16A-020 601 FAIRWAY VILLAGE COMMONWEALTH OF MASSACHUSETTS BP-2021-1837
Map:Block:Lot: 16A-020-
076 CITY OF NORTHAMPTON
Permit:Alts Renovations
Repair
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND(MGL c.142A)
BUILDING PERMIT
Permit# BP-2021-1837 PERMISSION IS HEREBY GRANTED TO:
Project# 2021 INSULATION Contractor: License:
Est.Cost: 2000 106188
Const.Class: Exp.Date: 12/28/2023
Use Group: Owner: TEICH,AUDRY K&MINDY ISACOFF
Lot Size(sq.ft.)
Zoning: URA Applicant: HOME ENERGY SOLUTIONS INC
Applicant Address Phone: Insurance:
68 RUSELLVILLE RD (413)203-2454 HOWC140654
SOUTHAMPTON,MA 01073
ISSUED ON: 09/08/2021
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.
Signature: (5114fL
O ff 1
y� ' I
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
\4.
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1 ,4 U �< The Commonwealth of Massachusetts
'vNI,, . •.rd of Building Regulations and Standards
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FOR
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rachusetts State Building Code,780 CMR MUNICIPALITY
o
USE
4r ildin --
' A op'ication To Construct. Repair, Renovate Or Demolish a Revised Mar 2011
;, �� One-or Two-Family Dwelling l
This Section For Official Use Only
Buildin Permmt Number: (jd 1 1 37 1 Date A ied:
_____Ily ql-7'202.1 ,
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: ' 1.2 A ss rs Map& Parcel Nu r
601 airway.Village -----
IQ , (
I.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(0)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.Lc.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone.: —__ Outside Flood Zone' Municipal 0 On site disposal system 0
Check
Chec if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Mindy Isacoff I eeds, MA 01053
Name(Print) City,State.ZIP
601 Fairway Village __ 516-849-7001
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 1 Existing Building 0 Owner-Occupied 0 1 Repairs(s) 0 ! Alteration(s) 0 Addition 0
Demolition 0 j Accessory Bldg.0 1 Number of Units Other lid'Specify: Insulation
Brief Description of Proposed Work2: Blown in insulation and air sealing
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I.Building $ 2000 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical 0 Standard City/Town Application Fee
❑Total Project Cosh(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: ..._.
S.Mechanical (Fire $ �
Total All Fees:$
Suppression
Check No. 17/ heck Amount: Cash Amount:
6.Total Project Cost: $ 2.000 ❑Paid in Full 0 Outstanding Balance Due:_,,,_
.
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1_06188 '_.. _ ._ 12/28/23.___
Sha__vn....-M.itc.hell_............._..__....._.......,.......__....._._...._._._____..._ License Number Expiration Date
Name of CSL Iloider
List CSL Type(see below)
68 Russellville Rd
�_____........_
No.and Street � Type1 Description
U i Unrestricted(Buildings up to 35,000 cu.ft.)
Southampton, MA 01073 ___ ! R Restricted I&2 Family Dwellin
City/Town,State,ZIP i M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
41_
Telephone Email address D ; Demolition
5.2 Registered Home Improvement Contractor(HIC)
i 193885 12/4/22
—
Home_Ener olutions Inc Shawn_MitchelL-.------ ------ HIC Registration Number Expiration Date
I HIC CotnpanvName or HIC Registrant Name
68 Russellville Rd b meenergysol.utions a@energy2_net_.__..
No.and Street Email t d re.
$outhampton,....MAD.107a_. ___.. 413.208-.2454
City/Town.State, 'LIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must he 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 tit No ...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property, hereby authorize Shawn Mitchell
to act on my behalf,in all matters relative to work authorized by this building permit application.
i
Mindy Isacoff 8/20/21
Print owner's Name(Electronic Signature) Date
SECTION 7b: OWNER5 OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest tinder the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
c .et-1.ttt2r J 741O.11 8/2W21
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will at have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
wvo,v.mass,gov!oca Information on the Construction Supervisor License can be found at www.mass•govr4ps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage.finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
1 3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of'Industrial Accidents
Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 0111-1750
www.mass.govidia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):Home Energy Solutions Inc
Address:233 College Hwy
City/State/Zi Southam•ton MA 01073 Phone #: 413-203-2454
Are you an employer?Check the appropriate box: Type of project(required):
, I am a employer with 4. I am a general contractor and I
6 New construction
employees (full and or part-time).* have hired the sub-contractors
I am a sole proprietor or -
listed on the attached sheet. , 7. 0 Remodeling
partnel
ship and have no employees 8, 0 Demolition
working for me in any capacity. employees and have workers'
9. Building addition
[No workers' comp. insurance eomp. insurance..
required] 5. We are a corporation and its 10.0 Electrical repairs or additiot
3.El 1 am a homeowner doing all work officers have exercised their 11.C] Plumbing repairs or additiot
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] ' c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 roust also fill out the se.coo bielow showing their workers'cosnpensation policy inforrnatiott
lonteowners 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-conrsetors anti state whether or not those entities ha.
,roployees If the sob-contractors have implores,they must provide their workers'comp,policy number,
I am un employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:AmGaurd Insurance Company
Policy*or Self-ins. Lie. #: HOWC25136,7 Expiration Date: 01/04/22
601 Fairway Village
Job Site Address. City/State/Zip: Leeds, MA 01053
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 S1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a 11
of up to$250.00 a day against the violator„ Be advised that a copy of this statement may he forwarded to the Office of'
Investigations of the DIA for insurance coverage verification.
I do hereby certify un e painsn perjury that the information provided above is true and correct.
Sir ature: Date: 8/20/21
"Pho #: -2454
. Official use only. Dv not write in this area, to be completed by city or town official.
City or Town: Permit/License #
Issuing Authority(check one):
I Board of Health 2r]Building Department 30CityrIown Clerk 4.0 Electrical Inspector 5Eilumbing
Inspector (EC:Other
Contact Person: Phone 0:
DocuSign Envelope ID: 16ACF436-CAD7-452C-88E2-FCB888BODE81
yy� Permit Authorization
mass save Form
Site ID: 4247535 Customer: MINDY ISACOFF
Mindy Isacoff
I, , owner of the property located at:
(Owner's Name,printed)
601 Fairway Village Northampton, MA 01053
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
-----DocuSigned by.
ffOwner's Signature: (SaCb
er r rt)bAD I I sJ+m_.
Date: 6/23/2021
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 For Office Use'Only
Rev. 102015