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35-283 I ff; PAACTIATING mass save PERMIT AUTHORIZATION FORM 1, J"/) b 1 T ll ei/C' /E- i , owner of the property located at: (Owner's Name, printed) / 5 Y1 VAA) J 4/1 fi /c f �?�s , ©� c(, (Property Street Address) (City/Town) 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. Ow • - r s Signature i Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: P, (Ifor e 0 _ 5o^ Slit;. ,' 1. 0 )- Participating Co Date Rev. 12132011 / i TR-tk fit., Office of Investigations = °mil. _= 600 Washington Street c at"' Boston, M4 02111 a. www mass.gov /dia Workers' Compensation Insurance Affidavit: Builders/Contra ctors /Electri clans /Plumbers Applicant Information !?lease 1 Legibly Name (Business orgarnization/tndividual): - 'P. ``� SO tli ;; � � L -- Address: fO` \ *\I* - woo - CiL /Sta#elZ .- A _-�C_ \yi C c3O V Phone n: (- ) 11 L Are you an employer? Cheek the appropriate to box: - Type of project required): 1_ rg. I am a employer with 4 ❑ lam a general contractor and I 6. ❑ New cowl ruction employees (fiilt aud/orparr time)."` have hired. the sub - cons auu,s 7. Remc�delu.g ant 2.0 1 a a sole ptuptiei r or portlier- listed on luxe attached sheet. l ❑ ship and have no employees These sob- con1Thciors bare S- ❑ Demolitio t working for me in any capacity. workers' comp. insurance. 9. 0 Building addition (No 'workers' comp- insurance - 5. ❑ We are corporation and its 10.[] Electrical pairs or additions recoiled] officers hive exercised their repairs or additions 3. ❑ 1 am a homeowner doing all WA - :riot of exemption pe rivIGL 11.0 Plumb/mg" . ep • myself [No workers' comp. : 'c $:1(4) webavc no 12.0 Roof repa insurance required.] t - employees.. (No ,mockers' 13 - 08se �nl `e v �3ea • - comp_ insurance icq area] - - Any appitcnntthat checks 1= 14 mast a]so fill out the section bel showing Ilieir wvzkets' covapeassdion policy information t• Homeowners who submit this affidavit eradicating they sic doing all Wmtitetid then hire outside contactors must submit anew afftda -at indicating such - { Contrareozs that ctueekffiisbosnanat embed MI additional sheet showing the name ofrite sob - contactors end their wolkets• camp_ Talicy iutv,uevtion. I am rot employer that is providing workers' compensation insurance/bp my employees. Below is the policy and job site innformaffon. Insnrarice Campalzy Naztle: C\ACLI t _. Policy r or Self- -ins. Lic. t; Us •J _<--' Expiration Date: L i — 1 — . Job Site Address:, ' Syj ®!Ai! ire I NA oi 0 ' c Attach a copy of the workers' compensation polfcy declarafioa page (showing the policy number and expiration date). Failure to secux'c coverage as regaxred under Section 25A of hIGL c. 152 can lead in the imposition o: "crmunal penalties of a fine up to 51,500.00 and/or One -year immprisomnent, as well:as`civil penalties in the form of a STOP WORT _ ORDER and a fine of up to $250.00 a day against the violator_ Be advised =tbata copy- of this statement may be forwatdej to t to Office of Investigations of the DIA for insurance coverage verification. - 1 do hereby c - under the pains an' .' erudite' s of `'perjury "that the information provided above is true a ad correct Signature: \ -: \ - ` k, IA Date: /'1 101 - Phone 4: t u[ 1j `'� '` Official use only. Do not -write in this areal, to be completed city or t©wn of, icid City or Tom:: - own: .- - .. .. - Permtt/License #t Issuing Authority (circle oae p - - - - - 11. board ut' 7E#ealtlr 2_ Building Department 3. City/Town Clerk 4.. Electrical Inspector 5. r hunt lug Inspector 1 .Other c oma# Person- Phone it: City of Northampton '`' Massachusetts % I . DEPARTMENT OF BUILDING INSPECTIONS i+ F`. 212 Main Street • Municipal Building , 4. , Northampton, MA 01060 s /'h i ' Property Address: \l` S/ \10 1.00e f ►fm-e n t e J Mt t, O o o. Contractor Name: SOS O\ (wort, / T i P & Q', k SO Int. Address: 4c& wooJ S r C- City, State: G fet"4+t'1i1,, MM Phone: t i a . - 171 36 Property Owner Name: Juicy n DI"ien Address: 1 s'11%,,.n Lunnir City, State: nbfPn(.e i IAIN 1 3-9Se ON Val (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. g‘,,, Contractor signature 4, ,, C / c , Date i s ) , 7 - . 0 1), SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ,�o a e Qh G eorlt CSS W137/ License Number (Ay gook S ee\ &ree elA , MI\ 0 1 0 1 1 1 1 - 3•o`3 Address 31 Expiration Date (4 Signature Telephone 9. Registered Home Improvement Co rector: Not Applicable ❑ • "' l t %b Company Name Registration Number 3 e �� n ry 0,4 Son T.Rt —at- 3,013 Address ( Expiration Date Ipi Hwy 4 Stree\ f reen f+eI IA p 01301 Telephone t l3I ` " 7 Pi- 3 3 f 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 ❑ 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 1083.5.1. 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, you 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) J Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Oth [t] Thhi 101n" Brief Description of Propose �q } Work: Kr $1 oWc OrNA 6cverten A 1 „ �f Cetlo.\DSe 10 4 ■ t n IA C 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 CONTRACTOR APPLIES FOR BUILDING PERMIT I, JUIal Q R A r°e' 1 1 , as Owner of the subject property 7 hereby authorize V %Se O Geary, to act on my behalf, in all matter's relative to work authorized by this building permit application. See At e Signature of Owner Date ` ose 0\ &t'5r3e , 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. 3 O Geer Print Name \_ , ■Nj10 1 ,ei C 6 _47403/4 Signature of Ow er gen Date v --- - i 2 g 2012 \ City of Northampton Status of Permit: Department use only PUG uilding Department Curb Cut/Driveway Permit ._csiocas 212 Main Street Sewer /Septic Availability "„;. ";4,,O'■o Ro 100 Water/Well Availability 1 Northampton, MA 01060 Two Sets of Structural Plans phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: 1l- Sy 1v Lc e. Map Lot Unit Ehre,.ce IMP Zone Overlay District //�� `0 1, Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 0 o brie t\ 1/ Syl4M 1--r^ht rl,rente, Any alo Name (Print) Current Mailing Address: See R \k0 Ae (413 "Sta! - (in t L Te lephone Signature 2.2 Authorized Agent: 3-0 Se P\ Gear, 64 0(1wo4 street (Trecnf^,e4; MA o 130 Nam- (Print) Current Mailing Address: �4 (4 74 E Signatur:t Telephone SECTIO - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 1 ' 1,1 V '0U1 Check Number 146"5 011 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date x File # BP- 2013 -0236 APPLICANT /CONTACT PERSON JOSEPH GEORGE ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604 PROPERTY LOCATION 12 SYLVAN LN MAP 35 PARCEL 283 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 4,c Fee Paid Typeof Construction: ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 99372 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9MATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER: § Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission _ Permit DPW Storm Water Management Demolition Delay L (r/34 ► Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 12 SYLVAN LN BP- 2013 -0236 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 283 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2013 -0236 Project # JS- 2013- 000386 Est. Cost: $2841.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH GEORGE 99372 Lot Size(sq. ft.): 40162.32 Owner: O'BRIEN KERRY D & JUDITH A Zoning: Applicant: JOSEPH GEORGE AT: 12 SYLVAN LN Applicant Address: Phone: Insurance: 64 HAYWOOD ST (413) 774 -3604 WC GREENFIELDMA01301 ISSUED ON:8/31/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: ATT I C INSULATION 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: FeeType: Date Paid: Amount: Building 8/31/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner