e(."
City, State:
Phone: J&, LI 21,1,AL
Property Owner
Name: )Tc? 11t.1 \ ? \
Address: \25 Nrwir\",
City, State: (') r,Ora\\::t(;ef �1\t , lu;l CAD
I, I (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