15B-032 (4) W CENTER FOR CONTRACTOR WORK ORDER
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Printed: 8/5/2014
Work Order Id: S40584P46095C332
Energy Saver Enablers LLC Patrick Melnik Phone(Eve): 413-537-0219
52 Fitzgerald Dr 311 Chesterfield Rd Phone(Day): 413-537-0219
Jaffrey,NH 03452 Leeds,MA 01053-9773 Site ID: S00002240584
- BawX8+9k
Location Description Quantity Unit$ Total $
Living Space Attic Floor Open Blow Cellulose 5" 1,280 $1.40 $1,792.00
Living Space Insulate Rim Joist With 2"Thermal Barrier Poly 80 $4.40 $352.00
Installed Measures Total $2,144.00
Note for Contractor: Hatch may need to be insulated, which would also require+12 linear feet, if necessary.
Incentive Payments
Weatherization Incentive $1,608.00
Total Incentive Payments $1,608.00
Customer Share
Total Customer Share $536.00
Less Deposit Of $178.66
Customer Share Balance(Due Contractor) $357.34
Center for EcoTechnology, Inc. - 112 Elm Street - Pittsfield, MA 01201
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PERMIT AUTHORIZATION FORM
1, Patrick Melnik ,owner of the property located at:
(Owner's Name,printed)
311 Chesterfield Rd Leeds
(Property Street Address) (City)
hereby authorize the Mass Save Home Energy rvices Program assigned Participating Contractor listed
below to act on my behalf and obtain a b ' ermit to perform insulation and/or weatherization
work on my property.
x
owner' Si e
Date
FOR CSG OFFICE USE ONLY
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Conservations Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project: ?
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Participating Contractor Date j
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For office Use Only
Rev.12132011
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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: 311 L,*-Js , MA
The debris will be transported by: _
The debris will be received by:
Building permit number:
Name of Permit Applicant
Z-ea
Date Signature of Permit Applicant
:- City of Northampton
Sys .,_ sic
_ r
Massachusetts
l DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address: �� Ga�f'Lr�l Gloms> A 4(453
Contractor
Name:
Address: b r
City, State: —;,�.+�Az,.4 A//-1 lns,49Z
Phone:
Property Owner n
Name: r ,AA (�
4; tom[
Address: 3(/ G til'��/�-I�rl� ej
City, State: LZ4J,5 , 177A A 5M-5::5
I, Lla-W5 (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
Date ?/Ig/!�6
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
_ p I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lepaibly
Name (Business/organization/Individual): Energy Saver Enablers LLC
Address: 52 Fitzgerald Dr
City/State/Zip: Jaffrey, NH 03452 Phone #: 603-532-6346
Are you an employer?Check the appropriate box: Type of project(required):
1.[✓] I am a employer with 5 4. ❑ I am a general contractor and I h ❑ New construction
employees (full and/or part-time),* have hired the sub-contractors
❑ listed on the attached sheet. ?. ❑ Remodeling
2. 1 am a sole proprietor or partner_
ship and have no employees These sub-contractors have S. ❑ Demolition
'
k
d h
employees and workers'
working for me in any capacity. ). ❑ Building addition
[No workers' comp. insurance comp. insurance.-
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.F1 Roof repairs
insurance required.] t c. 152, §1(4), and we have no Insulation
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
�Crmtractors that check this box must attached an additional sheet showing the name 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 am an employer that is providing workers'compensation insurance form),employees. Below is the policy and job site
information.
Insurance Company Name: American Alternative Insurance Company
Policy#or Self-ins. Lic.#: W AMC00010371-02 — Expiration Date: 3/8/2015
Job Site Address:_ CAAAI�tr,�.��d ----- _-_-_CityiState/Zip: _MA
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 andlor one-year imprisonment, as well as civil penalties in the for n of a STOP WORK ORDER and a fine
of up to 5250.00 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.
I do hereby certify un r the pans an penalties of perjury that the information provided above is true and correct.
Signature: __. —_
Date
Phone#: 603-532-6346 —--_------ —_ -- —
Official use only. Do not write in this area,to be completed by city or town official.
Project: Project Address:
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ Phone#:
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor: Not Applicable ❑ /
Name of License Holder: 6,0,L6 Abc- 4-Mg «e
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
<62, '-�Z - 1 J✓ J.. .�it•�c r AC1(-� D�y'SZ l° //i
Address Expiration Date
ZoTelephone
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. - Nome 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 M
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[0] Other ]
Brief Description of Proposed rr�,
Work: I hsa.� strip G-t��C-
Alteration of existing bedroom Yes J// 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: /V f g
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
1, Gi..t rt ck D" a-WI L as Owner of the subject
property
hereby authorize ( �
to act on my behalf, in all matters relative to work authorized by this building permit applicatio
e4A6�'-L .5
Signature of Owner Date
I, (,46U-6 A'(t.C► as 4A~/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.
G41y"
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: _ R: L R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: _
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department
Curb Out/Driveway Permit
l
212 Main Street Sewer/Septic Availability
LJ V
AUG 2 I 2014 Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
Electric, Plumbing&Gas Ph We 3-587-1240 Fax 413-587-1272 Plot/Site Plans
Northampton, MA 01060
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
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
- -1- �k � nik �// C�tras��r- Il P-J kajf, /J1R 6/15.3
Name(Print) Current Mailing �
/ �7 Z/y
Telephone
Signature
2.2 Authorized Aaent:
�2- ���� �✓ J l lu 6y (6z
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ,/ (a)Building Permit Fee
2. Electrical `f (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) y Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0213
APPLICANT/CONTACT PERSON CALEB AHO
ADDRESS/PHONE 52 FITZGERALD DR JAFFREY (603)532-6346
PROPERTY LOCATION 311 CHESTERFIELD RD
MAP 15B PARCEL 032 001 ZONE RR000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 0723316
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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
D olit' D lay
Signs re 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.
311 CHESTERFIELD RD BP-2015-0213
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 15B-032 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-2015-0213
Project# JS-2015-000401
Est. Cost: $2144.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CALEB AHO 0723316
Lot Size(sq. ft.): Owner: MELNIK PATRICK J&ALICE E TRUSTEES
Zoning: RR(100)// Applicant. CALEB AHO
AT. 311 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
52 FITZGERALD DR (603) 532-6346 WC
JAFFREYNH03452 ISSUED ON.812212014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC 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 8/22/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner