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23D-129 (2) 18 WINSLOW AVE BP-2021-0940 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23D- 129 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-2021-0940 Project# JS-2021-001609 Est.Cost: $2188.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JOSEPH GEORGE 99372 Lot Size(sq.ft.): 11586.96 Owner: ROGOVIN REBECCA L Zoning: URB(100)/ Applicant: JOSEPH GEORGE AT: 18 WINSLOW AVE Applicant Address: Phone: Insurance: 64 HAYWOOD ST (413) 774-3604 WC GREENFIELDMA01301 ISSUED ON:2/26/2021 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATIONANEATHERIZATION 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 Signati ''•. ' , • )2 • cSleiT FeeType: Date Paid: Amount: Building 2/26/2021 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner -CNA11T r..., ; 'J, 4�` a� City of Northampton �/� ! Bee d T ' Building Department �`'� V`� ,, S �, ,�a �, � k t � ��, St -..s��`' t Y �,-s7KX�i,P! a xs ra 4'— ?; s- 1 , a Y 212 Main Strtet � � ` - ", ° } f Room 10 FEBsl r Tr i l - - -; =' Northampton, MA 01060 N d z ��' 121 t "� phone 4Northa-1240 Fax p() ,4 � z, - � - ��-, , ' x ' 41� >, � � � r 4.. 'vnr1TFI-1 r Tr7��P✓1����1t'�M1}� ��g ',,L.',,,, �t'r A � 11 1 �' +'�t�' ?� APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY � r ,T v � � fY ` DWELLING ONLY SECTION 1 -SITE INFORMATION INSULATION PER 1.1 Property Address: MIT l� �j,�bw Ave_ This section to be compl d by office NOrII Map Lot I VA rnF ,/VGA Zone Overlay District Unit_______ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Elm St DistrictCB District • 2.1 Owner of Record: Rebeccc, Rn sir) ii `.,Ind }l Name(Print) I� y'lNI, W G^V. Orth" 1 o MA 01°bD e Current Mailing Address: 7 � I Signature ��t � (l 5 37'37� Telephone .,_Authorized Agent• Name(Print) \lc, olt St, GreenficM 1 �' Current M ling Address: ��3�1 illy Signature , , _ 71 _3LWW,�4 SECTION 3-ESTIMATED CONSTRUCTION COSTS Telephone Item Estimated Cost(Dollars)to be com.leted b •ermit a..Iicant Official Use Only 1. Building 41 Mt" (a) Building Permit Fee 2. Electrical 3. Plumbing • (b)Estimated Total Cost of Construction from 6 Building Permit Fee #66 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) I k�� Check Number `1 This Section For Official Use Onl Building Permit Number. � _ 1 Date Issued: / Signature: 2- Zy- 221 Building Commissioner/Inspector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) SECTION 4-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / Not Applicable 0 Name of License Holder: 3-0Sep\ GA y 41371 License Number (9 .ic ,5�, Gr**„f�ec�i MA4 0101 j/ oA3 Address \ Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable 0 P. Gene Soni .rAt• 15bUL Company Name '�A /� Registration Number N by a wr)od .S ( ii %�1�V\ 0 l30 oth,s1 031 Address ! )ll Expiration Date , Telephone �)J 7 '3i�r SECTION 5-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 14. No 0 Brief Description of Proposed Work NOTE:Ar OTE: INSULATION ONLY As„,10K, \WAS w\\-1. 4" 6(6 CI( CQII A Se (K-1't) I 'Of \\ ((VC , 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. Print Name off./1660Al Signature of Owner/Agent Date g be U,G\ R'pl 1rN , as Owner of the subject property (�� hereby authorize Tr)Sef‘ v Wfott to act on my behalf, in all matters relative to work authorized by this building permit application. See t c;t\et n)sll‘la,0)1 Signature of Owner Date City of Northampton Massachusetts 4. -1-4 ��.'. ,4 DEPARTMENT OF BUILDING INSPECTIONS ?, �7 212 Main Street • Municipal Building vy, 4�b. Northampton, MA 01060 "`^�3 j�'� AFFIDAVIT Home 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("HIC"). 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-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered Type of Work: T IISvti ief Est. Cost: 3 i I B. Address of Work: VI Ni\lin " A*. Date of Permit Application: na-/I I (41 I hereby certify that: Registration is not required for the following reason(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 RESPONSIBILITES 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 permit as the agent of t e owner: 04/14111 a.F., Vorie GyA So,, (. -441 0\ik, ,Okie—iX—ivls 15Uit Date Contractor Nam 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 foasM. City of Northampton 5 �._ ,/. Massachusetts ./126-4.'' cam, V1: \SO : ;1 DEPARTMENT OF BUILDING INSPECTIONS ti Fr. ' r 212 Main Streett4 Mu MA C.pal Building 1:V � . 40- *i Northampton, MANDATORY FOR HOUSES BUILT BEFORE 1945 Property Address: IC? \NW\bW AveVR. Contractor TT ff....,,��, Name: V°P, uwl, CMa 101A ► 'Inc. Address: Vi NoortsenJl 1\- City, State: (TreeNNAck, Nth , 000‘ Phone: 13 J- 11 -"V0A Property Owner Name: (Q )eJlA { )10\1n Address: \% \AR0lo i MO A City, State: N°4(Alltor [1V+ 000 I, -oie(s, bent (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 *14-'11- • Date Q 'yblam\ City of Northampton co HAMe. 749 3� { " Massachusetts DEPARTMENT OF BUILDING INSPECTIONS .3'. � � f 212 Main Street 'Municipal Building 0% b' µ T- Northampton, MA 01060Y {lam Debris 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. The debris from construction work being performed at: l8 VANSIOW AJ€(\ ,A , (Please print house number and street name) Is to be disposed of at: BrQk\ eorr Sulvcle, 431 Ver B►o lebro,VT (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) .o3 r��(i�la Signature • Permit Ap lic t or wner 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. rr i The Commonwealth of Massachusetts Department of Industrial Accidents 11111—:÷: • 1 Congress Street,Suite 100 • aai cif' Boston,MA 02114-2017 www.rass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/ElectricianslPlumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: Gf.C'C ca ,T&L City/State/Zip: thi /Alod .66.24ACkeleAJA Phone#: t '� 3't 167 Are you an employer?Check the appropriate box: C' Type of project(required): I l am a employer with / employees(f i1Landlor pan-time)" 7, ❑New construction 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. []Remodeling any capacity.[No workers'comp.insurance required.] 9, ❑Demolition 3.0 I am a homeowner doing all work myself[No workers'comp.insurance required.]' 10 C Building addition 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0 l am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof'repairs These sub-contractors have employees and have workers'comp.insurance.: t'�t 1 6.0We are a corporation and its officers have exercised their right of exemption 14. Other IYI�L T'� orpo g p per MGL c. 152.C I(4),and we have no employees.]No workers'comp,insurance required.] *Any applicant that checks box Al must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 for my employees. Below is the policy and job site information. i\-(1066,. insurance Company Name: Policy#or Self-ins.Lic.#: Li( C)6(2 LI 77 Expiration Date: At '' — l`—.)-10aj Job Site Address $ " ' tns 9w � City/State/Zip 'r��� �1 M At Nob 0 Alt is►ale �nP t let t 9 ►m > ts>lu Iug # P9 l ± tuml► rrantti eacp r��hondat�e) Failure to secure coverage as required under MGL c. 152,§25A 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. I do hereby certify and r the pains and p'nalties of perjury that the information provided ab ve is true and correct Signature: Date: 0 161/(q.+l Phone#: \ 1{3 " �� 3t l Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(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 Construct !Specialty .f. CSSL-099372 spires:02/11/2023 JOSEPH P GEORGE J. 64 HAYWOOP S , GREENFIELD-AAA 0130, Commissioner daA . '&nih Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only, TYPE:Corporation before the expiration date. If found return to: Registration z Expiration Office of Consumer Affairs and Business Regulation 156686_ 07/24/2021 1000 Washington Street -Suite 710 JP GEORGE&SON-INC "= Boston,MA 02118 ‘,) JOSEPH GEORGE i 1 ;►,Vi tho itiCf.-514__04. 64 HAYWOOD ST ifiee..4e4r / t GREENFIELD,MA 01301" Undersecretary 'Not alid i t signature RISES ENGINEERING OWNER AUTHORIZATION FORM Rebecca Rogovin (Owner's Name) owner of the property located at: 18 Winslow Avenue (Property Address) Northampton, MA 01060 (Property Address) hereby authorize �,P� &zoi e uhJ 5o , 31i. (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. The permit will be secured by the subcontractor, at no additional cost. It is the homeowner's responsibility to close out this permit by contacting their municipality at the completion of this work. /—DocuSigned by. £h4gr,;,1 ture 9/24/2020 I 12:12 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RISEengineering.com