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25C-145 (6)
33 ORCHARD ST BP-2019-0818 GIs#: COMMONWEALTH OF MASSACHUSETTS "a :Block: 25C- 145 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-2019-0818 Project# JS-2019-001352 Est.Cost: $1800.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: POTENTIAL ENERGY LLC 106184 Lot Size(sq.ft.): 5967.72 Owner: DIAMOND ALEXANDRIA zonine:URB(100)/ Applicant. POTENTIAL ENERGY LLC AT. 33 ORCHARD ST Applicant Address: Phone: Insurance: 4 DQUEEN TER (860) 506-4266 O WC SOUTH I NGTONCT06489 ISSUED ON:1/18/2019 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 5" DENSE PACK CELLULOSE IN ATTIC FLOOR, INSULATE BASEMENT SILL, AIR SEALING 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 1/18/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department City of NorthE mptc n #`- Building De Prtme t JAN 1 7 201 Permit 212 Main S reet �� • ` Room 1 0 1 k Northampton, A OR TH i�MDTON ^�nao , sit phone 413-587-1240 Fax - - Ottw APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR/�TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION op l% r f 1 f 1.1 Property Address: This section to be completed by office Map �SG Lot I �l� Unit MA- n(0(ao zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: I-�ob� D I, U c� ��3 oke swer Name(Priint), /^ Current Mailing Address:r7/ /}ur1}ol�i lA Tion YL'(i-#1' Telephone Z' 33 2 Signature 2.2 Authorized Agent: Wle,kOLAS AQ76Z ArAWI-26-r_ )d�i>'G� � 2rr-�� s�v ,&,L X Akj) Name(Print) Current Mailing Address: X-11 y13 2tS 0223 Signa re Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building /goo — (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) QQ Check Number 00 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 14o °►� Pbrnjr1A-L.6tjAk6q()5. co►y. EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 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 U. R: L,_ R: Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved arkin #of Parking Spaces Fill: volume&Location A. Has a Speci P rmit/Variance/ indin ev r be ssued for/on t site? NO © DONT KNOW O ES O IF YES, date issue IF YES: Was the rmi recorded at t e Regi of Dee ? NO © ONT KNOW © Y IF YES: enter Book ' Page. and/or Document#' B. Does the site contain brook, dy of ater or wet nds? NO O DONT KNOW O YES O IF YES, has a permit een or need to be obtained f m the Conservation Commission? Needs to be obtained O Obtained , Date Issued: C. Do any signs exist on the property? YES Q 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 © NO 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 D Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks Siding[p] Other ] I NSoc-A- oli Brief Description of Pr9pyy��ss�ed Work:1Nirn-(, JJ-' [ Zco` oLosClz! An(_Lox JA('SU 7'� /S�tS�lwusr/T -��lc.F,Al'? outs& Alteration of existing bedroom Yes_74—No Adding new bedroom Yes r<' No Attached Narrative Renovating unfinished basement Yes __X- No Plans Attached Roll -Sheet 6a.If Now house and or addition to existing housina.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 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 I, ajar 1R'yK6I)D as Owner of the subject property J��, hereby authorize 26W10NkL_C,N 'y to act on my behalf,in all matters relative to work authorized by this building permit application. k&wkwnoti Fern - Signature of Owner Date I, Ick (,tA-f ,a a_ 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. Sig ed under the pains and penalties of perjury. 2!c GA-5 MCI S'1-4, Print Name Signatur f er/ a Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder: �L S 1SI ck !�6//7 License Number SIJ QIJG��'nl TeRk�9C�, �rto�, Ci"` o�x'89271]9 Address Expiration Date W ;4L� /38027 Sig Telephone 9.Registered Home imorovement Contractor: Not Applicable ❑ -7OTCA)F&.6—q /9228/ Company Name Registration Number / ADeo BAC gu4 26, dew BRt�r Cr-0(.05'2- 6 2/128 Address T� '//` Expiratio Dat Telephone 7/,?N0273 40 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...... ❑ City of Northampton Massachusetts ��}s •• c'cc DEPARTDMNT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building yvbD� Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: 1dYUt.+riDK) Est.Cost: lD Address of Work: .23 001ht o -Twr Date of Permit Application: _ 1 1115-110 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): _^Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner: 1116-it 9 ?&TeA)1-0 t,CNd228 Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton Massachusetts DEPARTMMT OF BUILDING INSPECTIONS �J. 212 Main Street •Municipal Building ,t,.,•s C Northampton, MA 01060 s ••• `�4 Debris 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 by MGL c 111, S 150A. The debris from construction work being performed at: 33 0r e�w Sfkor (Please print house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: dumbras - 4S""e ' ' (Company Name and Address) /t;� Signature of Permit Applicant or Owner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth ofww :. Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston.,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/lndividual):PZrbirat U L`-C/Me/4DLAS Address: 4 D Que si E'R Pcc City/State/Zip: C Phone#: O_ •t zGG Are you an employer?Check the appropriate box: Type of project(required): 1.04 1 am a employer with 4. r] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. [J Demolition workingfor me in an capacity. employees and have workers' y p �'- 9. E] Building addition [No workers' comp. insurance comp.insurance.* required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGI. 2.❑ Roof repairs insurance required.] c. 152, §1(4),and we have no �SULAT 1014 employees. [No workers' 13.r-4 Other J comp. insurance required.] *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. 1Contractors 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 workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Nannie:§QTJEPRD ��$UR�R11C oJ� Policy#or Self-ins.Lic.#: O2MlE '(•CO r?q5 Expiration Daterwozoo- Job Site Address: 33 Orchard Street City/State/Zip: Northampton,MA 01060 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. I do hereby certify u r the pains and penalties of perjury that the information provide above is true and correct. Signature: Phone#• $6V'50( qz&(0 Official use only. Do not write in this area,to be completed by 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, Alexandria Diamond (Owner's Name) Owner of the property located at: 33 Orchard 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) 1-27-17 (Date) City of Northampton Massachusetts iE € DEPAP MENT OF BUILDING .INSPECTIONS 212 Main Street • Municipal Building bi ' Northampton, MA 01060 � Property Address: 3 �� Contractor �-- Name: Address: Qr�E" �iC{-a�CJ �Q�►�t RtJ" City, State: trier 6p',Tw►r 'i C?605-2L Phone: `7/3 798 Q2'73 Property Owner Name: &W9fAf-r Oikmp��A Address: 3 CIRC -tom '�G' r- City, State: I, vklf") 41sle (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