23A-095 12 SUMNER AVE BP-2020-1004
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23A-095 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-2020-1004
Proiect# JS-2020-001694
Est.Cost: $6866.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq.ft.): 5314.32 Owner. VILLANI PAUL D
Zoning: URB(100)/ Applicant. JOSEPH GEORGE
AT. 12 SUMNER AVE
Applicant Address: Phone: Insurance:
6414AYWOOD ST (413)774-3604 WC
GREEN FIELDMA01301 ISSUED ON:3/10/2020 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL AND ATTIC 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: 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 3/10/2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
... ��. Deploaaw
City of Northampton-0
Building Department
212 Main Street A R `9 �
Room 100 SULATION
Northampton, MA 01041 �'� ttFt
pr•�iH, �Nsr-
�',. phone 413-587-1240 Fax 413- N.pl�q cnONSoho ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property AddressThis section to be completed by office
�j �wry(�' w�2
Mapy1� Lot Unit
Fb���e)Mfl Zone Overlay District
�lode.
Elm St. District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
wnef of Record.--_---.._ �__. _
------- ---- ---
PUuI ��llo�,� 11 S�r�ner Ave.
Name(Print) Current Mailing Address:
��m
SeC ��Gcl�e�l -S�6-o'l�a
A
Telephone
Signature
2.2 Authorized Aqent:
J* (s0j 6y Nuywo�� sfi GrZe� fC�ul��}14)30�
Name(Print) Current Maili613)
Address:
- 7y - Aon
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building / ' (��6 �g a
b 0 ( ) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=0 +2 + 3+4+ 5) 66•y�l Check Number 10 -7V
►�I� /�f� This Section For Official Use Only
Building Permit Number: '-tel" �D — t v" Date
Issued:
r
Signature.
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisorr: o Not Applicable ❑
Name of License Holder: y Tfl�Pk V(A(4t �qM
License Number
w-00A St. Gree„j 0 01301 0AII I Goal
Address \��QExpiration Date
� ` y 13)�774-36oy
Signature Telephone
9.Registered Home Improvement Contractor. Not Applicable ❑
J,p, Geory mi sor,, 156686
Company Name Registration Number
4 Nn�d w _ ^fgeld,'AA, 01301 _ �-7/ 20,1
Address mn Expiration Date
Telephone tiW-774.3604
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....... No...... ❑
Brief Description of Proposed Work - NOTE: INSULATION ONLY
AJA ILI" 04 gU-40st to t'KWt in G�At(.
�OSeP� � as Owner/Authorized
Agent hereby declare that the 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.
J'm 'K Cho
Print Name
o3 os4rjjr)
Signature of Owner/Agent VDate
Pok AN \Jl�►W
as Owner of the subject
property O*T ^�
hereby authorize - v C'" (Th lr�t
to act on my behalf, in all matters relative_ to work authorized by this building permit application.
Signature of Owner Date
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building yJ 'b1
>�* 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 regristered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered.//gistere
Type of Work: I nS 010%0 n Est. Cost: bi�6 .n
Address of Work: 1�1 SlApi1►.pr Ave-
Date of Permit Application:_ 03/05 /3,010
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 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:
03-05 -�� ��P, Gtotl fon, JAL. �( ls6 w
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
Massachusetts
1 DEPARTMENT OF BUILDING INSPECTIONS a ;
�a 212 Main Street •Municipal Building yJA
Northampton, MA 01060 y �1'aC
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40,-S54, ]-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:
11 St.AMrgr Avf-
(Please print house number and street name)
Is to be disposed of at:
Vrok�ltboro S.Iyne ` SI Vernon Ave FkxPnceI fAA , aloha
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
J� 03-05-19,0
Signature of rmi Ap lic t 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.
City of Northampton
Massachusetts
4 NS
DEPARTMENT OF BUILDING INSPECTIONS S�
212 Main Street • Municipal Building
- -----
Northampton, MA 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: Ia S AMW AVE FbrenLe, N\A, 0 to 61
Contractor T
Name: P, �iPA le pal 5011 L T11 C.
Address: 61 \4(^jVV00d Sj
City, State: GrQenf i e jA % 01301
Phone: (4M -774-36oy
Property Owner 11
Name: Pain Vt11a'�►i
Address: 1� SOMA r Ave
City, State: f bfef)(f 11% 0 b 6�
1, Joko\ (TEOty (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 A`
Date 03 (g l;, o
.\ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
Workers' Compensation Insurance Affidavit: Gen
A licant Information eral Businesses
Business/Organization Name: JP George & Son INC Please Print Le ibl
Address: 64 Haywood St
City/State/Zip: Greenfield, MA 01301
Phone #: 4135311076
Are you an employer?Check the appropriate box:
1.2 I am a employer with (�6 � Business Type(required):
or part-time).* -`---•----t—employees(full and/ 5. 0 Retail
2•[] I am a sole proprietor or partnership and have no
6• Restaurant/Bar/Eating Establishment
employees working for me in any capacity. 7. Office and/or Sales (incl. real estate, auto, etc.)
[No workers' comp, insurance required] 8. Non-profit
3.[] We are a corporation and its officers have exercised
their right of exemption per c. 152' § ( )� and we 1 4 9 Entertainment
no employees. have
[No workers' comp. insurance required]* 1
0
,13 Manufacturing
4.E3 We are a non-profit organization,staffed by volunteers, 11II Health Care
with no employees.
[No workers' comp. insurance req.] 12-El Other ,
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensate n Policyinformation.
`n
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation organization should check box#1. ►tnation.
p nsation policy is required and such an
I am an employer that is providing workers'com ensation insurance for l
my em oyees Below is t
Insurance Company Name: ARBELLA he olic information.
Insurer's Address: VP
City/State/Zip:
_DU – —
Policy#or Self-ins. Lie. # 4220066477
Attach a copy of the workers' compensation policy declaration page(Showing Expiration Date: 8-1-2020
Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition(Show o g t e Policy number and expiration date).
fine up to$1,500.00 and/or one imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
penalties
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.
� v
Signature:
Date: 03 OS ua.o
Print Name . "�aS
Offne#: 413 -774.360 l use only. Pho
Do not write in this area,to be completed by city or town official
City or Town:
Issuing Authority(circle one): Permit/License#
1.Board of Health 2. Building Department 3. City/Town Clerk 4. ng Board 5. Selectmen's Licensing Office
Contact Person:
Home Address Phone#•
•�!�? !�O/%iillliz/./.Y'lll( (/ "fie --
Office of Consumer
Affairs
F,OfvI &Business Regulation '
E 11"ROVEMENT CONTRACTOp
TYPE:Coroora�on
ReGistration Regisfration valid for individual u
E%nt— r_ alio t before the e� use only
156686 07/24/2021 piration date, If found return to:
JP GEORGE Office of Consurner,e,;; irs and Business.
SO(V INC 1000 Washinoton Street
Suite 710 Regulation
Boston,ft4A 02'i18
JOSEPH GEORGE "
64 HAYINOOD ST
GREENFIELD,MIA
01301 `�'''f
Undersecretary t
Not afid itho t signature
Cor,tmonviealth of Massae
Division of Professio husetts
Board of Building Re nal Lice
gulatio nsure
Constructi� a la_ ns and Standards
t +aor
Cy S L-099372 Specialty
_�•
_ r}sires:
02/11/2021
JOSEPH P GEORGE
64'HAYWC)O D;�TREE.6.
GREENFIELD
_01301 a�
CornMiMsioner l�
DocuSign Envelope ID:82A9942E-88BD-486E-9D5B-M50B823E6C1
RISE
ENGINEERING'
OWNER AUTHORIZATION FORM
1, Paul Villani
(Owner's Name)
owner of the property located at:
12 Sumner Avenue
(Property Address)
Florence, MA 01062
(Property Address)
hereby authorize T. P- Gnt Mj s'o n i Zr%[.
(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.
DocuSgned by:
Owner's Signature
1/24/2020
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 02021 1339-502-6335
www.RISEengineering.com