12C-057 (3) 26 HAROLD ST BP-2020-1255
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 12C-057 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-2020-1255
Proiect# JS-2020-002113
Est.Cost: $2457.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOSEPH GEORGE 99372
Lot Size(sq.ft.): 10628.64 Owner: LACROIX STEVE
Zoning: RI(100)/URA(100)/WSP(100) Applicant: JOSEPH GEORGE
AT: 26 HAROLD ST
Applicant Address: Phone: Insurance:
64 HAYWOOD ST 413 774-3604 WC
GREENFIELDMA01301 ISSUED ON:511812020 0:00:00
TO PERFORM THE FOLLOWING ORK:INSULATIONNVEATHERIZATION
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 Si nature:
Feer e: Date Paid: Amount
Building 6/18/2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
DepartmeEon
Z City of NorthampFIAN
f Permit:
Building Departmt/Driveway Permit
rn 212 Main StreSeptic Availability
ROOM 100Well AvailabilityNorthampton, MA 01060ts of Structural Plansphone 413-587-1240 Fax 413-587- te PlansSpecify_
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO
SECTION 1 -SITE INFORMATION
<+ This section to be completed office
1.1 Property Address: b Map ( ZC, Lot 067 Unit
Zone Overlay District
Elm St.District CB District- —
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: a6 HyA S I
�fieve L��dax 16$-
Current Mailing Address: A'( \
°I3-
Name(Print)
('p-P, C14 Telephone
Signature
2 2 Authorized Anent:
ep �� � 6�
Sos
Current Mailing Address:
Name(Print) hj31-7OZq —3( 40U
Telephone 7
Signature
SECTION 3-E TIMATED CONSTRUCTION_-COSTS
Item
Estimated Cost(Dollars)to be Official Use Only
com leted b ermit a licant
1. Building dI/ i J Y7 2(, (a)Building Permit Fee
2. Electrical v (b)Estimated Tota(Cost Of
Construction from. 6
3. Plumbing Building Permit Fee
�6
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) 51, 36 Check Number 7
This Section For Official Use Only
�j Date
Building Permit Number: Issued:
Signature:
6- 19-Zozo
Building Commissioner/Inspector of Buildings Date
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [� Addition ❑ Replacement Windows Alteration(s) El Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [0 Siding[0] Other[1%
�nSv►la�ion
Brief Description of Proposed
Work: 1'1/�1r vU) Gb'L
Alteration of existing bedroom Yes No Renovatinnew bedroom g unfinished basement Yes Yes No No
Attached Narrative
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
1, Site �(/t061 as Owner of the subject
property
hereby authorize Sale Geos e
to act on my behalf,in all matters relative o work authorized by this building permit application-
to
I�',^l
Sed cncl,e� - `)
Signature of Owner Date
1 �aSepl, Geo ?- asOwnedAuthorized
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.
Print Name O I I �
Signature of Owner/A ' t Date
i
J Edi.
tName
-CONSTRUCTION SERVICES
d Construction Supervisor: Not Applicable ❑
SoSe��. G2orae. C53 0t�13'I a
ense Holder: License Number
, In �ao� s ��e� ee� ��t� o��o�
Expiration Date
Address
�� (413)77 -3�ou
Signature Telephone
9 Registered Home Improvement Contractor: Not Applicable ❑
1q. Rome min IsiW
Company Name Registration Number
(A d\ Vet,&e Id l AN 01301 7-)s =ao(S
Address ll -7"]i� Expiration Date
' Telephone����J- 11 J-36oy
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. 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 DweHifigs 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
The Commonwealth of Massachusetts
Department of Industrial Accidents
"s 1 Congress Street,Suite 100
Boston,MA 02114-2017
• www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORI'T'Y.
Applicant Information Please Print Legibly
Name(Business/Organi7ation/individual):
Address: ILA Lt
City/State/Zip: oix, R�Mt Phone#: 6 l3) S31 IC-76-
Are
G-76-
Are you an employer?Check the appropriate box: C N3U
�{ Type of project(required):
1.Uhl t am a employer with 157 employees(ffNjand/or pan-time)."
7. New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.fNo workers'comp.insurance required.]
3.r-1 I am a homeowner doing all work myself.[No workers'comp.insurance required.]' 9. El Demolition
4.❑i am a homeowner and will be hiring contractors to conduct all work on PAY• twill
my property. 10[DBuildingaddition
P
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees.
(]S5-F-1i am a general contractor and 1 have hired the sub-contractors listed on flee attached slice[. 12. Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance., 13. Roof repairs
G.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[KOther IVA v `a 0 V1
152,§1(4),and we have no employees,lNo workers'comp.insurance required.] if
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box inust 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'camp.poliey number.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: ,,jj#: 477 Expiration Date:
Job SrteAddress rCr�01 S\ Y City/State/Zip
A t apy�u he wQk c+tr,T' ►am en np ie�xl n ! shu ng � cyaanluubr�r an lie �r tton:+l area
Failure to secure coverage as required under MGL c. 152,ti25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certi ,under the pa acid nalties ofperjury that the information provided above is true and correct.
Si-enature: \ :Tv� ' Qb �I /t�Or�Q
Date:
Phone#:
Dfcial use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authottity(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Other
Contact Person: Phone#:
Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constructi- r Specialty
CSSL-099372 r.
Tires:02/11/2021
a'
JOSEPH P G€�ORG6 ,
64HAYWoo' '" 4
GREENFIELD 0!3 t4
:10 4L
.
Commissioner lftv-- `5*2
can .a 3racrud .
omce of consumer Affairs&ausin
'HOME IMpA0VEhiEI1ii, �s:RegdiaUon GO'
TYPE.C M RAGTDEI
fshation ornora6on' - Registratlonaralld'forindividuatuseonly
gyration before_the ex If found return to:
Rration date.
JP GEORGE&Sl]!d`J ;_ , 07/24%2019 Office of Consumer Affairs and business
KG 10 Park Plaza-Suite 5170 Regulation,lCr Boston,MA 02116
10
04 HAYWOODRSTEY
GREENFIELD,NAA 013b1�`'~
Undersecretary U Not v �d W ,
out Signature
City of Northampton
Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS 4t �
212 Main Street • Municipal Building
._yam Northampton, MA 01060
Property Address: O ���Id St' F�����e► /�� �lob�
Contractor p
/ ( &114� S, � lr\t•
Name: JIDW � &eo!lt / J,Q` 1
Address: �' Hm7%' o' St -ell
City, State: G oe r\',� , ��A o130�
Phone: HID-174- 304
Property Owner Sjege, LAamx
Name: J ll
Address:
City, State:
30Sp� RDr�-e (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 't
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: U HM)A 5V.
The debris will be transported by: Geode Oft", �fyi '2n c
The debris will be received by: 8rc4tie6f.)ro
Building permit number:
Name of Permit Applicanto ('�: L�r1
Date Signature of Permit Applicant
DocuSign Envelope ID:3DA50946-51FA-4E6C-9597-B2F36BAA25BB
RISE
ENGINEERING-
OWNER AUTHORIZATION FORM
I, Steve Lacroix
(Owner's Name)
owner of the property located at:
26 Harold Street
(Property Address)
Florence, MAO 1062
(Property Address)
hereby authorize �' &EO�e CA4 SPA, TIC.
(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.
DocuSlgned by:
b --1 11L�
& ature
2/26/2020 1 6:35 PM EST
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 02021 1 339-502-6335
www.RISEengineering.com