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23B-070 (6) BP-2021-2294 108 SOUTH MAIN ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 23B-070-001 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-2021-2294 PERMISSION IS HEREBY GRANTED TO: Project# insulation Contractor: License: Est. Cost: 6848 JOSEPH GEORGE AND SON INC 099372 Const.Class: Exp.Date:02/11/2023 Use Group: Owner: RYAN SHEILA K & JOHN E DAHL Lot Size (sq.ft.) Zoning: URB Applicant: JOSEPH GEORGE AND SON INC • Applicant Address Phone: Insurance: 64 HAYWOOD ST (413)774-3604 4220066477 GREENFIELD, MA 01301 ISSUED ON:12/15/2021 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATH ERIZATI ON 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: , g � • Fees Paid: $65.00 212 Main Street, Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner '` \\ Department use only �� City. of Northampton Status of Permit: c.. ......,....,..k9n, 4! ., Building Department Curb Cut/Driveway Permit Z12 Main Street Sewer/Septic Availability / ' 20(9, ` Room 100 Water/Well Availability \\' \0/ f/ Northampton, MA 01060 Two Sets of Structural Plans roti NspFe 41,8-587-1240 Fax 413-587-1272 Plot/Site Plans_ • q o,6ol oNs / Other Specify 4 APPLICATION TO.CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOUSH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION A� This section to be completed by office 1.1 Property Address: VA S pv,si lY1(r A Sk, Map Lot Unit f\orenc,€) No Zone Overlay District 010 k).)` Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: AON R 1(N\ 0 SOA M 5'1. F BI MP Name(Print) Current Mailing Address: "�1 i 13 14% oil ocl S ft AVVAGVA Telephone Signature 2.2 Authorized Agent: Sose Geor t 64 HIry40061\ s\, Gceemle►�,MA 01301 Name(Print) Current Mailing Address: ri.. -/131-7Tit -3604 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building j YuW gs (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from.() 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 06 5.Fire Protection 11 G 6. Total_(1 +2+3+4+5) b) oy IS- Check Number Yy (4, 4.1 QQ/� This Section For Official Use Only Building Permit Numb r: J+" a� ` ��� D ci ated: Signature: . - 1 _ Z Pi-ZOZ1 Building Commissioner/inspector of Buildings Date SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition [D Replacement Win•• Alteration(s) ❑ Roofing ED Or Doors 0 Accessory Bldg. ❑ Demolition ❑ _ Other MA Brief Description of Proposed ,,66__ /T of (f i�t, e (,` 'I� Work: A I r An' ( kc vy ''� bve ice, W11 5 f Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing. complete the following: a. Use of building:One Family Two Family Other_ b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction_ Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? _Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT (MN as Owner of the subject property hereby authorize So C7fortr to act on my behalf,in all matters relative to work authorized by this building permit applicatio . cet Qc'(Nc e1 1110�)*-14 Signature of Owner Date 3.0Set* Geor9Q, 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. JOS C r Print Name Signature of Owner/Age r Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder 3030\ G2orot, csil 491319- License Number Holwoodt Ante\ reef tlt l MAI o��o� Addr'- Expiration Date N \0 . 413)-M-3Wi Signature �= Telephone 9.Registered Home improvement Contractor: Not Applicable ❑ J• Q (yPort CAr4 SON,'VI(i 15 6C3 ‘ Company Name Registration Number irtrw1 A 5}ree ;�ret,, to id, MA of o1 7-J - LO Address \ , , ,� Expiration Date ' I )-77`1-3604 Telephone SECTION 10-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 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor_CMR 780, Sixth Edition Section 10835.1. Definition of Homeowner:Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or detached structures accessory to such use and/or farm structures.A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time,during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,von may be liable for person(s) you hire to perform work for you under this permit The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature - rah ```S --- f'r� a Massachusetts �w'. r144. , A DEPARINB:NT OF BUILDING INSPECTIONS G 'WI ? • .e l•` ;-';a'�L"' 212 Main Street • Municipal Building .v,�J,,.�.. -s' �. �% Northampton, MA 01060 y`• ` Property Address: r13� 50 \ Mv,n YF, Fiore/lie Contractor Name: l/ So$eo, Girt /a,P. Geole 0%4 Son, Inc. Address: rbi Hatywoock Sfireei City, State: U r e r'f id1, MA ono o Phone: (LtI3 -77 3604 Property Owner Name: Cl e 1,C'1 Ni Address: V3 5°`' WO Si. City, State: F V)Ont Q� MA I, 3osef\ (yearly (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. cl,)-194\f'\Cf `41,111(-114• Contractor signature Date ONIN r. , 1 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste 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. Address of the work: \©Z 5o"th Ntcnin S� The debris will be transported by: Ir. Ger vivid, Soo , '] ( The debris will be received by: 8 roll e6nrp Building permit number: Name of Permit Applicant Uoserl• `-e orle Ic) (4.141 Date Signature of Permit Applicant The Commonwealth of Massachusetts 1'' 'r2, Department of Industrial Accidents 1 Congress Street,Suite 100 1111 a'a (1* Boston,MA 02114-2017 ,"; www tftass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Anulicant information Please Print Legibly Name(Business//Organisation/individua[): Address: • aT n • City/State/Zip: . jy.&COC� * . ` vt &1 kki1 Phone#: Are you au employer?Check the appropriate box: ti3v 1 Type of project(required): 1. `.t I am a employer with 7 employees(fgll.andlor pan-time).* 7. ❑New construction 2.0 I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. ❑Demolition 4. I mu a homeowner and will be hiring to conduct all work on my10[]Building addition ❑ contractorsproperty. I will ensure that all contractors either have workers-compensation insurance or arc sole 11.[]Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.D I an a general contractor and 1 have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.= 13.❑Roof repairs 6.0 tk a are a corporation and its officers have exercised their right of exemption per MGL c. 14.(r Other WIS'Wt tC`''tl \A 152.i 1(4),and we have no employees.[No workers'comp.insurance required] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tt'ontrnctors that check this box must attached an additional sheet showing the natne,,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 ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site information. c t Insurance Company Name: IN 3 .\ t k Policy#or Self-ins.Lic.#: c14T' C°tt)(p '(77 Expiration Date: f 'D.C) DN Job Site Address 4O fl J'�1 h (^i n fi. City/State/Zip �1�rfA0 -1 �, �� A e t opy. '' e w r ei,;s''temp atioR tf:*c r'd (abe gtie-pollcy,numbelr ez pir'a term date) Failure to secure coverage as required under MGL c. 152,ti25A is a criminal violation punishable by a fine 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 DIA for insurance coverage verification. I do hereby certify un•er the p its nd nalties of perjury that the information provided abo e isrue and correct. \ ' t C1 .1 0 �4.) Signature: �� L u "1 Date: Phone#: `�13 774 360 Ofcial use only. Do not write in this area,to be completed by city or ton'n 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#: • • `/f15'ff1f 10-ettl Sfacc ATra jS&eutirteltrAsQut8 ion 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 Regulation 156686 07/24/2023 1000 Washington Street -Suite 710 JP GEORGE&SON INC Boston,MA 02118 JOSEPH GEORGE /1 `� �� • 64 HAYWOOD ST �/�r.m(C z e•s4. GREENFIELD,MA 01301 Undersecretary Not valid itho t Sig tore r Commonwealth of Massachusetts Division of Professional Licensure Board of Building Re.ulations and Standards Constructia,�s.'5n�F .Spr Specialty € CSSL-099372 Eicpires:02/11/2023 JOSEPH P GEORGE 64 HAYWOOD_1STREET,I+,' `- GREENFIELD MA 01301 Commissioner c, C, ? Strna,k, DocuSign Envelope ID:7C9F43B2-C793-4176-BCDA-E2440B7A0044 RISE ENGINEERING OWNER AUTHORIZATION FORM Sheila Ryan — —J_- (Owner's Name) owner of the property located at: 108 South Main Street (Property Address) Florence, MA 01062 (Property Address) hereby authorize 'P (eor o So ) Subcontractor(to be filled in 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. CDDocuSigncd by. -cf,,L,A 11A,- Ownen'gd74'a`tflre 12/2/2021 1 8:01 AM EST Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 4 Canton, MA 02021 1339-502-6335 www.RlSEengineering.com