16C-034 (3) 394 SPRING ST BP-2019-1068
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 16C-034 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-2019-1068
Pro ject# JS-2019-001735
Est.Cost: $2728.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group JOSEPH GEORGE 99372
Lot Size(sg.ft.): 148975.20 Owner: BLYTH MARTA
zoning: UPA(loovwSP(31 Applicant. JOSEPH GEORGE
AT: 394 SPRING ST
ApplicantAddress: Phone: Insurance:
64 HAYWOOD ST (413) 7743604 WC
GREENFIELDMA01301 ISSUED ON:3/27/2019 0:00:00
TO PERFORM THE FOLLOWING WORKAI R SEAL ATTIC AND BASEMENT, ADD 13" 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 3/27/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northampton
4���1
Building Department t
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-687-1272
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Property Address: �T� ((
This section ea
ection to he mM 6 ofRee
3114 SpnhL S�. Mapes Lot Unt
F(orfnce,l MA zone - OverlaYOlstrtet
Elm atmemet CBDlebict-
SECTION 2-PROPERTY OWNERSHIPIAUTHORRED AGENT
21 Owner of Record:
Mt}r}a siy�, 3d s r(n St, brrft A
wametPnm> cu<remMaiingAedrea+:
See `{t prod Telephone
Signature
22 Authorized Agent:
JokP�. Geot�c � 11Apt.Apd 5t. Grct�{rcU, MA
Name(Prim) Cunem Maung Adores Q)?D)
�lll -174- 36ol
SignaLae Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
item Estimated Cost(Dollars)to be Official Use Only
comoletedbvoemita licam
1. Building }$,q 1 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee / r
4. Mechanical(HVAC)
S.Fire Protection
6. Total={1+2+3+4+5) 0 Check Number
This.Section For Official Use Only
Building Permit Number. Dash
Signature: 3- z7" Z�Iq
Building Commissionemnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor.l / ,A Not Applicable ❑
Name of License Halder: tTDSt e11 GtArgt �9m
Ucenee Number
64 HNl"A s�, GfoElgj, 1'Nr 0)301 �ft� wt — a/I►hi
:&.A�, 4 (0)-77 `1- 303 Fxpkatlon We
3"gr Telephone
a-ftuiV s,"redHome(knprovement'antractor: .. Not Applicable 13
J. J.Q, Gen! )c mA spn u c, _ g ii
Com am Registration N mbar
X64n �a J�. &rt(.,jyU, MA 0130) 7 a4/ 1
Address -_ PP _ Expiration Date
N11arr/ %� _ Telephone 413 779 3'0'4 .
SECTION 5•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8))
Workers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide mis affdavk will resuk
in the denial of the issuance of the building perk.
Signed Affidavit Attached Yes....... fY No...... ❑
Brief Description of Proposed WorkNOTE; INSULATION ONLY
�ir Seal fait NA Nemtnt
Add 13e of Q11mli8fe t0 MWfj inlwlpf ipA in of C.
r �O� �feD '�
.. as OwnerlAumorized
Agent hereby declare that a statements nd infor;fi on the foregoing application are true and accurate,to the best of my knowledge
and belief. --
Signed under the pains and penalties of perjury.
dost (Ito
Phe Name
Sigreture of /Ag k T Date
I M(�Ia �lyt� as Owner of the subject
property
hereby authorize Je itf It GcOf3e
to act on my behalf,in all matters relative to work authodzed by this building permit appilc"�non.
}et AtAcitj )IR
Signature of Owner Date
City of Northampton
Massachusetts
() DP.BARTMW OF BMZDZM 131SPPECTZOHS
212 Main atsaut a Buri.uipsl Building
Morthampwu, M 01060 .ylr
AFFIDAVIT
Rome 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(" UC").
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- dsfiog owner-occupied building containing
at least one but not more than four dweMng unfts....or to structures which are adjacent to such residence or buRdmg"be
done by revstered contractors.
Note.,If the homeowner has contracted with a corporation or LLC,that entity must be registered.
Type of Work: 1\M0,fir°n Est.Cost:
Address of Work: 3`14 S rPj St. 4 b my f MA , _--
Date of Permit Application: 3 jd`d'I
I hereby certify that:
Registration is not required for the following reasou(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 RESPONSIBILI'TES 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 perout s the agem of the owner:
3111� �f� s,e. h1d Sa1,2ar. 1�6b�e
Date marketer 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
MdBBBChllD®t:tB
DIPARD2W OF BDILDING INBBBCTIONS F"
212 win St .t • Municipal enildi
NoitTampton, M D1D6D
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address:
Contractor
Name: . J, Q (mole Son IAC
Zn
Address: •ld l
City, state: &ypn �ltld� J A ol3ol
1,413 )
Phone: `' /71 -i�D4
Property Owner Q 1>
Name: ------
Address: 3I`lq S'rii W
City, state: F Iortnct MA p I o 6 a
1. a0gk Gto It (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 ownerwitha copy of this affidavit.
Contractor signature
Date 3 L?3- I
City of Northampton
Massachusetts S.
xiae� OF 9axrorsc xasrscrxoxs
212 a in Strad a a cipel 9uildl
aerthaeptan, rA 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40,S54,1 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 constriction work being performed at:
314 S r;�5 st
(Please print house number and street name)
Is to be disposed of at:
437 Vv�6ri Rd• BraWnora, VT
(Pease print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
3 ?,
Sign re Permit Wicant 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 of Massachusetts Pdnt Form
Department of Industrial Accidents
dtp �t Office of Investigations
I Congress Street,Suite 100
Boston, MA 02114-2017
rvww.mass.golvdia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leizibly
NameIBusiness/Orgmiiration/individuap_:^ \ �+1. ILv S�yV [1.y�.�� •1 �T�C
Address:—
City/State/Zip: uv�z�t 1` 0\3�i Phone#: CHt3� 7T k3f
Are,you an employer?Check the appropriate box:
general contractor and I Type of project(required):
1.9 1 am a employer with 'y 4. ❑ I an a g
employees(tuft anNorpost-time).
r have hired the sub-contractors 6. ❑New construction
2.El 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacityemployees and have workers'
P
cam .insurance.:
req 9. E]Building addition
workers' comp.insurance
required.) 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance requtred.l t c. 152, §1(4),and we have no (-
employees.[No workers' 13.®Other 1p5V LIT/Okf
comp. insurance required.)
No applicant that checks box d1 must also all not the stolon below showing their weaken compensation policy informalion.
t nomenwmrs who submit this affidavit indicating they arc doing all work and then him outside mmmeuxs must submit a new om&vit indicating such.
:Comrasers that check Ibis box must alrzched an additional shirt showing the name of the sub-ocntrodom and state whetheror an tame comes have
cmployccs. If the sub-contra<mrs have cogtloyesx,drcy mus,provide their wmkcre'comp.policy number.
I ola an employer that is providing workers'caapensvdon insurance far my employees Below is the policy and job site
Insurance Company Name:__. f „ p ` U _ 4
Policy d or Self-ins.Licp Expiration Date:
Job Site Address: 311❑ SPtlnl St. City/State/Zip: 1rJ11!Qit (1 oto 6a
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 5250.00 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 du beret, cervi u er rhe and enalthes n '
e a that the information provided above is true and correct
., t re' Dara 3 01�- [
Phone
Official use o hlv. Do not write in Ibis area,to be completed by city or town official.
City or Town: PernflULicense#
Issuing Authority(circle one):
I.Board of Health 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Other
Contact Person: Phone#:
Commonwealth of Massachusetts
Oinisron of Plot esstotal Licensure
Soard of Building Regulations and Standards
Constructio(�'StWf`Wgr Specialty
CSSL-099372 pires: 6271 V202t
r
JOSEPH PGh70RGE
"HAYWOON�§TRE `'
GREEt�� ti
LD Ot0 '�
S
/pf)K'�llb�
Commissioner C
;: f" td0%MJH9)tbE9AMrs,.04/41¢NIFkC/�.
HOME 1fdP ymtomomsonTRALTWi Raftmethe
0on Pmellor wide. Itfoune oMy
tYPE:2laoart0on Mce Yncarryiretion tle[e. a dBusi Business,
lo:
@ 1869 Hon Rte.5RI=19 10 Pa al la n-Suit Altelre and Buffilnesb Regulatlgn.
Z „ t}�86 _ 07YLU28t8 tO Park Plaza-SuHa 51T0
JP GEORGE&SOH INC Boston,MA 02116
JOSEPH GEORGE �.E.C� - aJu7'- -•�'
64 HAYWO005T :
GREENFIELD.MA 01301 UOdeNOt vaftd strifthout et natuts
mecretaly 9
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
I, Marta Blyth
(Owner's Name)
owner of the property located at:
394 Spring Street
(Property Address)
Florence MA 01062
(Property address)
hereby authorize T - G{prV " 30nr 1n (_
(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.
Owner's Signaf re
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335
www.RiSEengineering.com