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17A-063 (5)
251 BRIDGE RD BP-2022-0005 GIS#: COMMONWEALTH OF MASS&CH USETTS Map:Block: 17A-063 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONT CTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND ( GL_ c.142A) Category: INSULATION BUILDING P E RM I T Permit# BP-2022-0005 Project# JS-2022-000005 Est.Cost: $894.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JOSEPH GEORGE 99372 Lot Size(sq. ft.): 8929.80 Owner: JOSEPH GEORGE Zoning: URB(100)/ Applicant: JOSEPH GEORGE AT: 251 BRIDGE RD Applicant Address: Phone: I,as cmance: 64 HAYWOOD ST (413) 774-3604 WC GREENFIELDMA01301 ISSUED ON: TO PERFORM THE FOLLOWING WORK:INSULATION/WEATHERIZATION 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 UPO VIOLATION OF ANY OF ITS RULES AND REGULATIONS. S 4, Certificate of Occu•anc Si!nature: , 0 • - * *It iI FeeType: Date Paid: Amount: Building 7/2/2021 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner �/• L' ,. «r F ? 7,* � 3 71> >t 4ta a< 04 City of Northampton r i Building Depar `lien doe � � SL.k ( 1 • 212 Main Stree , C901` 1 � (<4 , s: 4"�r) Room 100--- ti00fiYll Northampton, MA 010 �q;'nh,�.� f x F �. �r � • `k Y".. s T J i s r r r phone 413-587-1240 Fax 413-587- ,q 07 c7., � �i ,h z TO y •ql � ., ,r''° . `,_„.._ • xR ' APPUCATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELL G ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT �, This section to be completed by office 1.1 Property Address: 8r3 Map I12 Lot t. Unit FI orence,AAA 01 1 Zone Overlay District Elm St.District CB District , SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Ergs RovNFci asi tritAle Pad. rlorerlCej MA ► 0106z Name(Print) Current Mailing Address: l i 1)_ i - sU/ t See Otcnc\ed Telephone ` Signature • 2.2 Authorized Agent: aoSe Pi\ Goo rye G4 No •wok - Creeei f i /k ciP, f t 01301 Name(Print) Current Maiiir�g Address: 1141°1 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 3g t-I 1 0 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) • 3. Plumbing Building Permit Fee (f6 4. Mechanical(HVAC) 4 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number I ('4 3C This Section For Official Use Only Date Building Permit Number. Issued: Issued: Signature: 7-Z-26ZI Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES I 8,1 Licensed Construction Supervisor: ,� Not ApplicableliGcr�� 0 Name of License Holder: SOS -01 VI) 9q 37 . License Number (A NA w04 - Gcee c ithk►ANol 3 pi 0410013 Address Expiration Date \ ,,) r ► _t-t 774- 3(o't Signature i Telephone 9.Registered Home Improvement Contractor Not Applicable 0 ,V, G€orV, (pr 50NI Dot. 15(��b Company Name J Registration Number 6y HGNyw�� . Gre At-Q,I+I IN\10\30\ o7( / .O 1 Address _ _\tk 1S j[ Expiration Date ` Telephone 13 ) ]19 "O� 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 `il, No 0 Brief Description of Proposed Work NOTE: INSULATION ONL Y Av r 520 (iAn .4..100, r;M pal InstAtOt IPA Ste A ()pe I, UflS-e i11 "-'" t , 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. v Ge3 Print Name �+`� 1 .. O( I9i? 1 Signature of Owner/Agent Date 1, E r i\l }t^Se‘ , as Owner of the subject property n ��p� hereby authorize T OSt P'\ rit to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date City of Northampton oaiHa�r Massachusetts '�, a F, ate Y •-1,44DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building z. ,mow Northampton, MA 01060 's 'ti 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 be registered. Type of Work: � Est.Cost: T e .115.A pn8L1` .. OD � Address of Work: gi.o* St Date of Permit Application: 0 o 1 gi(l��\ I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME IIIE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the a•-nt of the o er: DW i f )-\ Nell\ (Pori •,�.1 b\,A, I56b%6 Date C ntractor Nara- HIC Registration No. OR: Notwithstanding the above notice, I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature .--„AA4pr, City of Northampton i" ' •$�144 Massachusetts 'e�l{c lif r�� • : Ji DEPARTMENT OF BUILDING INSPECTIONS »-, ' , -,' 212 Main Street • Municipal Building tf fSk ., �q,(`b " Northampton, MA 01060 d;P. � MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: ).5 Df 4dt f,,J4 Contractor Name: able \ Geor e If. ()Rory_ cA4 Sin, lnt Address: (4 HAi\frin(A .)Y , City, State: Cr r Qei1 f i \& MN Phone: ILk 13) -119 ' 3L( i Property Owner Name: E rn i 'ems -USk,\ Address: aS 3-ottiQ K1. City, State: l OIrte) MA 1 OIo()'- I, 5ole_N Geof3t (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 \ , \1\,1 , Date 0( ia(1/a.0)-1 j�RSHAf�r City of Northampton 1 6Massachusetts f¢�J�j/. 7 1, . DEPARTMENT OF WILDING INSPECTIONS _ 212 Main Street •Municipal Building Q% Northampton, MA 01060 .t Debris Disposal Affidavit Af f i davi t 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: ),51 Bria t. (Please print house number and street name) Is to be disposed of at: Dr(46 0° Scn4VCle y 17 \Prnm 4, B mIl bo ro, y T (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) N.4 # eetpi4, 0‘12q/a021 Signature of rmit • ppli n r 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. The Commonwealth of Massachusetts I., Department of industrial Accidents IC y 1 congress Street,Suite 100 ili 1 Boston,MA 02114-2017 v mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): • Address: ( T.k-- o nL City/State/Zip: 1tI� iCd ,131 /1ketifk, Phone#: (4 13) � 1 I Are you an employer?Cheek the appropriate box: C V ti t Type of project(required): t.1.t am a employer with Al employees(ffty1Land/orpan-time)" 7. ❑New construction 2.01 am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling an capacity.1No workers'comp.insurance required] 3.0 1 am a homeowner doing all work myself:[No workers'comp.insurance required] 9. El Demolition 4.0 1 ama homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 El Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.0 I am a general contractor and I have hired the sub-contractors listed on the anached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp.insurance. r 1 �� 6.0 We are a corporation and its officers have exercised their tight of exemption14. Other iV1 'v t rpng p per MCI.c. 152. 1(4),and we have no employees.INo workers'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 state 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 my employees. Below is the policy and job site information. Insurance Company Name: k\-)a\o,.. . Policy#or Self-ins.Lie.#: 06(2 i( 7 7 Expiration Date: 'SI— I' Job Site Address °t S 1 .risk M. City/State/Zip I ( f ©� O, Attar a p;Y fitii3 t � .l o t r e r .-lttEoo tiey1ara q A4tfil o hcI iD ►wm' i . 04,4iratton 4 to Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a file of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the�DIA for insurance coverage verification. I do hereby certify ;der the pail a; penalties of perjury that the information provided above is true and correct. Signature: `4 Date: �'a-r'1'a 4�,1 Phone#: cii13)- "1 ��,_304 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): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: Commonwealth of Massachusetts = n Division of Professional Licensure Board of Building Regulations and Standards Construcdorrnakilitspr Specialty CSSL-099372 02/11/2023 JOSEPH P GEORGE ••,. • 64 HAYWOOD S V GREENFIELD:NA 01,,I1';- • •*-: 0 .11bISStiCSIS Commissioner cifaick K. Btnar;,.... • • • • ..are -Wite7z7reevreveaM eil://orAweze/kbielli • Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only, • TYPE:Corporation before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Wegulation 156686 -.H. 07/24/2021 1000 Washington Street -Suite 710 JP GEORGE&SON Boston,MA 02118 • ‘11 , \\Afklf— L5:14, JOSEPH GEORGE -- 64 HAYWOOD ST p GREENFiELD,MA 013- Undersecretary •61 ).Not alid itho q t signature •, DocuSign Envelope ID:F40DA603-B4A6-4C1C-964C-8F13FD56F2AA RISE8 ENGINEERING OWNER AUTHORIZATION FORM Emily Jean Fabel (Owner's Name) owner of the property located at: 251 Bridge Road (Property Address) Florence, MA 01062 (Property Address) hereby authorize S'1 • Gar,) O'nA 0.11 11►t (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. The permit will be secured by the subcontractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. c—DocuSipoed by: 7/10/2020 1 1:55 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com