24C-105 (7) 103 MASSASOIT ST BP-2019-1163
GIS 4: COMMONWEALTH OF MASSACHUSETTS
a : 1oc :24C- 105 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateaorv'INSULATION BUILDING PERMIT
Permit# BP-2019-1163
Proiect# JS-2019-001664
Est Cost $1917.00
Fee, S65 0o PERMISSION IS HEREBY GRANTED TO:
Const Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(y;R.): 14331.24 Owner: FIDDLER PEGGY
Zoning:URB(100) Ayolkant: JOSEPH GEORGE
AT. 103 MASSASOIT ST
AnallcantAddress. Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON.4/19/2019 0:00:00
TO PERFORM THE FOLLOWING WORILAIR SEAL ATTIC AND BASEMENT
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: 21 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 4/1920190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587.1272
Louis Hasbrouck—Building Commissioner
City of North I I � 4 y CJI
Building Dep rtm E C E I V p II
212 Main
Room 1 ) 6 °
Northampton, AD �ePR 2019
phone 413-587-1240 ax 4 3-587-1272
n=PT or ew!r, ir,SPFc.
o�rH11+17on..nn-0 _
APPLICATION FOR INSULATION FORA ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INSULATION PERMIT
1.1 Prooerts Address: - This section to be completed by office
103 Muis(A5Dit 5),, X Lot l/ UnitMap
f�r11 MPM Mp
Zone Overlay District
OIoG�
Elm St Dkbict CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
PC�ay FrdJler 1D3 /'�W)xSQt s�
Name(Pdnt) (t�� 4 11 Cunem Mailing Address: 41 )-N)3 - (PP
"'e /1� f�ffl Telephone
Slgneaae
23 Aulhodzetl AoenL•
Joie 11 Gilo )z 64 H2nj s�, . reeordiLAA-iD(3g)
Name(Pdnp Current Mailing Atltlress:
� ' (4131S3i1� 7�
Signaun, Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
conTietaid by permd awficant
1. Building 10 7 70 (a) Building Permit Fee
2. Electrical I-1 / (b)Estimated Total Cost of
Construction from fi
3. Plumbing Building Permit Fee
f�fLV
4. Mechanical(HVAC)
S.Fire Protection
6. Total=(1 +2+3+4+5) H17 • O Check Number
This Section For Official Use Only
Building Permit Num r. Date
Issued:
Signature:
Building Commisaionemnepectof of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
81 Licensed Constr' ction Sug irvis r. �r�� Not Applicable ❑
Name of License Holder Jonl, 1.Trent IT;t
License Number
4 a w s�. Gree +ie A 01301 License
Addms Expiration Date
X413, 774- 30y
&9natwe \ 'relephone
S RealsteredHomeimpmvem,re,n,tContzactor• - Not Applicable ❑ Y 1
.VQ �)AP r $7��Znc. - .. `J6 bib
Comeanv Name Registration Number
4 H mpg) Si Greenf Tel lMA, 01301 /as�jw
Address _ _ _ _ Expiration Date
Telephone 1Ily 36�y .
SECTION 5-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....... 4 No...... ❑
Brief Description of Proposed Work NOTE: INSULATION ONLY
.A',I Seal A�}jL arJ B'Senlo
Add 11' nF (ellvNe J�q eNr") �A,')wse, a
(dtil.
as Owner/Authorized
Agent heeby dedam tNbfJeregoing
application are true and accurate,to the best of my knowledge
and belief. --
Signedunder the pains and penalties of perjury.
(7eDO(!�
Print Name
QbLww. �,Q. r
Signature d Date
I, ho Figl Jler .as Owner of the subject
Property T r�
hereby authorize JoSep1 �e
to act on my behalf,in all maders relabve to work authorized by this building permit ait�lion.
See _47-19
Signature of Owner Date
City of Northampton
Massachusetts `•._re
4
D"AAMM OF 33MMING ZN8PBCrZONs
212 win etuaet . suilding '
NczUu ptan, tat 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
perforating work on such homes,a contractor most 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 bNlding�'be
done by registered contractors.
Nate:Ifthe homeowner has contracted with a corporation or LLC,that erufty must be registered
Type of Work: InSuloy"J Est. Cost: lq/7.10
Address of Work: 103 Aosasoi} 5�,
Date of Permit Application: 5/3011,
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00 -
_Owner obtaining own permit(explain):
_Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBH,ITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
313olja,F. 6p e " Son, Int. � Nm
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,l hereby apply for a building permit as the owner of the above property.
Date Owner Name and Signature
City of Northampton
Massachusetts
+j1 "' 'fry
5
nWART1$NT OF BUILDING INSPECTIONS
212 rfeia St eei • tl iu pel Building _cs
SerthampWn, HK 01060 -
MANDATORY FOR HOUSESBUILT BEFORE 1945
Property Address: �USSciSw'T NiF4m D, h1fl yJ060
Contractor
Name: JSP, irP.Dr�� ww� SDn, lnr.
Address: W Hfny'wp0 A $f,
City, state: U1 tQ1' ,Iilk "
{
Phone: 3) - 711-3L04
Property Owner p E
Name: YGF AIef
Address: Io3 Mtj5 ,Srm $t•
City, State: Ma , 0I)Gr)
I, JoSeQ� (reot � (contractor) attest and affirm that the budding 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 11� ILi Yom'
City of Northampton
s
Massachusetts
nceaxxemam OF aorrorera zsapscrzous �l
212 twin srr®e! •a Capel suilding 0'
NortAwpton, !A 01060R-41
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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:
I01 kfASSt icni St.
(Please print house number and street name)
Is to be disposed of at:
g[-kyy)m sch!%1431yerncn Rd, 6rP lednro VT'
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(ComppanyDName and Address)ddnss)
��Q
Signature of�Appiicant Owner wner 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 Print Frim
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
'r Boston, MA 02114-1017
s {k
www.massgov/ria
Workers' Compensation Insurance Affidavit: Builders/ContractorslElectriciansfPlumbers
Applicant Information /Please
/JPrint
�Legibly
Name Inusines.dlhgaiiariuNbrdiviu
1d`al)):
Address:6"'I
City/State/Zip: GQ�\ e-\A1` 0\;M7Phone#: �y13� -Jll�3E0�
Are you an employer?Check the appropriate box: Type of project(required):
I,® I am a employer widr _ S 4. ❑ 1 am a general contractor and 1
employees(Cull 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, ❑Demolition
workingfar me in an capacity. employees and have workers'
Y a Y 9. ❑Building addition
req workers' comp. insmanee comp.insurance.•
required,] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions
No workers
myself. ' cora right of exemption per MGL
y [ p 2. Roof repairs
insurance re uimd. f e- 152, t 13.®Other )yT
and we have no14
q )
employees.
[No workers' (G, ON
e
comp. insurance required.)
•nny applicant the,check,Ivx dl ma„Ann fill ora rhe section telnw-alwwing ftk workers eomprnW inn pnbey infomuliun.
r Home,xm, xAo,vhrnll,bisam&aknsdia,iny they are doing all work:rad then Fireo aide conaannrs mueuubmitan<w affida,a mdicn,ing w<h.
rCwmua,run slut check thu two nun anaehed an additional xb v ahnwing Ne name of the subcontr etun. and cute wli<ther or rot dui rnllties ba,e
employees. IRhc sub-mnrmc,ars hart utm�byces,they must provide tAcir workm'comp.policy number.
7 ant an employer that Lv providing workers'compe rsaaon insurance for my employees. Below is the policy and job site
nrInsurance CompanyName:--
. . r >\ �f
Policy 4 or Self-ins. Lic. p: HO'Xte6 UATI __ Expiration Date: —yy111� � � pp tt
Job Site Address: 1o)i R06S0Y3-%\ F• City/Smtelzip: Qf IPS DDt �nf Q�QV7
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure insecure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 8250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ofdm DTA for insurance coverage verification.
1 do hereb and a 'es o e 'u th
cent unde the ins at the Infornm6on provided above is true and correct.
t
Phone;F " ta s��i07.6
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License a
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 H:
� Commonwealth onealth of Massachusetts
Division of Professional Licensure
Board of Building Reg�JJuliiations and Standards
Constructlo*SjfprjvWr Specialty
CSSL-099372 `yam 3 tJaires:0211112021
i 1 a /
JOSEPH P OFI)7R(+E f?
W O
HAYWOD§
GREENFIELDMi} 01301
�l`,,, I{O��
Commissioner ✓"'
M. 1Consumar Mel.&Business Regulation
HONE IMPROVEMENT,CONTRACTOR" Re91aba0on valid for 4Wviduel use only
TYPE:'Corogation before One expira0on date. If found return to:
Raoistration €&g1ralJon Office of Consrurgr Affairs and Business Regulation.
_A56 688 0]/29/2019 10 Pak Plena-Sude 5170
JP GEORGE B SONtNC Boston,MA 02116
JOSEPH GEORGE -
GREENFIELD.MA01S01 Undersecretety got Ved�61Qrulture
Feb 271903:45p Peggy Fiddler 413-923-6010 P.1
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
I, Peggy Fiddler
(Owner's Name)
owner of the property located at
103 Massasoit Street
(PmperlyAddrssa)
Northampton, MA 01060
(P ioarlyAddress)
hereby au9rorms .rr P,
(Subconaaraw)
an authorized subcontractorfor RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my properly.This toren is only valid with a signed contract
&ga, 1.1
0""es
p2 -2t -Ioj
Dare
RISE Engineering,a Division ofThielsch Engineering,Inc.
60 Shawmut Road Unit 2 1 Canton,MA 02022 1339-502-6335
www.RISEengincering.com