36-018 (5) 23 FOREST GLEN DR BP-2017-1114
GIS n: COMMONWEALTH OF MASSACHUSETTS
•
Map:Block:36-018 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-2017-1114
Projecta JS-2017-001897
Est.Cost: $2466.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(so. ft.): 14505.48 Owner: CAIRNS NAOMI
Zoning: Applicant: JOSEPH GEORGE
AT: 23 FOREST GLEN DR
Applicant Address: Phone: Insurance:
64 HAY WOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON:4/5/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL ATTIC & BASEMENT; ADD 10"
CELLULOSE TO EXISTING INSULATION IN 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:
FeeType: Date Paid: Amount:
Building 4'520170:00:00 $65.00
212 Main Street, Phone(413)587-1240. Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-1114
APPLICANT/CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 23 FOREST GLEN DR
MAP 36 PARCEL 018 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
• Fee Paid . (is{{
Building Permit Filled out
Fee Paid
Typeof Construction: AIR SEAL,ATTIC&BASEMENT;ADD 10"CELLULOSE TO EXISTING INSULATION
IN ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
shed Stamm ut or Licens'99372
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
72-377
Sig . ire of But ding 0 icia 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
r�t1 City of Northampton Status of Permit:
�Qt� :wilding Department Curb Cut/Driveway Permit
QQQ. 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Avaiability
Northampton, MA 01060 Two Sets of Structural Plans_,_,
phone 413-587-1240 Fax 413-587-1272 Mot/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: creat Glen. Nn This section to bet
by office
tT^ 'U Map .�.1� Lot O k ' _Unit
1 brenct1 M"#/' U Zone Overlay District
a1 /'6 Elm St.District Ce District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,1 Owner of Record: r —�
Nf4Ot" CEA,IN 2-3 Forth &tell Or,
Name(Print) anent Mailing Address: (9t3)-yaj-Pyg?
See, AtkOICAA Telephone
Signature
2.2 Authorized Agent; f
Sosew &ecrAt 64 Hoywooch S3,Crree(.ftdlJsMA 0113i
Name iPdI ` r 1 Current Malting Address:
A a (1i3)-7? t -36a
Signature L 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
Coustruction bootie)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection rr�� �//y�
6. Total=(1+2+3+4+5) or Check Number XD' 706
This Section For Official Use Onfy
Building Permit Number: Date
— Issued:
Signature:
Building Commissionelinspeclor or Buildings
Date
SECTION 5-DESCRIPTION OF PROPOSED WOR$(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [pj Decks CI Siding Iol Other HZ
XnSN w _
Brief Descrip on of Proposed
Work: /lir Rpt twitic p„i1 6asen.e . Add Io ;Atte/ Pf ceilulsSG to Down,' Inivkwo k qct((.
Alteration of existing bedroom Yes No Adding new bedroom Yes Nn
Attached Narrative Renovating unfinished basement Yes �No
Flans Attached Roll -Sheet
Ga.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 ramify unit:_ Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
E Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masacheck Energy Compliance form attached?
h. Type of construction
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
X. Will building conform to the Building and Zoning regulations? Yes_ No.
I. Septic Tank City Sewer Private well City water Supply
SECTION la-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTORrAPPLIES FOR BUILDING PERMIT
f, NADP' �,fNrf\l as Owner or the subject
property rA
hereby authorize 3S h V=0r
to act an my behalf, In all mutters relative work authorized by this building permit application. /
$ce {}kco o, e1 3/1)7! >_
signature of Owner Date
�OSfg*1 (Sante. ,as OwneriAulbodzed
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,
JoSegh Ger"t — .
Print Name 1/
3 /111)7
c�R.
signature of Owne Co int J Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: f ,�y Not Applicable 0
Name of Litems Noidelt SQSePh &eommmt. — C1314°1312
License Number
b� H9woott Slitter) &ceeakie4, $ onot _ a-((• ani t
AddressEmanation Date
signature euphoria
R-.` , e. . o innn :-ment Cant ; Not Applicable ❑
S P. George c4 Son,Int, 15668()
Company Name Registration Number
64 H«7uvnadI 5tte-6 (TreeAftelet MA .olyol _ 7-as
� ADCs
Address \ r�tA `/f' 7 ^� Expiration Data
1111 Vri"' 77,)- /7`13604
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.C.L c.152,§25C16))
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 1083.5.1.
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 eh 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 perfonn work for you under this permit
The undersigned"homeowner"certifies and assumes responsibility for compliance with the Stale Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Mae achusetts General Laws Annotated
Homeowner Signature_ _
Print Form I'
• The Commonwealth of iviassachuseits
_ t')eaarhneni ofindrstria/Accidents
Office of investigations
i ronCoress Stre ySuite igh
Boston,P,>r - 02114-2037 ' il
www.;nass_gav/dia I
Workers' Compensation insurance Affidavit:Bz lders/Contractors/ Iectriciansfelumners
11:-7icsnt Information Tease Print Lesi [v
n
Name (Business/Oreanizadoiu ndi:aduall:.LP.George and Son, Inc./Joseph George
.44=ddress:64 Haywood Street 1
l
Cir,,/Sate/Zip:Greenfleld/MA/Oi301 Phone#:(413)-774-3604 —
j Are you an employer?Check the appropriate box: Type of project(required):
I am a general contractor and I
I
t i. I am a employer with° 1,
f a have hired ire sub-connectors �_ Near consauction
emoloyoes troll proprietor oar.-time). 1.
r.❑ I am a sole or pzrmer listed on the attached sheet i. (� Remodeling
1 ship and have no employees hese sire-contractors have S. ❑ Demolition
working for me in any eapaci employees and have workers'
coma.insurance.: 9. Building_addition
[Io workers'camp.insurance _ i,
5_ i We area corporation and its 10.0 Electrical repays or additions i
j inquire!.] > t
5.LI ; am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions i
rihtorptionpMOL
yself. [`oworkers'camp.
IZ-Q Roof repairs
j insurance rqu;ae]+ c i 61(4),ane a- have no
ce
empla}.-�->io avar}eers an Otherinsuati0n i4
comp.insurance required.) Ij
ire]icon that checks box PI must also Ili oat lm section below shoo:Ina than worker compcnsatian policy information_
titon:orvners who submit this affidavit indicationn UMW a2 Oita all for and then hire outside contntiors mustsubmn a naw-.1 davit indicating such_ 'I
Cmnrncmrs that clock This hoc moat auached an additional shenslm'rine.m=name of the sub-goose=and Stan istictlia or not Wise Crltili:S have
nniavees t f the 4t-contsstorr'hasc cn$oyc's,dict'mast provide rhti. worker;comp.satiny numbs,
Icon an employer that is providing workers`comoenrsarion nnsnrnncejar:he employees, Below is thepolic_y and job site !1
1;1.'7h-hint-loth
Insurance Company Nalne:Arbella
Poiicv=or Seif-ins..Lic.t: 9 1 6i " 7 1,3 Expiration Dated/29/2017„_ 6
job Site Address: a3 FOrel 6-k-A ..... Ur' City/State/Zip:4&WeiAM/ 01061 ',7
ktheh a cony of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure caverege as required under Section 2. A of MGL c. 152 can lead to the imposition ofsr'Sinai penalties of a
fine up to 51;509.00 andtor one-year imprisonment,a5 well as civil penalties in the form of a STOP WORK ORDER and a fine
or'up to S250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of Y
Investigations of the DIA for insurance coverase verifi :4o.,_
1 do herzby Curt&tinder the
�pains
s�Q`iand penalties of perrjjan�'d
,7trat the information provided above Is true wit!correct
yr[snzme, 1 �""t'` Date: 03/31/1 )
?hone-:( 3)-7-14-3634 GG
r •
I Qtriciat use wily. Do not Naive in this area,to be comviered m_�eny or town Official 1
li
City or Town: —_Permit/License !
i. .Suing a.uthori?:(tircie one):
Board of health 3.sandilgDepartnent 1 City/Town Clerk 4.Electrical Inspector 3,Plumbing Inspector
I 5.Other
IrI `Contact Person: Phone g:
!
:
City of Northampton \
1, Massachusetts
DEPARTMENT OF BLDG INSPECTIONS ` ^(
212 Hain StreetMAc
• iBending
1l Buding S
Northampton,
ton,, 0
MA 01060 E
Property Address: 2-3 Foreit &1eI brie
Contractor / Fa�y
Name: // 3bse f), (Teorgt /a,P• Gent e w.d S N, inc.
Address: U`1 HoNiw000k Street
City, State: GYQen;;tid,i MA 01301
Phone: NIP-77PN 36014
Property Owner Cwm J
Name: rr�� I o or
Address: 2-3 I')rfst Glen Drift
City, State: Florence, MA ,0106a
Sose(AN &earl4 (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 ,yt
�`-�1�'`
Date Oh /a017
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CSSL-099372
.,_ c. iot. 5:: SO Spec
4JOSEPHW GEORGESIRE
HAYWOOD STREET
GREENFIELD MA 01301
Expiration
Commissioner 02/11/2019
'f.-r.,u..-e.<s.n///a "Ooror/ror/
Office of Consumer.Affairs&Business Regulation License or registration valid for individul use only
- iOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
- 'i.,Registration: 155685 Type: Office of Consumer Affairs and Business Regulation
=-Expiration: 712512017 Private Corporation 10 Park Playa-Suite 5170
Boston,MA 02116
JP GEORGE&SON INC
JOSEPH GEORGE j-3/4‘m rAr 01)�LC
6 HAYWOOD ST � T-'-
GREENFIELD,MA 01301 Uadcrsecretan- Ndtvalid without signature
RISE60 Shawmut Road, Unit 2 Canton, MA 02021 I 339-502-6335
ENGINEERING www.RlSEengineering.com
OWNER AUTHORIZATION FORM
NA-ort , /ft/Lit) 5
(Owner's Name)
owner of the property located at:
Z3 F''4i G//n) )lei
(Property Address)
FLoit*Ct- M/ . 0 /062
(Property Address)
hereby authorize 3•rpp, GeA'% and Soo, Inc -
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowners
responsibility to close out this permit by contacting their municipality at the completion of this work.
Owner's S gnature
19311
Date
62016