34-024 r WI Painerinic •
mass save COMISCIIR
S.M4% tMOuc t, enttQV Ctt.Cn,
PERMIT AUTHORIZATION FORM
1 , l/ Mavn ee4 , 7/ r` , owner of the property located at:
(Owrs Name, printed)
e l 4e 1/ 11 A /` /t2 r'e'lic
(Property Str 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.
Owner' ignature
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:
j . r 0,4 Cryv r\t, / 13
Participating Contractor Date
Rev. 12132011
✓A4,4 '�lagilnnawf Rl`_64,4 � aclu:;• License or registration valid for individul use only
:: Office o - onsnmer atr nosiness ezulauon.: g y
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
„! Registration: 156686 Type: Office of Consumer Affairs and Business Regulation -
a-; Expiration _7125/2013 Private Corporatio 1 10 Park Plaza - Suite 5170
Boston, MA 02116
JP 'GEORGE & SON INC
JOSEPH GEORGE
64HAYWOOD - � ' - : .kj \ '+�i 'V)t ,l , IL:/-1 • ; '1 D _
i
GREENFIELD, MA 01301- Undersecretary ; • t
rY � } I\ot valid ►�ithaut signa�ure
NIa,Naeluisetts - Department of Public Safety
- b. Bo:irtl fif B uiltl hn :� f f :
1 Itr�ulaii,in. and : Standard,.
= -° 1-.' ns ruction. J'.. pert/ ?sor Special y1_icensr •
=F: °:L 99372 -
Restricted to WS,IC ,y v `
JOSEPH GE ORGE �
64 HAYWOOD STREET
GREEl1FIEL D, MA 0 "301
�--
�"� J� �' Expiration: 2/11 /2013
t : :nuni-' is nt•r Tr�": 99372
City of Northampton
( 1.-- 44 , . c,- s .,_
Massachusetts ��
` A 1%
y s w , s
C" "' , g "# DEPARTMENT OF BUILDING INSPECTIONS y 1 f
i „:
'ate 212 Main Street • Municipal Building �; ��
Northampton, MA 01060 !t Y?� `;
Property Address: I I -1 Ttn>icei 1-0 ?VIM) Free 1 M J
Contractor o - Se r
Name: 0 , (re o ) z
Address: V't I`loy eNA 5\ee _\
City, State: Clteen'st16‘ , (
Phone: 0 y -77ti - 3
Property Owner
Name: \NM'itA"n \ te'Nrer
Address: \\CA 1prY,t 1 \\ \\ PeN4
City, State: VArSente, 1 cAN
Sostpv,, (reof t (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.
Contractor signature fl.- \,,,igtiL
Date ').( - ( V )
t
r .,..i = ft Office of Investigation
��� �— 600 Washington Street
ir.r i r
£ _'1 :i Boston, hfA 021)1
art www mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Anuiicant Information Please Print Legibly
--�^ Cho �►�
Name {$ usauessiOrgainzatior� /Tndividtiai): � 1 L�. �
Address: f.01 \' - WOO ST -
City /State /Zip: A A �� � Phone #: 1 1 �Z (-'
Are you au employer? Check the appropriate box: . Type of project required):
1. Di I am a employer with i •. 0 1 am a general contractor and I 6 ❑ New coas'raction
employees (fu. 1jnd/or part tie). * have hx cd the sub - contractors
2.0 1 am a sole pAv1)Aietor or partner- listed on the attached sheet. Z 7. 0 Reinodelu.g
ship and have no employees These sub-contractors have 8. 0 Demolitio t
working for me in any capacity. workers' come. insurance. 9. 0 Building addition
o workers ' comp. insurance - 5. 0 We area corporation and its -
10.0 Electrical impairs or additions
r e q u i s e d . j o ffi c e r s brave exercised their
3.0 1 am a homeowner doing all wont - irigkt of cm tim perMGL 11.0 Plunmbing, 7cpairs or additions
• mryself [No workers' comp. c:1J52 0(4) and'ehaveno 12.0 Roof repa rs
insurance required.] t ezrrployees.. [No workers' 13_E] Otte- S.4 tai }i �n
comp. insurance required]
"Any al that checks box #j must also fill vut the section below showing their workers' compensation policy nn£omteti on
I Homeowners who submit Ibis affidavit indicating they ante wing all work and *entire outside eontmctors most submit anew affids 'it indicatitrg suck
Teontrectors tbiat cheek this box met aged en additional sheet allowing the nave of the Bab - contractors aod their workers' c.ornp. policy i „G"'Lation.
I am an employer that is prm ding workers' compensation insurance for my employees Below is the parity and jab she
information. .:
Insnr'ance Company Name: _ S
Policy # or Self -ins. Lic. # :_ �f 'J � - ' Expiration Date:
- -7 [ f7
Job Site Address: 1 T "r\ 'j N'‘ o Rood\ City /StatelZip: Rl et\Q., \ Ok ( *I
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 cart lead to tire imposition o::' curt dual pena1des of a
fr ae up to $1,500.00 and/or one -year itrprisonment, as well as civil pe aalties in the form of a STOP WORT : ORDER and a fore
of up to $250.00 a day against the violator Be advised that °a copy of this statement may be forwarded to t to Office of
Investigations of the DIA for insurance coverage verification. -
I do hereby .citify under t, - p , ' and penalties of pechay that the information provided above h true and correct
Si 14. atwre: dale ill '' 1 - Date: W 1 ...
Phon y • 60\-\ ' •
Official use only. Do not write in this area, to be completed' by cuy or town gtjiciaL 1
City or Town: Permit/License # •
Issuing Authority (circle one)'
I. Board of health 2_ Building Department 3. City/Town Clerk Q_ Electrical Inspector 5. P luml; iug Inspector
6.Other
Contact Person: _ Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
3nsec . (rel11c 051
License Number
64 H1 ,,,,, S \1eei Grfe,; ',eIGk,,I,N 913,7)) W11/I5
Addres Expiration Date
131 " 1-1` - 3 \ AIS IL
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
S+F (gory 6,4 Son 1'I r,t. 15(CS6
Company Name Registration Number
� 4 H tm., v„ootl\ S ve (Treen4'4 M A of kr 7 , ,05/ MV
Address Expiration Date
1 v ti Y ' l �. Telephonet413 l l 7 14 -1v)vl
—
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 I . 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 108.3.5.1.
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) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [LEI]
Brief Description of Proposed IN S�l t^fit�,r,
Work: Air Se k,,c U n ViAi "`en\• , Acka $ O t- cell tAVa etcAn .
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 k 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
c
W 1 \tits r ' r ' r r , as Owner of the subject
property
hereby authorize 5. t r' ( o*
to act on my behalf, in all matters relative to work authorized by this building permit application.
see p}k(^4e I11
Signature of Owner Date
a0r' 6 t, -2ortt , 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.
Josep\ (re3r
Print Name
Signature of Owner /Ag: nt Date
� Department use only
j ' is V `J City of Northampton Status of Permit:
4 Building Department Curb Cut/Driveway Permit
i ` 20 212 Main Street Sewer /Septic Availability
i
Room 100 Water/Well Availability OP EU, DO NORTHAMPTON, MA 01060 NS Northampton, MA 01060 Two Sets of Structural Plans
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
1.1 Property Address: This section to be completed by office
ICI T ey 'A\ ROC1c�
Fro `eme r
Art
Map Lot Unit
( St 00- Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
\AO\t" ' re rnr; r VI Twg(e f- k;1\ Roue Fl,tmce1 PAP W Name (Print) 4\ Current Mailing Address: (400 3 3 cA0
she fry \\e 4\ Telephone 1
Signature
2.2 Authorized Agent: r
�oSe(l GP®r1d 64 11(7,0)4 S\ , .veer tIe j to o} ?fll
Name (Prin 1 Current Mailing Address:
��. ''� (4,3 '16
Signature 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
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) f ) % 1356 ,19 Check Number 4/96'0 •
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0793
APPLICANT /CONTACT PERSON JOSEPH GEORGE
ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604
PROPERTY LOCATION 119 TURKEY HILL RD
MAP 34 PARCEL 024 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out _ ) Q
Fee Paid ) V
Tvpeof Construction: AIR SEAL & INSULATE ATTIC
New Construction r. >
Non Structural interior renovations YY
Addition to Existing a
Accessory Structure + — .1(
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
INFO ION 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
6 ,tion Delay
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.
119 TURKEY HILL RD BP- 2013 -0793
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 34 - 024 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 -0793
Project # JS- 2013- 001357
Est. Cost: $2356.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq. ft.): 148104.00 Owner: PARKS CYNTHIA A & FAYE E HOLLENDER C/O WILLIAM YENNER
Zoning: Applicant: JOSEPH GEORGE
AT: 119 TURKEY HILL RD
Applicant Address: Phone: Insurance:
64 HAYWOOD ST (413) 774 - 3604 WC
GREENFIELDMA01301 ISSUED ON:3/5/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEAL & INSULATE ATTIC - copy of utility final
inspection report required
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 3/5/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner