32A-220 B ' 2022-1317
22 HANCOCK ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
32A-220-001 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-2022-1317 PERMISSION IS HEREBY GRANT D TO:
Project# INSULATION Contractor: License:
Est. Cost: 2500 HOME ENERGY SOLUTIONS INC 106188
Const.Class: Exp.Date: 12/28/2023
Use Group: Owner: GUIDERA DANIEL P&SUZANNE K GOTTSHANG
Lot Size (sq.ft.)
Zoning: URC Applicant: HOME ENERGY SOLUTIONS IC
Applicant Address Phone: Insurance:
233 COLLEGE HWY (413)203-2454 O HOWC 140654
SOUTHAMPTON, MA 01073
ISSUED ON: 10/13/2022
TO PERFORM THE FOLLOWING WORK:
INSULATION/WEATHER IZATION
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:
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 VIO ATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: '
. a' , CS- i
I ill
Fees Paid: S78.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Office of the Building Commissioner
1(155
City of Northampton r.' __
Building Department
( OCT i 212 Main Street 2 INSULAION
) Room 100
, „' Northampton, MA 010
r t r
phone 413-587-1240 Fax 413-5 I 'i -r ir- r„ f,r,i,vE
Ot4L.
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING�` � ONLY
SECTION 1 ]
SITE INFORMATION l l t S ULA 1 If ;f! PERMIT
This section to be completed by office
1.1 Property Address: a
22 Hancock St Map /J Lot p� Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Daniel Guidera____._ 22 Hancock St
Name(Print) Current Mailing Address
413-587-0807
Attached _ Telephone
Signature
2.2 Authorized Agent:
Shawn Mitchell 233 College Hwy Southampton MA_Q10Z3
Name(Print) Current Mailing Address:
S (, yL. � � � _413-203-2454
Signat�,re_ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
2500
2. Electrical (b)Estimated Total Cost of
Construr.11on from(6)
3. Plumbing Building Permit Fee
447 S2
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+ 3+4+5) 2500 Check Number t yp
This Section For Official Use Only
Date
Building Permit Number -��- /3/ 7
issued:
Signature: /42 10- i 3- ZD ZZ
g
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED: EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8,1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder:Shawn Mitchell _ 1061,88
License Number
68 Russellville Rd 12/28/23
Address Expiration Date
413-203-2454
Signature Telephone
O. Registered Home Improvement Contractor: Not Applicable 0
Home Energy Solutions Inc. 191885
Company Name Registration Number
233 College Hwy Southampton MA, 01073 12/4/22
Address Expiration Date
Telephone 413-203-2454
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 IV No,..... ❑
Brief Description of Proposed Work NOTE: INSULATION ONL Y
Blown in insulation and air sealing
I, Shawn Mitchell _ _ as r/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the bee of my knowledge
and belief,
Signed under the pains and penalties of perjury.
Shawn Mitchell
Print Name
1 0/6122
Signature of Owner;Agent Date
I, Daniel Guidera , 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.
Attached 10/6/22 ---
Signature of Owner Date
City of Northampton
A Massachusetts � -
DEPARTMENT OF BUILDING INSPECTIONS
212 Mein Street • Municipal Building
Northampton, MA 01060
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of in a
properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
Location of Facility: Springfield, MA
The debris will be transported by:
Name of Hauler: Waste Management
Signature of Applicant: 5` rri,�?�l t��ia� Date: 10/6/22
The Commonwealth of Massachusetts
1... -...1 Department of Industrial'Accidents
'y'l ...-...r.:1.,71F., Office of Investigations
Lafayette City Center
2 Avenue de Lafayette, Boston, MA 02111-1750
t ',4147,5'
www.mass,gov/dia
Workers' Compensation insurance 4ffidavit: Buiklers/Contractors/ElertricianstPlumbers
Applicant information Plepse Print Legibly
. . . .
Name (ausinegsiorganizaiictondividual):Home Energy Solutions Inc
Address:233 College Hwy
City/State/Zip: Southampton,MA 01073 _., .. Phone #: 413-203-2454
Are you an employer? Check the appropriate box: Type of project (required):
I ern a employer with 5 4, E I am a general contractor and I
6, 0 New construction
employees (full ardor part-time).* have hired the sub-contractors
. .........
listed on the attached sheet, 7. 0 Remodeling
I 2 L I am a sole proprietor or partner-
These sub-contractors have
ship and have no employees 8. 0 Demolition
working for me in any capacity. employees and have workers'
, 9, 0 Building addition
o workers' comp. insurance comp. insurance.- I
required] S. 0 We are a corporation and its 10.0 Electrical repairs or additioi
3.E I am a homeowner doing all work officers have exercised their 11.0 Plunking repairs or additioi
myself. [No workers' comp. right of exemption per tv1CIL
12,D Roof repairs
insurance required.! ' c. 152, §1(4),and we have no
employees. [No workers' 13 ii Other
•
comp. insurance required] I ,
*Any applicant that checks box;I must also fill OW the action below showing their workers'compensation policy information,
Homeowners who submit this attkiavir indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
Contractors that cheek this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have
employees, If the sub-contractors lla%e employees,they most pnwide their workers'comp.policy number,
/am an 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. Lic. 0:HOWC361807 Expiration Date: 01/04/2023
Job Site Address. 22 Hancock St City/StateiZip:.NoVIA 01061
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$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a If
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded'to the Office of
Investigations of the DIA for insurance coverage verification.
(do hereby certift un - t e pains and penaltie- ' jury that the information provided above is true and correct.
Date: 10/0/22
.440$101-,
Pho c#: - -
. ,
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: , Permit/License #
Issuing Authority(check one):
I EBoard of Health 20 Building Department 3.0City/Town Clerk 4.0 Electrical I Salumbing
1 inspector 6.00thcr
(1
1,1 Contact Person: Phone#:
il.. -
DocuSign Envelope ID:CA82F87D-4F38-40C4-906B-CE48EDF5D87D
RISE
ENGINEERING"
OWNER AUTHORIZATION FORM
Daniel Guidera
(Owner's Name)
owner of the property located at:
22 Hancock Street
(Property Address)
Northampton, MA 01060
(Property Addres olutions Inc
Home
233En Coll ergtyon MA0,1073
Southamp
hereby authorize
(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.
/—DocuSigned by:
Nita Atitkint
7/29/2022 1 2:58 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