39A-066 (2) BP-2022-1094
12 HAMPTON TERR COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
39A-066-001 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-2022-1094 PERMISSIONIS HEREBY GRANTEI TO:
Project# INSULATION Contractor: License:
Est. Cost: 2963 COZY HOME PERFORMANCE 102169
Const.Class: Exp.Date: 12/10/2022
Use Group: Owner: Z BARCLAY DAVID H&LYNN
Lot Size (sq.ft.)
Zoning: URB Applicant: COZY HOME PERFORMANCE
Applicant Address Phone: Insurance:
180 PLEASANT ST#200 4135290200 46-845373-01
EASTHAMPTON, MA 01027
ISSUED ON:09/02/2022
TO PERFORM THE FOLLO WING WORK:
INSULATION/WEATH ERIZATI ON
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Bunning Inspector
Underground: Service: Meter: Footings:
Rough: Rough: House # Foundation:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature:
( !if 1 .
• •
Fees Paid: $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
(lffire of the Rnib1ina Commiccinner
. . _ s &vG�c%t1--)
I.
RECEIVE
sEf� I
' -A 2.022 The Commonwealth of Massachusetts FOR
B d of Building Regulations and Standards MUNICIPALITY
T of ruaDIn,r,insPEc nRTNAA4PT chusetts State Building Code, 780 CMR USE
010F0
—BuildingON y��4 er 10 t�pplication To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One- or Two-Family Dwelling
This Section For Official Use Only
Buildin Permit Number: &A .?..1'. ioq y Date Applied:
l 6.--th0420...>, /7/ q-z-20-0-z.
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Add,.rye�s�s: "re/// y 1.2 Assessors Map& Parcel Numbers
I.to Is this an accepted street?yes no Map Number Parcel umber
j 1.3 Zoning Information: 1.4 Property Dimensions:
,
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.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 if ves❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: .
o,s tck. i ctrt:,,Lel °c r r,to is1-, No C l 0(0O
Name(Print) City,State,ZIP
i , R-t c. -ft-)-) rt rat ce,. kt{3 _3 2e -`i 3 f0 iteL:l;d it . c 100 C r J I uc•0rn
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ❑ Addition 0
Demolition 0 Accessory Bldg. ❑ Number of Units Other Specify: ..L x154--(ccfx.f
Brief Description of Proposed Work2: t,.5, c5roaf 1,K;et}-+..iA+2.r.t-ic-) l'YWA.Sct.reS
_t4lr (er.5 } k5e.r,leeNt 5.(IS - r icjrJ 60ct(-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building $ 9,ci 3 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
0 Total Project Cost3 (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees:$
Check No. �0Check Amount: L16 Cash Amount:
_6. Total Project Cost: $ , 9 (c ❑Paid in Full 0 Outstanding Balance Due:
F
f SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
i a 4 P1-rn5 An 1 s liv(0 0 List CSL Type(see below)
No.and Street Type Description
up to 35
EA5 i I%Ff(v!0Tc* II 3i a ) R Restricted 1&2Buildings Family Dwelling
cu.ft.)
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�y
SF Solid Fuel Burning Appliances
1113' Si.°r O i3Q ►vtkNk5etetYty02hr,yint;,(s 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) i Ca .,..�..2 0 9\5 I Lii 3
Coy), t1Urn* Per
Of 1)14 C,C. HIC Registration Number Expiration Date
1 Co pan Name or HICRegistrant Name
�i a 1 et-.S, n1 St it300 clita4o,1er Q f*,y cu2 V\gm4..(a,
No,and St et d
' 4NN4 3-kclA) It' Q'U ) 411"r�iX-i" f3 Email address
City/Town,State.ZIP Telephone
SECTION 6:WORKERS'C't'I'tit3 NSA'1 ION 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.
SECTION 7 ;:OWNER ALT110I IZ ATK TO 1W COMPLETED WHEN
CONT,RAC'I CIR t) O%t NE ,'S AGENT Aert.tES FOR)6UILDING PERMIT
I,as Owner of the subject property.hereby authorize Q r1':)'MoZ Q t U," �: r✓
to act on my behalf.in all matters relative to work authorized by this building permit application.
i- S+ ;,e<. Au'tti 1'Zy :, 45-2411 Iv,c6„1. ms►. uc Loi l ix-)-
Owner's Signature Date t
'h.CTlON T 7b: APPLICANT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained
diin this application is true and accurate to the best of my knowledge and understanding.
Contractor//Owner s Agent/Owner)
gent/Owner ignature Date
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 Bpi 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
w ww.mass,Cov!ot:j Information on the Construction Supervisor License can be found at%Mw.mass.gov'dps
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
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
•
?o�t:S gn Envelope ID:925003A9-0714-111SD-9A80-w BSLISMAI-C9
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
David Barclay
(Owner's Name)
owner of the property located at:
12 Hampton Terrace
(Property Address)
Northampton, MA 01060
(Property Address)
hereby authorize
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.
wner's Signature
Date
RISE Engineering, a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 I Canton, MA 02021 J 339-502-6335
www.RlSEengineering.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
• =;jRl_ 1 Congress Street,Suite 100
� �t_= Boston,MA 02114-2017
V ,�? www mass.gov/dia
Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Busitsess/Organizationflndividual): C c HI,is l t �t r f t Lr;t�i�j CC
Address: 1 g U i /frisks r Sr *->t:0
City/State/Zip: �es:+kki--10f rt rn13 6(6 r7 Phone#: 10 3 • s i' ey;
Are you an employer?Check the appropriate box: Type of project(required):
Lai i am a employer with p employees(full and/or part-time).* 7. ®New construction
2.0 i am a sole proprietor or partnership and have no employees working for me in B. 0 Remodeling
any capacity.[No workers'comp.insurance required.]
3.�1 am a homeowner doingall work myself o workers'co9. Q Demolition
ys (Ai comp.insurance required.]'
4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 1 Building addition
ensure that all contractors either have workers'compensation insurance or are sole 11.®Electrical repairs or additions
proprietor,with no employees, 12.❑Plumbing repairs or additions
5.0I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.QRoof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.®Other I h,Sc
152,§1(4),and we have no employees.[No workers'comp.insurance required]
"Any applicant that checks box 41 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 aub-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:- , 41it f zt1..® /till (90___.___-_--
Policy#or Self-ins.Lic.#: u't/ 3 j3 - C / - /7 Expiration Date: // / i7 //a 0
Job Site Address: I 140.r r-, -7—er City/state/Zip: Nol^r/ t /174 o/060
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A 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 coil under the pains an enalties o erjury that the information provided above is true and correct
Signature: Date:
Plgne#:
Official use only. Do not write in this area,to be completed by city or town official,
City or Town: Permit/License#
l Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
• City of Northampton
IP` - ( `
) '''i ;' 'r i Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS � 4
+ G1
To hi)
1, 1< .
212 Main Stnast a Municipal Building
Northampton, MA 01060 SrW pM a,.
Property Address: /a Flan--eOh 1-ec, 1 V1 .4n-pf rk Ai G(6 cc
Contractor �+
Name: C.dJ7—'7 1 o _ Ze .,P'txrn0ti,N,(Q.
Address: \ c6 l'\ C 12\5 \' '
City, State: ` F '/C h 1si
Phone: 'AA - )4.6\° C� •Q%
Property Owner
Name: t� V1c 64 tr,(A.y
Address: /L fIM we l-) Te2,
•
City, State: ).,1:2-f-i^di rtii, m/9- 0I c 6,c,
I, Mee,1 Z 1i (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.
t
Contractor signature,/
v
Data 0,2/ y' f 1_
{
r , , yzrr
Base:!on your Energy SPecealises reconitereelation% Wee home 1.,4.I4=1,
improvements.Before mov lv 1,4wart:i pleas„-l',111L'w all the 411 trut 400., t.:
CUSTOMER INSTRUCTIONS
1. Hire a qualified.leeneed contractor to evaluate and/or 1e+riudtair:tee wr..rtf4errvatierm!-<.,,.-
2.Submit signed and completed copies of this form and a copy of the pad c etntrecie •
Assessment to:RISE Engineering,60 Shawntut Rd,Unrt2.Canton,MA 02021 or email t'
3.The weatherization incentive will be deducted from the customers co-payment amot,
•
will be issued in the event the amount exceeds the customer's co-payment.rrn0urst
4.Complete the recommended weathenzatlon improvements.
5.The Mass Save HEAT Low—offers interest-free finencieg opreorturieres tree eee lee
barriers Learn more at reasssave.com'en,savin°}teesiclential-r tesee, ' ,
CUSTOMER IMFOPMAT n :: :_. :. ::....:'.�.:.. 3.2,:..._. .......-_. .. „
Customer Name: David Barclay _ Client rr nr ssitr:.iii 341063
Site Address. 12 Hampton Terrace r_it Northampton mA 0 1060
Phone Number' 413-320-9510 _ davidbarclay100@h0tmaiLC0m
Customer/Homeowner Signature /rye �..... ....__. aatc: ,l.3 ...- _
. . .. r,x a ' asp '; ,�,� � � -
i,A-; .. m�,� a ' r�s
To detcrmrne it there is any active: .',rib and tube wiring the contractor w` evsivate the!peew 4 3, ,.tt,:,, f s:,l,„ 11.•,
woatfrerization recommendaboie have been made:
0 Attic Floor 0 Attic Wall (,)Attic Slope ie Exterior Walt ', tia>"ont=ot V Gather,Sill Plate r»,,-.r
14'have performed my inspection and determined there is no tive knob and tube wiring in the area selected below,
-...j Attic Floor '_,r Attic Wall ',Attuc Slope Niel,fixterior Wall !Basement /'Other:Sill plate Center __
Contractor Namet:�LW'+ • y /L .rq„�'l�}t�lN14if id 'G AT —Tilt , ,,y} ....„.,..._ .
Address:4 t t d.5,21-v�F1 ri) RS City: J%�� � State:,,g . '.ip:_�.0,0ve
Company Name: License Number: C 3 Z 3?
Contractor Signatu • Date: 4-*4 CU
My signature confirms that i have performed my inspection of the electrical systems listed above and have corrected any barriers as
rnd:cated.my signature also confirms that i have read and agree to the Terms and Conditions outlined on the hack of this farm.
MEt3HANICAL SYSTEM BARRIERS=unto s2S0 ince.ret ee(T :c ittice out by licensed contractor,
High Carbon Monoxide:Contractor is to service and re-evaluate the selected mechanical system(s)and reduce the carbon monoxide level
as measured in the undiluted flue gas.to below 100 parts per million(ppm).
Draft Failure:Contractor is to correct the draft in the selected flue(s).Refer to table on reverse for acceptable draft ranges.
High Carbon Monoxide - - Draft Failure
Existing CO ppm: Revised CO ppm: l Existing Draft Pa: Revised Draft Pa.
T Heating System ;_ _�
,
Hot Water Heater
Other. ____.__...
Spillage:Contractor is to correct the spillage of flue gases in the selected mechanical system(s).Must not spill after 60 seconds of operation.
;le Heating System ( ,Hot Water Heater 0 Other.
Contractor Name:
Address: City: State: ZIP.
Company Name: License Nuriber. _ _______...___ ._._.
Contracoo►Signature: Date: _
My siggnature confirms that I have performed my inspection of the mechanical systems listed above and have corrected ant barriers as
indicated.My signature also confirms that i have read and agree to the Terns and Conditions outlined on the back of this form.