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32A-220 B ' 2022-1317 22 HANCOCK ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 32A-220-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2022-1317 PERMISSION IS HEREBY GRANT D TO: Project# INSULATION Contractor: License: Est. Cost: 2500 HOME ENERGY SOLUTIONS INC 106188 Const.Class: Exp.Date: 12/28/2023 Use Group: Owner: GUIDERA DANIEL P&SUZANNE K GOTTSHANG Lot Size (sq.ft.) Zoning: URC Applicant: HOME ENERGY SOLUTIONS IC Applicant Address Phone: Insurance: 233 COLLEGE HWY (413)203-2454 O HOWC 140654 SOUTHAMPTON, MA 01073 ISSUED ON: 10/13/2022 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHER IZATION 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO ATION OF ANY OF ITS RULES AND REGULATIONS. Signature: ' . a' , CS- i I ill Fees Paid: S78.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner 1(155 City of Northampton r.' __ Building Department ( OCT i 212 Main Street 2 INSULAION ) Room 100 , „' Northampton, MA 010 r t r phone 413-587-1240 Fax 413-5 I 'i -r ir- r„ f,r,i,vE Ot4L. APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING�` � ONLY SECTION 1 ] SITE INFORMATION l l t S ULA 1 If ;f! PERMIT This section to be completed by office 1.1 Property Address: a 22 Hancock St Map /J Lot p� Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Daniel Guidera____._ 22 Hancock St Name(Print) Current Mailing Address 413-587-0807 Attached _ Telephone Signature 2.2 Authorized Agent: Shawn Mitchell 233 College Hwy Southampton MA_Q10Z3 Name(Print) Current Mailing Address: S (, yL. � � � _413-203-2454 Signat�,re_ Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2500 2. Electrical (b)Estimated Total Cost of Construr.11on from(6) 3. Plumbing Building Permit Fee 447 S2 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+ 3+4+5) 2500 Check Number t yp This Section For Official Use Only Date Building Permit Number -��- /3/ 7 issued: Signature: /42 10- i 3- ZD ZZ g 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:Shawn Mitchell _ 1061,88 License Number 68 Russellville Rd 12/28/23 Address Expiration Date 413-203-2454 Signature Telephone O. Registered Home Improvement Contractor: Not Applicable 0 Home Energy Solutions Inc. 191885 Company Name Registration Number 233 College Hwy Southampton MA, 01073 12/4/22 Address Expiration Date Telephone 413-203-2454 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 IV No,..... ❑ Brief Description of Proposed Work NOTE: INSULATION ONL Y Blown in insulation and air sealing I, Shawn Mitchell _ _ as r/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the bee of my knowledge and belief, Signed under the pains and penalties of perjury. Shawn Mitchell Print Name 1 0/6122 Signature of Owner;Agent Date I, Daniel Guidera , as Owner of the subject property hereby authorize Shawn Mitchell to act on my behalf, in all matters relative to work authorized by this building permit application. Attached 10/6/22 --- Signature of Owner Date City of Northampton A Massachusetts � - DEPARTMENT OF BUILDING INSPECTIONS 212 Mein Street • Municipal Building Northampton, MA 01060 CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: Springfield, MA The debris will be transported by: Name of Hauler: Waste Management Signature of Applicant: 5` rri,�?�l t��ia� Date: 10/6/22 The Commonwealth of Massachusetts 1... -...1 Department of Industrial'Accidents 'y'l ...-...r.:1.,71F., Office of Investigations Lafayette City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 t ',4147,5' www.mass,gov/dia Workers' Compensation insurance 4ffidavit: Buiklers/Contractors/ElertricianstPlumbers Applicant information Plepse Print Legibly . . . . Name (ausinegsiorganizaiictondividual):Home Energy Solutions Inc Address:233 College Hwy City/State/Zip: Southampton,MA 01073 _., .. Phone #: 413-203-2454 Are you an employer? Check the appropriate box: Type of project (required): I ern a employer with 5 4, E I am a general contractor and I 6, 0 New construction employees (full ardor part-time).* have hired the sub-contractors . ......... listed on the attached sheet, 7. 0 Remodeling I 2 L I am a sole proprietor or partner- These sub-contractors have ship and have no employees 8. 0 Demolition working for me in any capacity. employees and have workers' , 9, 0 Building addition o workers' comp. insurance comp. insurance.- I required] S. 0 We are a corporation and its 10.0 Electrical repairs or additioi 3.E I am a homeowner doing all work officers have exercised their 11.0 Plunking repairs or additioi myself. [No workers' comp. right of exemption per tv1CIL 12,D Roof repairs insurance required.! ' c. 152, §1(4),and we have no employees. [No workers' 13 ii Other • comp. insurance required] I , *Any applicant that checks box;I must also fill OW the action below showing their workers'compensation policy information, Homeowners who submit this attkiavir indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such Contractors that cheek this box must attached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have employees, If the sub-contractors lla%e employees,they most pnwide their workers'comp.policy number, /am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:AmGaurd Insurance Company Policy#or Self-ins. Lic. 0:HOWC361807 Expiration Date: 01/04/2023 Job Site Address. 22 Hancock St City/StateiZip:.NoVIA 01061 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 If 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. (do hereby certift un - t e pains and penaltie- ' jury that the information provided above is true and correct. Date: 10/0/22 .440$101-, Pho c#: - - . , Official use only. Do not write in this area, to be completed by city or town official. City or Town: , Permit/License # Issuing Authority(check one): I EBoard of Health 20 Building Department 3.0City/Town Clerk 4.0 Electrical I Salumbing 1 inspector 6.00thcr (1 1,1 Contact Person: Phone#: il.. - DocuSign Envelope ID:CA82F87D-4F38-40C4-906B-CE48EDF5D87D RISE ENGINEERING" OWNER AUTHORIZATION FORM Daniel Guidera (Owner's Name) owner of the property located at: 22 Hancock Street (Property Address) Northampton, MA 01060 (Property Addres olutions Inc Home 233En Coll ergtyon MA0,1073 Southamp hereby authorize (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. /—DocuSigned by: Nita Atitkint 7/29/2022 1 2:58 PM EDT Date RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com