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23C-072 (2) 63 WILLOW ST BP-2020-0849 GIS#: COMMONWEALTH OF MASSACHUSETTS MW:Block:23C-072 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Categoory: INSULATION BUILDING PERMIT Permit# BP-2020-0849 Project# JS-2020-001457 Est.Cost: $2000.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sg. ft.): 17685.36 Owner. WIENER NOE Zoning: URA(100)/WSP(100)/ Applicant: JAY BOLAND AT. 63 WILLOW ST Applicant Address: Phone: Insurance: 233 COLLEGE HWY (413) 203-2454 () WC SOUTHAMPTONMA01073 ISSUED ON:1/27/2020 0:00:00 TO PERFORM THE FOLLOWING WORK.-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 1/27/2020 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1.272 Louis Hasbrouck—Building Commissioner — De City of No ham ton / i Building epa e0), 4 T 212 PJi in S eet N 3 � mv.�. R m 1T 41 Northampton, phone 413-587-1240 Fax 4 , 5 7 VCT/o7060 N ` APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY r -77:�SECTION 1 -SITE INFORMATION INS ULA TION I ERMl T l This section to be completed by office 1.1 Property Address: Lot_ O 7� /' 6,V�" ��✓ Map Univ r-r Zonae Overlay District i ;i � Elm St.Distdct _ t;6-District I SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT i i 2.1 Owner of Record: Name(Print) Current Mailin dd ess: Telephone Signature 2.2 Authorized Agent: i -er �l u . h S � hl 70 X 37 Current Mailing Ad ess: Name(Pant) #i3a°3 - Signature Telephone -- SECTION 3-ESTIMATED CONSTRUCTION COSTS (tern Estimated Cost(Dollars)to be Official Use Only completed b permit a licant -----" - 1. Building (a)Building Permit Fee at ©ao 2. Electrical (b}Estimated Total Cost of Construction from 6) 13. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection _ Check Number 6. Total=(1 +2+3+4 +.5) j a This Section For Official Use Onl �« Date Building Permit.Dh.,mber:` Z` issued: - s Signature: I Building Commissioner/Inspector of Buildings Hate EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) _- � .. _. ..._ _, ,r- _ .. .� _, ��. . . . : _.. . � ' � ._ t.,._ .._. ,. ._ _ -:- tcc�'P�. �� i`� ,. SECTION 4-CONSTRUCTION SERVICES i 8.1 Licensed Construction Suiervis E Not Applicable ❑ Name of License_ older; Q Q^t,� 10 J KG License Number ddress /;6 Expiration Date Signaqre Telephone UBQW-MgMt' Home-IrgtormenI:Contractor Not Applicable G JL- Com an r game // LL i Registration Number L, fAddress E moon Date Telephon SEC'FtQtill 5-QRS'GOFAPElMTION INSURANCE AFFIDAVIT(I1l.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 :n the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... Or' No...... ❑ Brief Cescription of Proposed WoNc OTE INSULA A[ +ULA TIO N ONLY I Agent hereby declare that the statements and information on the foregoing apohcation are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signatufe of Owner, Date Property as Owner of the subiect hereby authorize to act on my behalf. in all matters relative to work authorized by this building permit ap icadof. Signature of Omer Date r^SS 2019 WEA T HER1Z 1 1 S aVirl Bf thou?tf energy cffi:lrney BM R M C...,R H\I C N Gtl B V E S Based on your Energy Specialist's recommendations,your home can benefit from program-aligiible In'ulation and/or air sealing Improvements.Before moving forward.please follow aft the instructions below to remediato your wentherlxatlon barrier,. CUSTOMER INSTRUCTIONS 1.Hire a qualified,licensed contractor to evaluate and/or remediate the weatherization barrier(s). 2.Submit signed and completed copies of this form and a copy of the paid contractor invoice(s)withlri 60 days Of your Home Energy Assessment to:RISE Engineering,60 Shawmut Rd,Unit 2,canton,14A 02021 Or email to ColumblaGast4Alnfo-.RISEenginecring.com. X The weatherization incentive will be deducted from the customer co-payment amount of the weatherization work.A rebate check will be issued in the event the amount exceeds the customer's co-payment amount. 4.Complete the recommended weatherization improvements. "� Cgl l��i>Y ••�Z:�lifa�l Customer Name: oe Weller Client u or Site ID: 488242 srceAddress: 63 Willow RL=d $ -tee city. Florence State: MA zips 01062 Phone NumberI is�rr 34 ` 41 Ts$9 - - - _Email:_� @.r�e_9G qma!l./com Customer/Homeowner Slgnatur Data: To determine if there is any active knob and tube wiring,the contractor will evaluate the following areas where eligible Mass Save' weatherization recommendations have been made: Q Attie Flocr 6tic Wa1'4A;.tic Slope VJ Exterlor Wall asement OOther. O Cthec ¢Uihave performed my inspecVornt and determined there is no active knob and tuba wiring in the areas selected below. ( ys R.Kie Hlaarr 4rKiiae Wall ttic Slope tor Wallasement 301her. /l ave ❑Othar. read and agree to the Terms and Conditions on the back of this form. t Contractor Namu -Q(^ �4 14 r Address: ?_ /'g-1 J� f SF city. (�hG..-�Pan stat . zip-_0/622 Company Name: 4+. r� License Number. '12 S3 Contractor Signature: Date: F 7 �;_ lir. -:i:: - iu'c•t -,u."; High Carbon Monoxide:Contractor is to service and re-evaluate the selected mechanical system(s)and reduce the carbon monoxide level. as measured in the undiluted flue gas,to below 100 parts per million(ppm). Draft Fallute:Contractor is to correct the draft in the selected flue(s).Refer to table ort reverse for acceptable draft ranges. l— — I'jrigoDgr'iiii.,:1ip:irr, ____ '_ _ __ __I rfi•( 7}fir __^M� Existing CO ppm: j Revised CO ppm: I Existing Draft Pa: Revised Draft Pa: ^Hoating System i Hot Water Heater ,other. --•--------•� I Spiliagm Contra&tor is to correct the spillage of flue gases in the selected mechanical system(s).Must not spilt after 60 seconds of operation. O Heating System ❑Hot Water Heater O Other. C!1 have performed rrri Inspection and have corrected the items noted in the areas selected above. ❑1 have read and agrer:to the Terms and Conditions on the back of this to— Contractor Name AddreG^ City. Stade: zip: Company Name: License Number. Contractor Signature: Datu: ContlnuLhI an back (page 1 of 2) RISE ENGINEERING' OWNER AUTHORIZATION FORM 1, Noe Wiener (Owner's Name) owner of the property located at: 63 Willow Road (Property Address) Florence, MA 01062 (Property Address) hereby authorize (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. T1 Owner's Signature wt Dat RISE Engineering,a Division of Thielsch Engineering, Inc. 60 Shawm ut Road Unit 2 1 Canton, MA 020211339-502-6335 www.RISEengineering.com City of Northampton 'l * Massachusetts `- DEPARTMENT OF BUILDING INSPECTIONS .6' 212 Main Street s Municipal Building Ncrtnattpton, MA 010$0 Property Address: �� /1 uo (,�) Contractor Name: � S7104 ^�J�,C� ay 'd 0-5-5 City, State: a OH mg g Phone: Property towner Name: Address: X93 (AJl �rll.J City. State: "MP—w MA 1. 56,UjA k4a�VI !contractor] attest and affirm that the building 1 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 co y of this affidavit. Contractor signature Date t l 1 �'��. �� - �. �a ., The Commonwealth fMass huset`s "= Department of Industrial A ecidents Office of Investigations �. Lafayette Crt , Carter aon,JVA 0,2111-1750 2 Avenue de Lafayette, B&s Workers'Compensation In uran Affidavits Gen ral Businesses xt rzt Itatr�tttt 'tense Mnt,,Le fbly 1 Business/Ot artizatioi,i ',N'am z -"Orri Energy Solutions Inc.Address:2,3.3 College Hwy City= tatei iT);Southampton Mix 01073 Phone :413-203-2454 A re you an employer?Check the approprisoe boy,: Business T (required): an a ertr oyer with. ._._ � ' '�(full arm . Detail orf*av-tzrne).* & Restautant/HarEating Establishment . I am a"proprietor or partnership and have no 7. Office andior Sales(incl. real estate,auto,etc.) errtlrlayees working for ine in any catty, [No workers'comp. insurance required] i3. Non-profit £. we are,a corporation and its officers have exercised 9, Eiftertaintrient their right of e enr tiorn per c. 152.,§14),and, we have no employees, ['�o workers' cornp.insurance required]" 11, Health Marc 4. We are a nor-profitorganization,strtffcd by volunteers, with no employees. ''o wt)rk rs' coma,insurance rcq.j 12. other fa z checkflwx#I rust siso fill out the. U0a helow showing their Workers"csnupmsiian policy inforimation. —Jf th4 corp ora r. ticorr havtexempted thenyselves,but the c rpmMi nt h t,Aha vn* a c "cavewwion lxilicy ix required and such an cir <rli7aalk zt shovid check lox#1. 1 ram an easy hger that is providing workers z compensation insurramcejor my employees. Below is the policy information, Insurance C;ofnpa-ny; arne: ARD Insiurance Company �w insurer's Address:16 South, Pieter 7r citylStatc Fifa: Wilkes-aarre PA 18703 I'{slicy#or Self'-itis, l,ic #HOWGI40654Expiration 1 �.1i4;21 :Attach a copy of the workersi compensation pommy declaration page(showing the policy nurrmbtr r,nd ex ir;sti6n date). Failure to secure coverage as required under§25A of MU c, 152 can lead to the imposition of criminal penalties of a fine up to 1,5(YWO andior€rne-year irriprisortment,as well as civil penalties its the farm of a STOP WOR ORDER Aird a fine of ups to 5250,00 a clay against the violator. 'Be advised that a copy of thisstatentent array be Ibrwarded to the Office of Investigations of thc DIA for insurame coverage verification. I fir)hereky calif, maA& and pe. at the inform ation providedabove is trine and correct 3 Ir�r 413-203-2454 t yJivi al list,mini,', D#not in Ods om,to be,complete by ch�r or to official. City or Town: Perini ' Irs'suing Aathor~Ity(check one): 10 oard cal health 2Z]Building Department 3LICity/Town Clerk 4.01icensin Board electruers's Oflice bw (Aher Contact lie rsrra.: Phone .. _ N.ai il'�y►P I�"t�', Y ifiR Zi*N`.l l fJ�„C'fbv.4�9a �'.�� -AILLAf1S .. ' - n+,� r ,.d •, �? g t`` 'i.• < KR " rd°` ` G vR'!s. + tt �'M4 r y">