23A-123 (8) 20 MIDDLE ST BP-2017-1168
GIS a: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A - 123 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-2017-1168
Project# JS-2017-001972
Est.Cost: $3607.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(so. rt.): 13503.60 Owner: WYMAN GINA
Zoning: URB(100)/ Applicant: JOSEPH GEORGE
AT: 20 MIDDLE ST
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREEN FIELDMA01301 ISSUED ON:4/20/2017 0:00:00
TO PERFORM THE FOLLOWING WORK AIR SEAL ATTIC AND BASEMENT ADD 6
INCHES OF 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 4/20/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
File# 13P-2017-1168
APPLICANT/CON'T'ACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413)774-3604
PROPERTY LOCATION 20 MIDDLE ST
MAP 23A PARCEL 123 001 ZONE URB(I00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONINC FORM FILLED OUT
Fee
BuiPaid 6
Building.Permit Filled out
Fee Paid i
T oeQLC t t'rn: AIR SEAL AND BASEMENT ADD 6 INCHES OF CELLULOSE TO EXISTING
INSULATION IN ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 99372
3 sets of Plans I Plot Plan
THE FOLLOWING:ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF TION 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 ANDfOR 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
Dyelay � `..
4110
Signature of I ilding 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.
1
:/' \\\ Department use only
o�� \ • City of Northampton Status of Permit:
,,'l /. Building Department Curb CuUDriveway Permit _
212 Math Street Sewer/Septic Availability .....-
Room 100 Water/Well Avaflabflty _v
Northampton, MA 01060 Two Sets of Structural Plans".
it phone 413-587-1240 Fax 413-567-1272 PbdSite Plans
Otter Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 •SITE INFORMATION
1.1 Property Address: 10 AP re CI•
This section to be completed by office ..
V` Map (7tly9 Lot [di Unit
!lorincei MA
!i ( Zone M,
Overlay Distn
0 !A U l Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
'
21 Owner of Record:
i 7
&iAm wNIhM a ANCUle S �OflAF`�j_
I t F °fi
Name(Print) C' //Current Nailing Address: (v3)- 37{,UpI
!Y-
71 e, AkkolcAte1 Telephone JJ 7I p 1
Signature
2.2 Adrhorfied Agent r�
SOS ep1, (seAT4t 64 Hrnywoo6t s-t. r,Freeni;egYI.it•tW one&
Name iPnt Current Mailing Address:
I 413)-714 36att
Signature ` Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
lgIIIIIIIIIIIII Ee6mated Cosi((Wars)to be Olikial Use Only
com.leted by permit applicant
(a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
CO(%(nicfio-n 6om{6)
3. Plumbing Building Permit Fee
4 Mechanical(HVAC)
5. Fire Protection
6" Tatar=(1 +2+3+4+5) 3/G07,06 Cheek Number j6V(� ili
aTCS—
This Section For Official Use Only
Building Permit Number: Date
Issued:
signature:
Building Commi:dicner/Inspector of Buildings
Cate
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House D Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs Io] Decks (IC Siding[0] Other Mil
tnJv, cort
Brief eypion,eProPos@tl
Work: ' L /Mil L1kreAll 6 IAif of cel/wIoce _
14J IcJivn
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 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 stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck 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
k. Will building conform to the Building and Zoning regulations? Yes No.
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
&INNA WNMfn/1 ,as Owner of the subject
property ST St !C�yy1
hereby authorize \ uCorge
to act on my behalf,in all matters relativelo work authorized by this building Permit alicatj n.
See MVAO,,edf P4fI4I1
Signature of Owner Date
•
3o5C4\\ &edr9t ,as Owner/Authodzed
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.
JoSeph Geon,
Mint Name ��K A 0y/i4/i
Signature of Owners ge t kJ Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:yy' Georg.
Not Applicable El
Name of License Holder: UDSepl\ VCorg. CS31c493111
License Number
6w Hbvw00m Strce\ iureenk(e1h MA 01301 a-ll. a�ii
Address \ Expiration Date
�!1 (413)-P1-3bo4
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
J• P, George ci Son,tut, \suss
Company Name Registration Number
69 Horwood\ Strep\ 6-reer,$telith AN 01301 7-25-2915
Addres Expiration Date
Telephoned X3)-779-3604
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 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,oris 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,volt 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 Slate Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated
Homeowner Signature
City of Northampton
r jai' Massachusetts I
v Se 9 j "I
t \ % DEPARTMENT OF ex+sznnca saspscazoxs :1%.-c3, °":":19 r l
t:%
212 Main Streetar •o Municipal Bui2dio4J
n '�11 pg tt )) Northampton, MP 01060 t
Property Address: (•f-Q oridol It it. HollAte, /inn to Jo6a
Contractor
Name: tt JoseOt, &ear e, /a,P. £eoteg 64 it SON, c. ..._
Address: b't HmYwaoa Strtei
City, State: Green4;eld,, MA o1361
Phone: ett3)-774- 3604
Property Owner
Name: cii D el \AI Morn
Address: ?-O .,Mtid)le St.
City, State: FIo(vice, MA, t0106)"
I, Jo epl' &for 4 _(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 09 Otir tI
The Commonwealth of Massachusetts
Print Form I
LLiepartment of Industrial Accidents
Office of Investigations •
7 Congress Street,Suite 100
Boston,MA 02714-2017 •
www.mass-gov/die
Worker? Compensation InsuranceAffidavit:Rug derslContractorslElectnctaus(lumbers
imeie=ni Information Please 'SI e&ii14
Name (Business!Oreanizationflndividual):J.r?. GGorge and Son, Inc./Joseph George
Address:55e Haywood Street
Citv4State/`L-ip GreenfteidrMAd)i301 Phone#:(413)-774-3604
--
Are
SII
yo an employer?Check the appropriate hot Type of project(required):
i jI am a general cont-actor and!
J'I P J
I mm a es(bull
with r '- Q
6. 1]New eonsauction
employees(bill and/or parr-time).* have hired the sub-cone-actors
3.0 I am a sole proprietor or partner listed on the attached sheer ?, Q Remodelm_
shipand have no employees Then_sub-contractors have
& D Demolition
;cantina For me in any capacity. employees and have workers' I(
comp_9nsutrnca� 9. 11 Building addition
[No workers'camp.insurance
raquireG.l 3officers- 0 We area corporation and its 10.0 Electrical repairs or additions �f
i—'- v. have exercised their
1 ' am a homeowner doing ail odaI LQ Plumbing repairs or additionsJ
myself.[No workers'camp. right of`.z mption per MGA
2,Q Roof repairs
it-Olin-11<Zregektdl* e 1 io §I(4),and we have no t
employees_NU workers` 3.�OtheTIH6Ut3II0n
�I
compinsurance required]
lir annlimnr that checks box 31 must also till our dm aS
section on sipm : it
rinz mwor orf compensation policy information,
' aomoowver,who submit this affidavit faineant.then ae doing a0 wors and then hire omsida conimators mustsubmit a maw affidavit indiodoe au&
mmacrors time check this bas must attached an nddizionai sacrasbouine dm noma or au:aubconuanors andstaw rrliea¢r or not those emits tram
m npioycs. ?f the sub-cmcmetors ham cmptoytrs,they must provide their vortex'comp.policy numbs:.
I an WS employer that is providing workers'conmensmion lnsttra2tgfor Pm,employees- Below it thepalier anti job site
fnibnvmtion.
Insurance Company Name:Arbella
i ALL
Policy el or Self ins.Lie.#: /^.,At9.�II ffnnj 3-3-b 1 1/41 1 (J Expiration DateCtt4I24120(7' T `tt �t
lob Site Address: 30 Mak cit Cy/Staceizip;i,b(t4LQ) MA ,olo&a
F.w Tacit a copy of the workers' compensation policy declaration page(sho sing the policy number and expiration date).
ailure 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 SLS00.00 andtor one-year imprisonment,as well as civil penalties in the form ofa STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
iiivesti etions bfthe DIA for insurance coverage vn€mSon,
I As hereby ce;tIM;under are pains and.enalei u perjarr that the it formation provider((above is true and correct.
Ste `1. .,) . A,�i�2,`t1/4,..v., ._. o /VI h i _.._.._
,attire: ' - Date:
Phone 554131-774..3604 _
IQ07eial'use only. Do nor write in this are,to be camplereday any or toren ofcia[ ^y
li
I Cry or Town: Permit/License
Issuin5 Autharirr(circle one):
. eoa rd of Health 2. Building Department 3.Citi/Town Clerk 4.Electrical inspector y Plumbing inspector
a.Other_
1 ^
LaCL P
TWIRL Phone 14:
‘11
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
!sSe
' icense': OSSL ii
�oasi;action Sucerrsal c;Swuaairy ..
JOSEPH P GEORGE a flea key 1
64 HAYWOOD STREET
GREENFIELD MA 01301
'a Expiration:
Commissioner 0251112018
lL.-'f..i.,,...www/4/1.52—11nxrr.,.IG
Office of Consumer Affairs&Busness Regulation License or registration valid for individul use only
' *HOME IMPROVEMENT CONTRACTOR before the expiration date. 1f found return to:
f2egistmtion: 156688 Type: Office of Consumer Affairs and Business Regulation
_:; Expiration: 712512017 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
JP GEORGE&SON INC
JOSEPH GEORGE
64 HAYWOOD ST
GREENFIELD,MA 01301 tiedersecretan• No valid without signature
RISE60 Shawmut Road, Unit 2 I Canton,MA 02021 1339-502-6335
ENGINEERING www.RlSEenglneering.com
OWNER AUTHORIZATION FORM
I, n bYDAr W/ AN Di
(Owner's Name) //
owner of the properly located at:
o�d AUC CLe 5\ ,
(Property Address)
(Propertyy Address)e (+� J
hereby authorize V, �' " eo Je �'^ 50 A � ZnC ,
(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 homeowner's
responsibility to close out this permit by contacting their municipality at the completion of this work.
I ♦L • I
am(. Atu
Own l.'s Si. ature
Date
•• 6.2016