25A-159 (7) 245 NORTH ST BP-2020-0766
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 159 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-2020-0766
Project# JS-2020-001321
Est. Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: POTENTIAL ENERGY LLC 106184
Lot Size(sq.ft.): 13982.76 Owner: TAYLOR SAMUEL&SHERRY
Zoning: URB(100)/ Applicant: POTENTIAL ENERGY LLC
AT: 245 NORTH ST
Applicant Address: Phone: Insurance:
4 Q QUEEN TER (860) 506-4266 O WC
SOUTHINGTONCT06489 ISSUED ON:1/2/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.•WEAT HERIZATION/INSULAT ION
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 1/2/2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1,272
Louis Hasbrouck—Building Commissioner
�"' Department use only
City of Northanjpton Status of Permit
-k =y� Building DepaAmen � ut/DivewayuPermit "
212 Main Street #;Sep c Availability.
} 'x Room 100rlWe 'Avallability, f
Northampton, MA 1060 1 20'9 Tw' Sets of Structural Plans
P
hone 413-587-1240 Fa of -1272 Pi t/site Plan,
N�ArH Ain�N�in�c her ecify
APPLICATION TO CONSTRUCT,ALTER,REPAIR;.RENO )"4"4 ' DEMO ISH A ONE OR TWO FAMILY DWELLING
SEC. ON 1 SITE INFORMATIONu f, i'
\', This section to,be completed-by°office
1.1 roperty Address:'' s
�. Map' V Lot I ={' Unit r
�r `'P .
NLA-
NJ 10(off Zone Y .. Overlay District
ieiii- CB District
SECTION 2';PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Se,,L--e,L Tem lar S- N D�Aje%. 3-+ce.-'n/or4.4.a=om rnnIaGb
Name(Print) Current Mailing Address:
A%S - S$SC'74�.l
S82 Cauert2 :un.�1rn� Telephone
Signature
2.2 Authorized Agent: 1
Name(Print) Current Mailing Addr ss:
Signature Telephone
SECTION 3 ',ESTIMATED CONSTRUCTION.COSTS
Item Estimated Cost(Dollars)to be - , Official Use Only
com leted by,permit applicant
1. Building oa (a)Building Permit Fee
.LoOo ;
2. Electrical (b)Esfimated Total Cost of
`Consfruction froml 6 '
3. Plumbing 1301ldmg Permit Feed
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) '�ppp eD Check.Number -
y' `F T
D hisZection For Official Use=Onl
Budding-Permit ,fjDate
Issued K
VU
Building CommissoneNlnspector of;Buildings „ Date
nA13 Qo �.t9�Ivs.CoM
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 t—T Tx– 1r
Side L:0 R:= L:= R:= [�
Rear 0
Building Height IUR « 9 �" -%:y s
Bldg. Square FootageK 0 %
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces C�
Fill: F,N .
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES
IF YES, date issued: ,
IF YES: Was the permit,recorded'at the.Registry of Deeds?
NO 0 DONT KNOW ®'' YES. 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained - 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exc ation,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.
r f
-'SECTION 5-DESC2RIPTION.;6F PROPOSED.WORK;(check all-agphcatile) k<' '_
New House ❑ ; , Additierr Replacement Windows Alterations) Roofing
Or Doors D
Accessory Bldg. [ ;4erriolition ❑ New Signs.. ;Decks.-,[Q Siding.[ ],:. „Other[W—;- ^'
Brief Description of Proposed
Work-S:- {•�cti'�{ic !J" .d d,14 •9'Gen Qr31Cd-at.l w— `f'+1 cf F67S-"b -C'tl .
Alteration of existing bedroom Yes No Adding new bedroom Yesl No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
sa:If New house,and•'or::addi ionto ezistM housm + :color lete the'followiln - , ,.`: :•� . :-;
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. �1c. Dimensions
e. Number of stories?
f. Method of heating? rZ, Fireplaces or Woodstoves—.Number of each l
g. Energy Conservation Compliance. .,Q-5 Masscheck Energy Compliance form attached? �rs8
h. Type of construction
I
I. Is construction within.100 ft.of wetlands? :Yes .---/No. Is construction within 100 yr. floodplain Yes_k._,, No
i
j. Depth of basement or cellar floor below finished grade S,{�
k. Will building conform to the Building and Zoning regulations? _�Yes No
i
I. Septic Tank City Sewer_� Private well City water Supply
;SECTION Ta=OWNER AUTHORIZATION=TO BE COMPLETED•WHEN ';, _<
OWNERS AGENT;OR`CONTRACTOk"APPLIES•FOR BUILDING PERMIT
I, S Q'n L.ue.l TGrt Io ,as Owner of the subject
Property
hereby authorize gt4en6-al Enerey
to act on my behalf,in all matters relative 1b work authorized by this building permit application.
!z f zg(tang
Signature of Owner Date j
I, cede r�tGl trrgAw -Jl/ "cA YXQ:Jk4e- ,as Owner/Authorized
Agent hereby declare that t e 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.
Print Name
fill 1x1ZVft
Signature of Owner/Agent Date
SECTION 8'-CONSTRUCTION.SERVICES .;<
8.1 Licensed Construction Supervisor: ) Not Applicable ❑
Name of License Holder: f t Cho� byes es C.5 A- 10(pit i
License Number
4 121
Address Expiration Date
igna0" . Telephone.,
4 p
9.Reregistered Home Improvement Contractor: Not Applicable ❑
C k En CrAu L LC 1 Q 22 Sf-4
Company Name V!- Registration Number
1 40Ad DM S -9-,k 2,-r- Ate o I-SnAt'a c,i of-M-2
Address Expi�Da et
Telephone 4)3- ?--0a 23'
;SECTION 10 WORKERS'COMPENSATION,INSURANCE AFFIDAVIT,(MsG.L A611§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this applicatiori.: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
rtil G
r y DEPARDONT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building ivy r,a.
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 he registered
Type of Work: (, er 4a.;'moi o n I 1 c%L", ,,A or, Est. Cost: ,2pDD-°O
Address of Work: 2,4 S' t1r44% Ske'at- ABC
Date of Permit Application:
I
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 FORAND 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:
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
ss S�
Massachusetts
"• DEPARTMENT OF BUXLDING INSPECTIONS
212 Main Street • Municipal Building Ode fib~
Northampton,. MA 01060 ss c
Massachusetts Residential Building Code
Section 110.R5.1.2
Homeowner: Person(s) who own a parcel of land on which he/she resides or intends to reside,
on which there is, or is 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.
Section 110.R5.1.3.1 . , .
Any homeowner performing work for which a building permit is required shall be I exempt from
the licensing provisions of•780.CM& l�10:R5 provided-that'if-ahome owner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
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; you may,be liable for person(s) you hire to perform work for you
under this permit.
i
City of Northampton
Massachusetts ycri�
DEPARTMENT OF BUILDING INSPECTIONS �� r
212 Main Street •Municipal Building
Northampton, MA 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 1i 11, S 150A.
The debris from construction work being performed at:
2-4V MOAN
(Please print house number and street name)
Is to be disposed of at:
1-�r Q'Jur.atf,�g 7 Q�cu cl' c1p �1s.�n�i l tQ.Gf
(Please print name bhd to ation of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
.n
(Company N�cnd Address)
Signature of Permit Applicant or Owner Date
i
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.
0
I
II
Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston, M:a§bachusetts 02118
Home ImprovemenE.Contractor Registration
Type: LLC
d _ f d4 Registration: 192284
POTENTIAL ENERGY LLC
rr ; gay , ( Expiration: 06/21/2020
1 HARTFORD SQUARE i �:' ?a
BOX 2-E
NEW BRITAIN,CT 06052
Update Address and Return Card.
SCA 1 0 20&1-05117
aiee raomml��urc¢�f�..l�2lsa�csel�� ,
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
;'TYPE:LLC before the expiration date. If found,return to:
Registration Expiration Office of Consumer Affairs and Business Regulation
922$4=
06/2112020 1000 Washington Street-Suite 7101
Boston,MA 02118
POTENTIAL ENERGYGLC r,%., ,
- , v
NICHOLAS MEIS ERS �2 CGQ
1 HARTFORD SQUARE_-, e
`
DOOR 65 SUITE 21s ter` Not ot valid without signature
NEW BRITAIN,CT 06052
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
ConstructioQ S*6 �Wigo,1 &2 Family
CSFA=106184 w ¢� Fires-04/27/2021,
NICHOLAS A1. ,;FEISTER;;
344 ANDREM ST ` y
SOUTHINGTi*CT DSMW
,S
t=�•i
Commissioner
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
IF 600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information J i Please Print Legibly
Name (Business/Organization/Individual): �t3ri 4, CtJc%_ Y_ (�
Address: / i4ARl 02()c%0yigE -_1_)boR (05
City/State/Zip: I-,4- 06052- Phone##: 1-//3-796-0273
Are you an employer?Check the appropriate box: Type of project(required):
1.% I am a employer with—l� 4. E] I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g, 0 Demolition
workingfor me in an capacity. employees and have workers'
y p �'• 9. E]Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL h 2.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees.[No workers' 23.[4 Other I&UTA MQ
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.
#Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for nay employees.; Below is the policy and job site
information.
Insurance Company Name: �wZ&.Su ew ROUP
Policy#or Self-ins.Lic.#: 02.W6- C(Z 0J45 Expiration Date: D 05 2020
Job Site Address:245 North Street City/State/Zip:Northampton,MA 01060
1
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.
Ido hereby certify under thepains and penalties ofperjiiry that the information provided above is true and correct
sign e: /[ Date: 19/13/2019
Phone#• 713 .7g6.O2_73
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, Samuel Taylor ,
(Owner's Name)
I
Owner of the property located at:
245 North Street
(Property Address)
Northampton,MA 01060 ,
(Property Address)
hereby authorize Potential Energy, LLC , a certified Mas's Save Home
Performance Contractor, to act on my behalf to obtain a building permit and to
perform work on my property.
i
Owner's Si nature
12-13-19
(Date)
i
City of Northampton
f � „ Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ® Municipal Building
Northampton, MA 01060
Property Address: . 5° �lor- S+MeA- Alac .s�to�m�uA- r>Aot"'0
Contractor
Name: U-4-ectal F �
Address:
City, State:
Phone: W 1 --79 k- - o a-�
Property Owner
Name: . CL.VVN , l T�vlo�
i
Address: IAS" Mov�� s4cce-k--
C ity, State: �1 ea c e ® ,r► ^, F}- c� t a G,c7
I, c -:c l F-ner4!�, GLC, (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