25C-099 (12) 55 GRANT AVE BP-2022-0004
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-099 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CON FRAC FORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2022-0004
Project# JS-2022-000004
Est.Cost: $3374.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 8319.96 Owner: HAAS DEBORAH
Zoning: URB(100)/ Applicant: JOSEPH GEORGE
AT: 55 GRANT AVE
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774-3604 WC
GREENFIELDMA01301 ISSUED ON:7/2/20210:00:00
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 UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy signature: �1
. . r ; � •
it
FeeType: Date Paid: Amount:
Building 7/2/20210:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
r _
De., .is,
yi-'".}4apro. City of Northampton- 1• � a sr
f, °�"�, ; �1 Building Department f "
212 Main Str .:,,,,, . J.
' �v>* 4 Room 100 ,t �., �0 �
{ y Northampton, MA 01 '2,n
3>= 3. phone 413-587-1240 Fax 413- 7G3 +
l �� t 1V..iYr
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY LING ONLY
SECTION 1 -SITE INFORMATION I NS U LA TION PERMIT
This section to be corn e by office
1.1 Property Address: 5Z ('rr,A} AVM
11 Map . 6—C..., Lot
Unit
►v DftiNrArAM'On IPA
Zone Overlay District
Elm St District CB District .
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
bboroh 4 ) S5 i'r�n Avg Mo�FI�Um�t�n, MA, 014(00
Name(Print) Current Mailing Address: (Lon,
L13) .14
1 —1""IJ L
See G3 t .fie A Telephone
Signature
2.2 Authorized Agent:
050\ ()Rory Cl lily wood s\-. Greg,f;elf °13o1
:::: :t)
(P Current Mailing ddress:
13) - 774 - 3 9
Telephone
SECTION 3-EST ATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
� (a)Building Permit Fee
1. Building 1374
2. Electrical (b)Estimated Total Cost of
•
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 06-
5. Fire Protection
6. Total=(1 +2+3+4+5) �13�i y� _ Check Number ( ( ��
This.Section For Official Use Only
La da I Date
Building Permit Number. J issued:
Signature: 7"2-ZpZ g
/7
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION d-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0 r
Name of License Holder: NC \ G t %g/7.1
License Num r
64 t-101\NO od S� rep ;e.11 MA ,0130) oa�jlp,og3
Address
Expiration Date
YPOR-Ckildt -Rti(� (4I.3' 771-36°'1
Signature Telephone
9.-Registered Home Improvement Contractor. Not Applicable 0
(fly (AAA 5oni. ISIAA
Company Name Registration Number
(-;-1 v,0,01 Gre,e f MAI0)3o1 o7fAkliao,
Address Expiration Date
( Telephone (113)-114-3v"
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 0
Brief Description of Proposed Work NOTE: INSULATION ONLY
Air SAnl C/AlkL ov► 60SenW
InSul(4tz. C rowv1 3roce a" Fire ON fi1.err
I 305t()I\ )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.
• J0Se(1, Geort
Print Name
o'q-acv (*)
Signature of Owner/Agent Date
bOf&!) UG►� ,as Owner of the subject
property n /_
hereby authorize 39Jeti h v 4)9k
to act on my behalf, in all matters relative to work authorized by this building permit application.
)et (A-t-c4eu‘ 00s1/3.0)
Signature of Owner Date
City of Northampton
aYHaio�\` hs,
Massachusetts
+ , c .Y* DEPARTMENT OF BUILDING INSPECTIONS .
• 212 Main Street • Municipal Building t7°• '
tC 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 be registered
Type of Work: 111Sv\I Est. Cost: 3/ 37't,`“)
Address of Work: 55 6-rfrit !Ve
Date of Permit Application: Ob /VI/IA).,
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 1'Hh,BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the a a of the owner:
06/VI hr-0 JOQK )).4\ 1, /fit KVA
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
QKryR k` City of Northampton ,�
Massachusetts r. .,41 '` 7 DEPARTMENT OF BUILDING INSPECTIONS Kit ig
t ��, 212 Main Street • Municipal Building 44p.„R,r ,,.,�r3
'"'-1'---- Northampton, MA 01060 1
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 55 GflA„ Rvt.
Contractor Name: 305-QPl, Goo fl al. (Ale ovo 30/ inl.
Address: Vi f-kch'j\woOA St--
City, State: 6,24 id&► API
Phone: .k,3) 'I 11-3101
Property Owner btb�r�� 1�1 UU
Name:
Address: Ss Gam\ N�-
City, State: NO IA\NUr*n r i\ 0100
1, 3OSe G€ Q (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 1 ,\(\ ,
Date 06 I)-°60-1•1
City of Northampton _
si
Massachusetts '
tqf
DEPARTMENT OF BUILDING INSPECTIONS a%
, d 212 Main Street •Municipal Building Uyr,�Y4 pb
Northampton, Ma 01060 A, " j1
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 111, S 150A.
The debris from construction work being performed at:
55 6-rot AVenvt
(Please print house number and street name)
Is to be disposed of at:
1lU Q.knro SAile 931 Veiv101 . DrAlleboroi yI
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
,1 ' R `iNt O / / o )
it • -
Signature of 'erm Ap lica or 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
1' !1, Department of Industrial Accidents
SraTarr I Congress Street,Suite 100
.al .�wr
Boston,MA 02114-2017
'=,.�' www.i'nass gov/dia
Workers'Compensation Insurance Affidavit:BuilderslContractors/ElectriciansiPlumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Aicant Information Please Print Legibly
Name(Business/Organizationllndividual):
Address: t"» "s � '' ` OAA }--- -'
City/State/zip:-6 &J(O4 (*e4 i3IV Phone#: C4 t�� l i 07 6
Are you an employer?Check the appropriate box: ' 13 '( Type of project(required):
.1:54 I am a employer with '7 employees fatlandior part-time).* 7. 0 New construction
2.0 I am a sole proprietor or partnership and have no employees working far me in 8. [(Remodeling
any capacity.(No workers'comp.insurance required.}
9. ❑Demolition
3.0 I am a homeowner doing all work myself.]No workers'comp.insurance required.]'
10 Building addition
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.[]Plumbing repairs or additions
5. I am a general contractor and I have hired the sub-conrctors listed on the attached sheet.
13.[]Roof repairs
These sub-contractors have employees and have workers'comp.insurance.=
6,0 We are a corporation and its officers have exercised their right of exemption per MGL c.
]4.( Other het v 1410t1
152. l(4),and we have no employees,)No workers'comp,insurance required.]
*Any applicant that cheeks 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 far my employees. Below is the policy and job site
information. 1\1-
w‘c,...Insurance Company Name: t g�
Policy it or Self ins.Lie.#: 11 °6( `i 77 Expiration Date: _
Job Site Address: 55 GliniA Ave*e_ City/State/Zip:, NeliftlAr1p1°n r PAf ,01)
Attnelteop3!ufhe�vgirrk'ranmpc?!?' a3r n`faI►�► ! 7! ►
ttta�t+a uia►Ir,e► •>rzx�►3iri��ttol�d�te}-
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the ILIA for insurance
coverage verification.
I do hereby certif.under he ; in. nalties of perjury that the information provided above is true and correct.
Date: o b 1a01)-°
Signature: `
Phone#: ( t 3)- 4 -3Lcy
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
6.Other
Contact Person: Phone#:
Commonwealth of Massachusetts
. 5 Division of Professional Licensure
'
Board of Building R ulations and Standards
Construct 4r Specialty
f.
CSSL-099372pires:02/11/2023
JOSEPH P GEORGE
84 HAYWOOET;STREE1 74
GREENFIELDJ)A 41301 •
fpi, 0
Commissioner djs e.
ale Yfrnzrna�zcuectfl/ o- rlrLssric/t�usell� — .. v.
•
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 Exaltation Office of Consumer Affairs and Business Regulation
156686 ` 07/24/2021 1000 Washington Street -Suite 710
JP GEORGE& INC Boston,MA 02118
17-7-77,7
JOSEPH GEORGE \&( s^i,s
64 HAYWOOD ST _: •
d(iti. ls�' Va i
GREENFIELD,MA 01305 i 4 • Not Melitho t signature
Undersecretary 9
IIII
I I
DocuSign Envelope ID:66617786-6787-4239-B34D-2EBB8A4199BA
RISE
ENGINEERING-
OWNER AUTHORIZATION FORM
Deborah Haas
(Owner's Name)
owner of the property located at:
55 Grant Avenue ,
(Property Address)
Northampton, MA 01060 ,
(Property Address)
hereby authorize j,1, V0)1 I O11c 3DA) Z1t ,
Subcontractor(to be fille •n by office)
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.
i
DocuSigncd by.
Vt,i3OV'au, (kactSS
Own 'g'.I rigeure
2/9/2021 I 10:33 AM PST
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335
www.RlSEengineering.com