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16C-034 (3) 394 SPRING ST BP-2019-1068 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 16C-034 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-2019-1068 Pro ject# JS-2019-001735 Est.Cost: $2728.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group JOSEPH GEORGE 99372 Lot Size(sg.ft.): 148975.20 Owner: BLYTH MARTA zoning: UPA(loovwSP(31 Applicant. JOSEPH GEORGE AT: 394 SPRING ST ApplicantAddress: Phone: Insurance: 64 HAYWOOD ST (413) 7743604 WC GREENFIELDMA01301 ISSUED ON:3/27/2019 0:00:00 TO PERFORM THE FOLLOWING WORKAI R SEAL ATTIC AND BASEMENT, ADD 13" OF CELLULOSE TO ATTIC 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: FeeTvpe: Date Paid: Amount: Building 3/27/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner City of Northampton 4���1 Building Department t 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-687-1272 APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PERMIT 1.1 Property Address: �T� (( This section ea ection to he mM 6 ofRee 3114 SpnhL S�. Mapes Lot Unt F(orfnce,l MA zone - OverlaYOlstrtet Elm atmemet CBDlebict- SECTION 2-PROPERTY OWNERSHIPIAUTHORRED AGENT 21 Owner of Record: Mt}r}a siy�, 3d s r(n St, brrft A wametPnm> cu<remMaiingAedrea+: See `{t prod Telephone Signature 22 Authorized Agent: JokP�. Geot�c � 11Apt.Apd 5t. Grct�{rcU, MA Name(Prim) Cunem Maung Adores Q)?D) �lll -174- 36ol SignaLae Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS item Estimated Cost(Dollars)to be Official Use Only comoletedbvoemita licam 1. Building }$,q 1 (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee / r 4. Mechanical(HVAC) S.Fire Protection 6. Total={1+2+3+4+5) 0 Check Number This.Section For Official Use Only Building Permit Number. Dash Signature: 3- z7" Z�Iq Building Commissionemnspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4•CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor.l / ,A Not Applicable ❑ Name of License Halder: tTDSt e11 GtArgt �9m Ucenee Number 64 HNl"A s�, GfoElgj, 1'Nr 0)301 �ft� wt — a/I►hi :&.A�, 4 (0)-77 `1- 303 Fxpkatlon We 3"gr Telephone a-ftuiV s,"redHome(knprovement'antractor: .. Not Applicable 13 J. J.Q, Gen! )c mA spn u c, _ g ii Com am Registration N mbar X64n �a J�. &rt(.,jyU, MA 0130) 7 a4/ 1 Address -_ PP _ Expiration Date N11arr/ %� _ Telephone 413 779 3'0'4 . SECTION 5•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(8)) Workers Compensation insurance affidavit must be completed and submitted with this application. Failure to provide mis affdavk will resuk in the denial of the issuance of the building perk. Signed Affidavit Attached Yes....... fY No...... ❑ Brief Description of Proposed WorkNOTE; INSULATION ONLY �ir Seal fait NA Nemtnt Add 13e of Q11mli8fe t0 MWfj inlwlpf ipA in of C. r �O� �feD '� .. as OwnerlAumorized Agent hereby declare that a statements nd infor;fi on the foregoing application are true and accurate,to the best of my knowledge and belief. -- Signed under the pains and penalties of perjury. dost (Ito Phe Name Sigreture of /Ag k T Date I M(�Ia �lyt� as Owner of the subject property hereby authorize Je itf It GcOf3e to act on my behalf,in all matters relative to work authodzed by this building permit appilc"�non. }et AtAcitj )IR Signature of Owner Date City of Northampton Massachusetts () DP.BARTMW OF BMZDZM 131SPPECTZOHS 212 Main atsaut a Buri.uipsl Building Morthampwu, M 01060 .ylr AFFIDAVIT Rome Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor(" UC"). M.G.L.Chapter 142A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement removal,demolition,or construction of an addition to any pre- dsfiog owner-occupied building containing at least one but not more than four dweMng unfts....or to structures which are adjacent to such residence or buRdmg"be done by revstered contractors. Note.,If the homeowner has contracted with a corporation or LLC,that entity must be registered. Type of Work: 1\M0,fir°n Est.Cost: Address of Work: 3`14 S rPj St. 4 b my f MA , _-- Date of Permit Application: 3 jd`d'I I hereby certify that: Registration is not required for the following reasou(s): _Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): _Building not owner-occupied _Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILI'TES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury. I hereby apply for a building perout s the agem of the owner: 3111� �f� s,e. h1d Sa1,2ar. 1�6b�e Date marketer Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton MdBBBChllD®t:tB DIPARD2W OF BDILDING INBBBCTIONS F" 212 win St .t • Municipal enildi NoitTampton, M D1D6D MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: Contractor Name: . J, Q (mole Son IAC Zn Address: •ld l City, state: &ypn �ltld� J A ol3ol 1,413 ) Phone: `' /71 -i�D4 Property Owner Q 1> Name: ------ Address: 3I`lq S'rii W City, state: F Iortnct MA p I o 6 a 1. a0gk Gto It (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 ownerwitha copy of this affidavit. Contractor signature Date 3 L?3- I City of Northampton Massachusetts S. xiae� OF 9axrorsc xasrscrxoxs 212 a in Strad a a cipel 9uildl aerthaeptan, rA 01060 Debris Disposal Affidavit In accordance of the provisions of MGL c 40,S54,1 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. The debris from constriction work being performed at: 314 S r;�5 st (Please print house number and street name) Is to be disposed of at: 437 Vv�6ri Rd• BraWnora, VT (Pease print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 3 ?, Sign re Permit Wicant or Owner Date If, for any reason,the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Pdnt Form Department of Industrial Accidents dtp �t Office of Investigations I Congress Street,Suite 100 Boston, MA 02114-2017 rvww.mass.golvdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibly NameIBusiness/Orgmiiration/individuap_:^ \ �+1. ILv S�yV [1.y�.�� •1 �T�C Address:— City/State/Zip: uv�z�t 1` 0\3�i Phone#: CHt3� 7T k3f Are,you an employer?Check the appropriate box: general contractor and I Type of project(required): 1.9 1 am a employer with 'y 4. ❑ I an a g employees(tuft anNorpost-time). r have hired the sub-contractors 6. ❑New construction 2.El 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacityemployees and have workers' P cam .insurance.: req 9. E]Building addition workers' comp.insurance required.) 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance requtred.l t c. 152, §1(4),and we have no (- employees.[No workers' 13.®Other 1p5V LIT/Okf comp. insurance required.) No applicant that checks box d1 must also all not the stolon below showing their weaken compensation policy informalion. t nomenwmrs who submit this affidavit indicating they arc doing all work and then him outside mmmeuxs must submit a new om&vit indicating such. :Comrasers that check Ibis box must alrzched an additional shirt showing the name of the sub-ocntrodom and state whetheror an tame comes have cmployccs. If the sub-contra<mrs have cogtloyesx,drcy mus,provide their wmkcre'comp.policy number. I ola an employer that is providing workers'caapensvdon insurance far my employees Below is the policy and job site Insurance Company Name:__. f „ p ` U _ 4 Policy d or Self-ins.Licp Expiration Date: Job Site Address: 311❑ SPtlnl St. City/State/Zip: 1rJ11!Qit (1 oto 6a 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 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 du beret, cervi u er rhe and enalthes n ' e a that the information provided above is true and correct ., t re' Dara 3 01�- [ Phone Official use o hlv. Do not write in Ibis area,to be completed by city or town official. City or Town: PernflULicense# Issuing Authority(circle one): I.Board of Health 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person: Phone#: Commonwealth of Massachusetts Oinisron of Plot esstotal Licensure Soard of Building Regulations and Standards Constructio(�'StWf`Wgr Specialty CSSL-099372 pires: 6271 V202t r JOSEPH PGh70RGE "HAYWOON�§TRE `' GREEt�� ti LD Ot0 '� S /pf)K'�llb� Commissioner C ;: f" td0%MJH9)tbE9AMrs,.04/41¢NIFkC/�. HOME 1fdP ymtomomsonTRALTWi Raftmethe 0on Pmellor wide. Itfoune oMy tYPE:2laoart0on Mce Yncarryiretion tle[e. a dBusi Business, lo: @ 1869 Hon Rte.5RI=19 10 Pa al la n-Suit Altelre and Buffilnesb Regulatlgn. Z „ t}�86 _ 07YLU28t8 tO Park Plaza-SuHa 51T0 JP GEORGE&SOH INC Boston,MA 02116 JOSEPH GEORGE �.E.C� - aJu7'- -•�' 64 HAYWO005T : GREENFIELD.MA 01301 UOdeNOt vaftd strifthout et natuts mecretaly 9 RISE ENGINEERING OWNER AUTHORIZATION FORM I, Marta Blyth (Owner's Name) owner of the property located at: 394 Spring Street (Property Address) Florence MA 01062 (Property address) hereby authorize T - G{prV " 30nr 1n (_ (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. Owner's Signaf re RISE Engineering,a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335 www.RiSEengineering.com