29-526 (9) 25 GREGORY LN BP-2019-1132
GIS 4: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:29- 526 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv, INSULATION BUILDING PERMIT
Permit# BP-2019-1132
Proiect# JS-2019-001841
Est.Cost $2396.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sp.ft.), 5880.60 Owner: LEAHY SEAN
Zoning, Applicant. JOSEPH GEORGE
AT: 25 GREGORY LN
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON.411 812 01 9 0:00:00
TO PERFORM THE FOLLOWING WORILAIR SEAL ATTIC AND BASEMENT, ADD 8# 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•
FeeTvoe: Date Paid: Amount:
Building 4/18/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
B P- 19
C4 of Northi imptgEECEIV
t. Building Dep rtm nt
212 Main rest APA 1 2 2019E
Room 100
Northampton, t IA 0
phone 413-587-1240 F ax 4t%,%jtwnn o
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
swnoti 1 .SITE INFORMATION INSULATION PERMIT
1.1 Property �Address: TillsTillssection tabs comm-ple�tedd�by-cities S Gre�pr7 L&ot Map ?,91 Lot�_Unit__
Flotente)n*A/ Zone Overlay District
Elm at Distria4_ CB DbWet
SECTION 2-PROPERTY OWNERSMPIAUTHORIZED AGENT
2.1 Darner of Record:
Sem LeQ:�j aY 6ftE4 LG,,,C Ffo te,�ip ohs
Name Trial] I Current Mailing Address:
su RttG�ed6a31 568 14y)
Telephone
Signature
2.2 Authorized Agent:
SoSeph CTcoA� 6y HtAw.00d si- Greynfielel, Mhr �l)ol
Name(PMI) Cunent Mailing Add ss:
�w� 774- 36)4
SlgllaWre Taleptwrte
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Oniy
completed by nit a licant
1. Budding 31, 34of) (a)Building Pem It Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
S. Plumbing Building Parrott Fee #(DS
4. Mect anical(HVAC)
G.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This.Section For Official Use Only
Building Permit Num Dag
Issued:
Signature: /- 1Z-20j9
Building Commesioner/lhapector of BuNngs Dale
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SEC71ON 4-CONSTRUCTION SERVICES
8.1 Licensed Cmretruetlon Supervisor. ",�, Not Applicable 0
Name of License Holder; 3'Djeb GQDr�Y Coil - 915D
License Number
Address64 } a�Wwj Si. Greenfield /AA, 91301 'f ll1al
Expiration Date
'
774-3(o4
Signature Telephone
S Realctered Home hapioveinent Contractor. Not Applicable ❑
If• (foro MA on, 211. 156666
company ame
Registration Number
4 7/as/�ti
Address _ Expiratlon Date �-
Telephone 'I� -16oti
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,g 25C(6))
Workers Compensabon insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will resuh
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ,,j( No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
Alf Seel 0,01 Lino batmen}
Add B° Df cellylare }o exiljhn� inJnl°Qan in t}�it
I. tSDSt PIS V�(AQ as Owner/Authorized
em
Aghereby declare that statements an information on the foregoing application are true and accurate,to the best of my knowledge
and belief. - -
Signed under the pains and penalfies of perjury.
S Geo e
Prim Name I Sgrialure W Owner/Ags II
ent
er _I Date
I, Sem 1—�rM`� ,as Owner of the subject
property l 1
hereby authorize J'o3eRll Geof4c
to act on my behalf, In all matters letive ro work uthorized by this building permit application.
See Att>»t},e,I 04�f I y
Signature of Owner Date
City of Northampton
Massachusetts
F. / S
1 IIEPARI4ffiNT OF SOZLDrN6 INSPSCTIONS
212 rhin $treat 0lmwicipel euildi0g �✓ pOb
aortM1empton, M 01060 (�
AFFIDAVIT
Rome Improvement Contractor Law
Supplement to Permit Application
The Office of Consunner 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
perfornring work on such homes,a contractor must be registered as a Home Improvement Contractor("TUC").
M.G.L.Chapter 142A requires that the"reconstruction,alteration,renovation,repair,modernization, conversion,
improvement,removal, demoltion, or construction of an addition to anylira-existing owner-occupied building containing
at least one but not more than four dwelling units....w to structures which are adjacent to such residence or building"be
done by reEistered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be d.
^^registere
Type of Work: Z h SU��Io^ Est.Cost: ' d l q 6.io
Address of Work: _ 00r�- Lyne
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(exptain):
_
Job under$1,000.00
_Owner obtaining own permit(explain):
_ er
Building not own -occupied
_Other(specify):
OWNERS OBTAINING TREIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed render the penalties of pequry:
I hereby apply for a building permit as the agent of the
41001 1 S.P. Ror e wd Jones, y`�a . Pot,
Date Contractor Name 1X,111C Registration No.
OR.
Notwithstanding the above notice,I hereby apply for a building perntit as the owner of the above property:
Date Owner Name and Signature
City of-Northampton -
`
a
Massachusetts "t
D212$ 818T a 8OIL8ZN6 INSPECTIONS
232 Neiv Street a Nvn 010 Hvilding
NoitEampWn, lmi. O106D
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: �S GIn Lune _
Contractor
Name: Rome me W, sm 'Int.
Address: 6y H4IWnDQ M
City, state: G1fenf-01 /SAA, OT1
Phone: �� �3� 304
Property Owner Sem)em Le Uw
Address: a5 Crret)rt LCOZ
City, State: MA 1310L),
1, SoSt�n Genre (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 ✓\U l
Date
City of Northampton
aMassachusetts
DffiABTII&BP OS BDILD=212 Nein etraah .lNn Pal Baildi g
Norlheplp ' NW 01060
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:
aS Grc)ory Lrae
(Please print house number and street name)
Is to be disposed of at:
pf6'k C6oro Sulva)z 1431 �Qfnon Rd. Bfat}leboro, Vr
(Please print name and lomdon of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
iiL51iI
Signature, f Pe mit Applikant6rOwner 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.
- - - Z.\ - The Commonwealth ofAf ssachusetts ---- - Print Form - ----_--
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston, MA 02114-2017
.. - www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPiumbers
Applicant Information ,fir e/�`, Please
pPrriintt(L�.eeaibiv
Name lliuvinss/OIrgmdaatim✓Individ�u,u_l):_ ^, �L.yN'� fir'-^-' UV ��-V�-1 "`Y' ` " ��
Address:—6J l�r-X..1 5'
City/State/Zip: U ee\1 06 \ k Phone 9: Cy13� S� � IC)
Are you an employer?Check the appropriate box: Type orproject(required):
1.® 1 am a employer with_ 5' 4. ❑ I am a general contractor and 1 6
employees and/or part-time).
r have hired the sub-contractors New construction
2❑ 1 am pro a sole propnetor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have uo employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' y ❑ Building addition
fNo workers' comp.insurance comp.insurance.•
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL I2.❑ Roof repairs
insurance required.]r c. 152, §1(4),and we have no
employees. [No workers' I3.® Other�SVIG�nb9
comp. insurance required.]
•My applicant Iha cM1ecks hna al must also fill our Ihr section bel.o showing n eir wurkeri compmsnion policy informanun.
t numenumrn why whmil N,amm.it iMiating tluy are doing all work and then hire..id.conuamtxs moa submit a new amdoo,indicming.mch.
;Cnmrwmn thin chink Ihis bo.nmst anadted an additional sheet shnwing the name urthe subwnuacmn anA slate wheWer or not Wore mulies have
empiaYtts. Frlhc subcontmcmrs hove unq�leyccs,t>Ky must provide Wcir wotkers'rnmp.pdiry number.
1 am an employer drat is propiding workers'conspensadan insurance for my employees. Below is die policy and job site
information.C
Insurancance Company Name:_ _,
1 �
Policy 9 or Self-ins,Lic.P: HAX�C C Expiration Date: U— 1 I 0i__
Job Site Address: kbq L0^f City/Slate/Zip:_fIORbI I DWI
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 andlor 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 maybe forwarded to the Office of
Investigations of die DIA for insurance coverage verification.
I it,,heDebt an-&render the Pains and veaaltf o u dmf the in ormaaon provided above is true and correct
C' m _ -fl'(-. __ Datc O41 or I�
Rhone 4 13) Us3 i /07`6 -
Official use only. Do not write in this area,to be completed by cup or town official
City or Town: Permit/Licenw#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
G Other
Contact Person: Phone#:
Cmnmenwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constructvpg,;S�WkUgr Specialty
CSSL-099372 �> 4, 0
E;pires: 02111/2021
JOSEPH P GEORfA HAYWD§GREENFIELD/A�
Commissioner
fM.. i��sw'/ou f eltl _
Ms.of ConwmerMid.&Wide.Ream aun
HOME IMPROVEMENT-CONTRACTORRegistration valid for Individual use only
TYPE:Oararmim- - beforethe a>miration date. If found realm to:
R ictratien EXPiration Ofaoe of Consumer Affairs and Business Regulation..
158_§86 07rA=19 10 Park Placa-SUM 5170
JP GEORGE&SON INC Boston,MA 02116
• JOSEPHGEORGE
M HAY OOD ST
GREENFIELD,MA 01301 - Undersecretary Not vafid w hold signature
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
I, Sean Leahy
(Owner's Name)
owner of the property located at:
25 Gregory Lane
(Property Address)
Florence, MA 01062
(ProperlyAddress)
hereby authorize 5•P, -10a Tnf.
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work oonmyy/property.This form is only valid with a signed contract.
Owner's
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
50 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335
www.RISEengineermg.com