32A-024 (3) }
mass save CONTRACTOR
PARTIMM
PERMIT AUTHORIZATION FORM
O n K�.�{ J L Pe'
cova",
I iZof Se- rd r:h ^ T ' 7'' of owner of the property located at:
(Owner's Name, printed)
1s thev► v St t.,kc, �•�,�fl)., p/1A 010 60 ,
(Property Street Address) (City/Town)
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property.
Owner's Signature
8/5/13
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
Rev. 12132011
,.,.., -.., The Commonwealth of Illassaehmsetts
...,a.......,,•
P Department of irtdustrial Accident's
, :Tr
Office of investigations
' .-.1' 1--7-;'ii=1 600 Washington Street
,-.?.— ,T___27, ,,...;;
'.4ii, Boston, AL4 02111
Workers Compensatiot Insurance Affidavit: BuildersiContractorsT,lectricians/Piumbers
Applicant Information Please Print Legibly
, -
.
Name(Sosim.sss-;Oreonizationitilliivici.c.ai): '71-0 a. i - , 'il,01:10a-
.A.dfireSS: •___ 2,i.-:, 0}, R 0,3A
C;ity 1 StateiZip:.1 0/ - •. MA 0 I 0 CD --17'L07-15 : ill 3- (pea-7- 31304 24
• 1 3 . iLi--(204
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Are you sn employer? Cheek..4P opproptinte 7:307.7 ; Type of Ira:Feet(requiren):
4, i7 '. ,,,,-, := :%±: 7-"•,,,r■'. •.,1'1',',7•':i-,.`....,,,': f ■
1.Ls".7 i am a ern)ioycs,;viti'l
r.v ,.„..i<7,,,,i,-_,Lnr.,,,,,,,,..11...,,,r, 'i ; ••,.:. - 1. -,--, ,Oit:',...1.th.....luz:
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yr,'oyes tilcall andor i-,art-rrrie). ,
ilsie:i .:lt .,.-Iliaellec:i c:..1.,..tt.t. 1 ', 7, n iiernodeling
2.IVi am a soie proprietor or patner- ./. ie
ship and have no employe,:.-= These sub-contraztors have i , , ,---1
, . Oornol4lon
wOrliing fOr me L any zapaehy a"
eiwriloyees-ari:.
Buildin,:-. f..i.d.fiti011
[No workers'comp.insumpec Cf:;710. :0-4:::::71T<CCI.'
required.1. 1
5. 3raljnr,:aty; its : I 13,r---1 Electrical repairs or additions
.E.1 l we are a com.
2 El i ,arri a homeowner doing.all ,.iip cifierers have ex trcisec=,U.leir i 1 l:.1 i PlumbiliF repairs ar additiOnS
,I;i&I't Of''''''''P'•:i'" "'=,• i,,rrit : 1 .
myself.171\13 Woricts cop. '' ''' ' -- t 2.7 aoof reT.).airs
s.urance.zequirea]t c. (4). ann we;hzivc,
emnioye es. N ._.Li Other
: I
carep. insuranct;reczo:re,-..',..:
■ I____„.
Any applicant that cheeks box 41 must&Ls°fill out az seederi below rbowiag their worlters'eompentOden.paliey information.
Homeowners who submit this affidavit indio.Mag they me zinc au wont nr,11.than:Arc outside cortiniv.ers must submit z new affidavit indicating such.
tContamrs that check this box mini attached as aaditional sheet showing the name of the sub-contactors end state wizetec;or riot those entities have
employees. If the sub-eontracters have employees,they must proviee their worle.,rs'camp.ooliey;lumber.
I ant an employer that is pmviding Worker COMpelffiltiOn 2.nsgiratne for my‘..,mployees. Below Zs the policy and Joh site
infiirmatifilo
-,---
irisuranee Company Nwhe.: .R+-lan414-__ Lor 511.Q\-)--3 -1S1- C-.
---
Pr.iliey ti or Seif-ins. Lic.#: I-0 to i (..10 i b4s ?'- 11.-2Aion i-.1,te: i 1 -01 - IS
I_.
Job Site Address: 7- e_hery- S—V-ocel- 0,:::.,),,,,,,t,:teizi,"-)i: 0 p-6-)
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Attach a copy of the workers'cone • don policy declaration page.(showing the policy number anti e-e.pirntion dote).
Failure to secure coverage as m-,...tuir,:.-d.u2-ider Secti:an 25A of MOL c. :52 can lead to the imposition of criminal penalties of a
fine up to S.1,508.00 aria/or one-year Itnotisonment,as\veil as civil penalties in the form of a STOP WORK.ORDER and a fine
of up to 5250.00 a thy aaainst the violator. Be advised that a copy of this statement may be forwarded to the Office of
lnvesticxations of the DIA for insurance eavemele'vcrifloation.
I do hereby cart& ruder the pains and peneIti2s of perjury that the iilfOrmaiion provided above is true and carreet.
Signature: ,.. . T.3,a,..
.„ - ... - 1
T_•:,‘ ‘,;-!.
k 110n,tr. -1-1-Yb- i_.tal--S1'30 <-4■ 3 - D 114- ;-2-`- Lc-
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p officia Ilse only. Do not wthe in thii opea,to be Coi-tipieieei by eky oF tOwn tlijk4471., li
i II!
ii City or Town: 11;Cirtntl.I.Li.LciTitse;:',
V
it issuing Authority(eireie once , I,
li 1.Board of Health 2. Building Department 3.City/Town ts3;:cz-k. 4. Electrieni inspeetor 5. Plumbing inspector !II
11
11 6.Other i
g
It Contact Person:. ii=hone
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
102
ii5yk -i Tad_ n Ar1A- 01 () O D1(29
Address Expiration Date
Signature . v elepribne
yt
9. Re is ered Home Improvement Contractor: Not Applicable ❑
mgr Soli+inn
Company Name Registration Number
►a PAddress `�(� /�] Expiration aattee�` 'n 1( ' I o I O S o Telephone ii'3'7/L ! 31 3& c-/'.'c I1 3
SECTION 10-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 '❑ No ❑
11. - Home Owner Exemption
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 license,provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition El New Signs [p] Decks [p Siding [0] Other[IZ3V-
Brief Description of Proposed ( (—(--,� j_„SGC 13.1 G� �. -C,--). I(n
Work: y_}-( � � �rl I
Alteration of existing bedroom Yes ' No Adding new bedroom Yes i°
Attached Narrative Renovating unfinished basement Yes _No
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
I, t7� ^ r `( 1 c as Owner of the subject
property •)rs4--
j
hereby authorize •T V-t,1L � M � St)(,t 1_; � 05
to act on my behalf, in all matters relative to work thbrized by this building permit application.
Signature of Owner Date —
✓�
I, l 1C) ! -C �o �( S
n I , as Owner/Authorized
Agent hereby eclare 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 of perjury.?Z
Print Name
rvti , •
Signature of Owner/Agent'ut,+ , ii ;° Date 0 — .
Ar 07
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q` YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO a
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO a
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO EI
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
r` 1
(C� rte, ' �;�� i,, —� Building Department Curb Cut/Driveway Permit
i I 212 Main Street Sewer/Septic Availability
LISEP 3 0 2013 Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
ton 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Ele;tric, Plum�brnd&Gas Inspections
Northampton. MA o�OeO Other Specify
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
1 esha MA S l -e e.'T Map Lot Unit
p ( O�� b I D(.00 Zone Overlay District
/
\��-
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
0nnt) r' \)(\ (o� f,
Name( Current Mailing Address:
R ���JJJ Telephone , I t3 3 0..-r ' C
Signature d l(✓ 1 °°� .d
2.2 Authorized Agent: II 4U1iY)( o1 r f \� `tna,r �)u- is 3 is P►_ d, , m.
Name(Print JJ Current Mailing Address: G� J O i(Y:.---1-`
4: ,,: , N).3 -0C) 3130
Signature Telephone
r.V ._
SECTION 3-ESTtiATEO yONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 3 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+ 3+4+5) Check Number g/5 W
This Section For Official Use Only
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0405
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 18 CHERRY ST
MAP 32A PARCEL 024 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �`� �
Fee Paid Siit
Typeof Construction: INSTALL ATTIC INSULATION&AIR SEALING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101880
3 sets of Plans/Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit 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
40100.- 01
/o- '73
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.
18 CHERRY ST BP-2014-0405
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-024 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-2014-0405
Project# JS-2014-000694
Est. Cost: $3000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 3310.56 Owner: MCKAY DONOVAN
Zoning:URC(100)/ Applicant: JAY BOLAND
AT: 18 CHERRY ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMAO1050 ISSUED ON:10/4/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION & AIR SEALING
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 10/4/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner