36-133 (4) Permit Authorization ��,,'
mass save Form
CONTRACTOR
Site ID: 50132231 Customer: Kenneth Elkas
1, Kenneth Elkas ,owner of the property located at:
(Owner's Name,printed)
319 Brookside Cir Florence
(Property Street Address) (City)
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's Signature: � L `Q
Date: "�--�j " Is-
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Bryan G. Hobbs Remodeling
346 Conway St
Greenfield,MA 01301
Participating Contractor Date
For Office Use Only
Conservation Services Group • 50 Washington Street,Suite 3000 • Westborough,MA 01581 • 1800.480.7472
Rev.062015
City of Northampton
Massachusetts !<<
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building JdS �Ca
Northampton, MA 01060
Property Address: j 9'-ot)y ✓ !
Contractor t
Name: r-rl Of L-95 Ban G.Hobbs Remodeling
346 Conway St.
Address: Greenfield,MA 01301
City, State:
Phone:
Property Owner
Name: 'i <'o o
Address: 5 9 ro
City, State: '>rCJ",C:e—
I, W G 0b 0 (contractor) attest and affirm that the building I intend to
insula oes 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
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: 31
The debris will be transported by: IYt�►r�m U��>?�
The debris will be received by: ( 0 .
Building permit number:
Name of Permit Applicant C
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Invesdgadons
600 Washington Street
'kT Boston,MA 02111
www.mass.gov/dia
Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicaut Information Please Print Legibly
Name (Business/Orpnization/tadividual): Bryan G. Hobbs Remodeling.
onway St.
Address:
Greenfield,MA 01301
City/State/Zip: Phone
Are you an employer?Check the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(fall and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. $ ?• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
requirod.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑,Roof repairs
insurance required.]t employees. [No workers' 13.[ Other
comp.insurance regUned.] r
*Airy applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.'
t liomeownars who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
$Contracio n that check this box must attached an additional sheet showing the narne of the sub-contractors and their workers'comp.policy information.
I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site
information. r�1t {� d
insurance Company Name: >A 1`� �"]�.)tit -� �1�,�t���w`l�.+c'_� �C��`�Oar)�;1
Policy#or Self-ins.Lic. #: rzz .A)0.5 13 Ci Expiration Date: 10 ,-Oji,6
job Site Address:21 9 (t Y-( t City/Statelzip: rl of C ki(e-, Nl V- C)i U b.2—
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 fine
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.
I do hereby certify under the pains and penalties of perjury that the information provided above Is true and correct.
RilMag re• �/�YC��` k�-0(��1O Date:
n #: .. I e7S-''
O kind use only. Do not write In this area,to be completed by city or town official
City or Town: PermitUcense#
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 M
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 0 (93982—
ryan G.Hobbs Rem a Ing License Number
346 Conway St. 4
Greenfield,MA 01301 `�
Address Expiration Date
Signatu Telephone
9.Realstered Home Improvement Contractor: Not Applicable ❑
i � 9 ��E3. Hubbs Remodeling Company Name 346 Conway St. Registration Number
Greenfield,MA 01301 -1 1 Z-; 111
Address l Expiration Date
Telephone W-3 7'75 `iJJ
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 Exem flon
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 buildiniz 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 Alterations) ❑ Roofing ❑
Or Doors F--1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[
Brief Descripption pf Proposed /
Work: (,t /I C. Hoar Qgyl blow ( dtofole, ✓tAf � e-,:46 f rdYi�'f�2�dr✓tc;-1 Patrrtr 0,41 C, A0';(cl%
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 .
1. 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, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
a ture of Owner Date
I, 6 Y'CA C,� b �✓ as Owner/Authorized
Agent hereb 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.
r Yya wall " 0 )✓�
Print Name
Signature of Owner ent 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 ® DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW C) YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
1� C. Do any signs exist on the property? YES 0 NO 0
\� IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® 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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
1:'
r City of Northampton Status of Permit:
EPBuilding Department Curb Cut/Driveway Permit
V, 212 Main Street Sewer/Septic Availability
0�' Room 100 Water/Well Availability
�.. __�Northampton, MA 01060 Two Sets of Structural Plans
.pf6ne 413-587-1240 Fax 413-587-1272 Plot/Site Plans
o 70'A-c- - Other S eci
fy
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
i 9 Yo 0 15,5 I'j-P, i r C i P Map Lot Unit
r'1 C e— Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i{ n,�c1�! c1 �jaS ► 1�rysirJe ('a r- 1'tvrCrCc M�
Name(Print) Current Mailing Address:
Telephone fir.1
Signature 'i 'i
2.2 Authorized Agent: Bryan G.Hobbs Remodeling
346 Conway St.
Name(Print) Gfwnfield, 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 (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total= 0 +2+3+4+5) I - D Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0844
APPLICANT/CONTACT PERSON BRYAN HOBBS
ADDRESS/PHONE 346 CONWAY ST GREENFIELD01301 (413)775-9006
PROPERTY LOCATION 319 BROOKSIDE CIR
MAP 36 PARCEL 133 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid W11A,4e
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 83982
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOjMATION 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
re of Bufldi g 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.
319 BROOKSIDE CIR BP-2016-0844
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 133 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0844
Project# JS-2016-001434
Est.Cost: $2133.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BRYAN HOBBS 83982
Lot Size(s9. ft.): 35327.16 Owner: ELKAS KENNETH A&LORETTA A
Zoning: Applicant: BRYAN HOBBS
AT. 319 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
346 CONWAY ST (413) 775-9006 WC
GREENFIELDMA01301 ISSUED ON:11612016 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 1/6/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner