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43-155 URBAN & SONS INSULATION CO. INC. 385 LIBERTY STREET SPRINGFIELD, MA 01104 (413) 783 -0701 - (413) 732 -3922 FAX (413) 525 -8116 ' of Customer Name Address �(1 UT � mVVI ��y "M give permission to pull a permit for my City or Town home to do insulation work to be done by Urban & Sons Insulation Co., of Springfield, Ma. Any questions please call me. 413- 783 -0701 Salesman for Urban & Sons Date Pct Ltr bo-A- ti Property Address: C� Contractor —� Name: r�Q� �' Svh� �h�J (IJt vk Address: L � � �r```la S� City, State: DT`s V'h L UN Phone: IT Z Z Property Owner Name: l�` Address: G\ 1 ���� `�Y1cNt1 City, State: 1n V �wr Z } O w �ti\ \, -A!� (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 Date fie z �, �` HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines `Tlomeownee' as, " Person(s) who owns a parcel on which he/she resides or intends 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 home owner." The building department for the City of.Ngrthampton wants persons) who. seek to use the home owner exemption, act as their Own - construction `supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations. The inspection process requires that the.building department be called to inspect work at various stages, which include foundation/footino (before backfdl), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these. inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occuoancv until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper " in conjunction to the building permit issued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made understand the above. .(Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location r ' The Commonwealth of Massachusetts Deparincent of Ihdustl ial Accidents . Office oflnvestigations 600 Washington Street Boston, MA 02111 www mass gov /dia - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/plumbers - App licant Information Pl ease Print Le�qliy Name (Bud ess/org on/Indivi&,4:. Q nc QWri S ©t lr� S� O Y - • .Address: .City /Statetzip: 01 -c � - Phone. #: Are you an employer ? .Check the appropriate•bo= - Type ( of P I et p ro'e r te' 1. �iam a employer with 1 Z - 4. ❑ I = a general conhactor and I . employees (fall and/or part t i me ) . - have hired 6. New construction hired the sub-contractors ❑ 2_0 I am a sole proprietor or pa:tn=_ listed on- the•attached sheet 7. El Remodeling s* �1 have nQ may= These sub - contractors have $. Q I3cnolition working for me man y capacity. ?lay- s_- and_have workers . l� svor)oess'. of rte) 5. E]. We sit; a coipviation and its 10.0 Electrical repass or additions 3_ oil he ve aezased t� . Q I am a homeowner doing all work r • 11.0 PInmbing repairs or additions myself (No waakets' tromp- sight of exemption per MGL 11EI.Roofrepairs insurance re4t&ed7 t X.152, §1(4); and we have no - .employees: (No wmirrrs' - 13.0 Other SIP- insurance rte}. *Any ghat -ba x #t ==MAw sn out the section bdaasfio i poKay t Homeownma aBo submit thu afaavic g they we doingan worm sad theahfre card& caw== most mbut a mw affdwdt m cz6ng sx:fi_ IConuactors that drelc this boi aascamched an additiaoai sltiei slowing the name of the sub�eanor�tas a4d sla�wl�co;�t- rtrose- entices nave . • employees. ti the hax employees, t aooc3Qis' camp _poTicynumbw f= an mykyer tha ispro Wn workers' compew4 ion irrsuraace for iuy anPloyam Below fs tlu pokey and job site - informadfoff- _ Insurance Company Name `n'� • 1;M y �.t �w Policy # out Self- -ins. Lic: A %"I 1'hZ Q � 3.. G I � _ Expiration Dato :. 1 ' o f G (06 Job Site Add res s _� - 1� �� C� V\_ Crtyi3tafelZip: �f'�C �1`Ll 1't'1 14 F Attach a Copp of the workers' compensation policy: declarafion pa„ae {showing the pgIiep number and es�uation date). Faslnre. tdr secure coverage as i mir.Seon 23f I�GL c T32 can lead to 8be is of penalties of a ftne lip to $ I,500.00 andlor one yeas a - as well as civil penalties in the foam of ti STDP W ©Rg- QRDI R and a fine of up tD $250.00 a day against the violator ; Be advised a cop3' of t his statement play be fo to the ,0�ce,o ; v ahons ofthe IA -. ; ins urance cov _ s for ins' eraaie ve�scafion: + _ lurelSy cefyuirder�theparns '�f ofpe�ury :tkdt "the in�ormadoarravrdeilae ° _ - - - Side- /� .^�.� - - : - - - - _ _ . - _ b � = _ ... !' � . _ • � �- � t - Phone #k , Z : 3 O,�` 4L:w use only. Do not write iii this area, to be coiVkied by or town official -City or Town: PermitlL[c # Issuing, Authority (circle one): J. Board of Health 2. Building Department 3. CitylTown Clerk .4. Electrical Inspector 5. PIumbing Inspector 6. Other E Contact Person: Phone #: z SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction \ Not Applicable 11 Name of License Holder ' T 1 U V\, U`N °, U Y1 In/ ;� -? e License Number e0) Cr Address Exorabon Date Signature Telephone (r-k 173 (A Company Name Registration Number Address f;c iration Date y Telephone SECTION 10- WORKERS' COMPENSATION_ NSURANCE AFFIDAVIT (W-G L. 0. 152, - ? G( & }) 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...... ❑ 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 Lcense, 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 i SECTION:5- DESCRiFniDtLOFPROPOSF } WO RIE (check all aat ltcabie) New House Addition Replacement Windows Alterations) Roofing ❑ Or Doors 13 Accessory Bldg. ❑ Demolition ❑ New Signs tol Decks [M Siding [CIJ Other [CA Brief Description of Proposed ��� �� ` Y_ a Work: V W `� C C' Lk �r O�, Alteration of existing bedroom Yes No Adding new bedroom Yes No � Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 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? E 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. Witl-building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION Ta` OWNERAtl!1EHOR�TION 't`Qf3E- GQMPE,E7ED Yft[�I�I - , OWNERS AGENT OR CONTRACTOR APPL IES FOR-BUII DING PERMIT as Owner of the subject property hereby authorize LJ �__ C � O ►�� �V�<l lt,�'� cT vt to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, 1 _((kY\ � 1C In as Own A oriz Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best edge and belief. Signed under the pains and penalties of perjury. 1 1 �GY, L �� Q►� Print Name C� Signature of Ovpv6RIVkge7 �� Date Section 4. ZONING Alt Infommtion Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be fi in b y Building Depwftnenf Lot Size t Frontage Setbacks Front Side L: R: L: R Rear Building Height +— Bldg. Square Footage Open Space (Lot ama minus btdg &paved C� # of Parking Spaces t �' Fill: volume & Location A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT K NOW ® YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book i Page - -�-� and /or Document # r B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: j C. Do any signs exist on the property? YES Q NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q IF YES, describe size, type and location: E. Will the construction adivity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a cornmon 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. bwlaing uepartment r� IVE 1 R Street 100 o ampton, MA 01060 j OCT 2 OrW 4 3- 7 -1240 Fax 413 -587 -1272 NADI CT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE .INFORIfIfi4TM_ .:. 1.1 Prooerty Address This sectioni to be 1comp leted by office I ► �CjCAlr�l�`,� Sf' n z SECTION 2 PROPERTY OWNERStfIPtAUTHLNt#ZED AGEat 2.1 Owner of R ecord : Gl� Name (Print) r I� `I � I / Current Mailing Address: U"Q 5 4 M .S w V` vvi C) k r Signature Z J E e � h P(} Telephone ` I �, 2.2 Authorized Anent: Name (Print) Current Mailing Address: (� Signature Telephone � � � _ -� SECTION 3- 'ESTIM1kTEDCQNSkTRIfiCTION07J Item Estimated Cost (Dollars) to be C}ffiaal Use Only completed by rmit applicant 1. Building ng'Penitit Fee 2. Electrical (6} i= stimatecl Total Cosfi of .:Gonst ruction froth 6 3. Plumbing Butlirng PecialtFee 4. Mechanical (WAC) 5. Fire Protection 6. Total = 0 + 2 + 3 + 4 + 5) 'c Check Number Tltiis: Section rtht.On . Date Building Permit Number. Signature: B uifding " �amr iit ss i o n e dlrispec�or� =B�tHnas . _ - ` udiv + File # BP- 2012 -0420 APPLICANT /CONTACT PERSON URBAN & SONS INSULATION CO INC ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413) 732 -3922 PROPERTY LOCATION 29 HAWTHORNE TER MAP 43 PARCEL 155 001 ZONE SR(100)//WP/WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSULATE 2ND FLR ATTIC & ABOVE GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/ Statement or License 101878 3 sets of Plans / Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN PRESENTED: ved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Pen 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 ry Z �� Signature of Building 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. 29 HAWTHORNE TER BP- 2012 -0420 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 43 - 155 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- 2012 -0420 Project # JS- 2012 - 000664 Est. Cost: $1075.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: URBAN & SONS INSULATION CO INC 101878 Lot Size(sq. ft.): 91911.60 Owner: MAGUIRE CHARLES M & ELIZABETH A C/O EDWARD R GALE Zoning: SR(l00) //WP/WSP II Applicant: URBAN & SONS INSULATION CO INC AT. 29 HAWTHORNE TER Applicant Address: Phone: Insurance: 385 LIBERTY ST (413) 732 -3922 WC SPRINGFIELDMA01104 ISSUED ON :1012512011 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSULATE 2ND FLR ATTIC & ABOVE GARAGE 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 10/25/20110:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner