22D-068 (3) ;7 SC
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OWNER AUTHORIZATION FORM
i
(Owns s Name)
owner of the property located at
(Property Address)
Y:--'to �C� v
(Property Address
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.
Owner's Signature
Date
SECTION 8--CONSTRUCTION SERVICES'
8.1 Licensed Construction Su ervisor. Not Applicable ❑
Name of License Holder:
License Number
KOM � 4V::n-k o M-6-) I P I Ob
Address Expiration Date�j
Signature
Aft-
Tele one
® q15 -21q, Zg1 LI
.,n ✓ maw r- ., ,,.Y - a,€ vzt',a rr a
mp n>' r �-. Not Applicable ❑
too _
Companv Name Registration umber
�( Expiration Date
Telephone ✓77 Z 7'_2 /1
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 p rmit.
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 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
w, y.
SECTION 5-DESCRIPTION.OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[0] Other[Co
Brief Description of P posed/1 , L L.� � ( �� � r n Qs S �'r �
Work: f7 i-y"f11 .WL k.�`ri Y L'
Alteration of existing bedroom Yes No Adding new bedroom Yes No `
Attached Narrative Renovating unfinished basement Yes -No
Plans Attached Roll -Sheet
sa=1f' �� rseI � it�taxilsalislna cci � e#lie'ftiQwanu:
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 law OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matter relative to work authorized by this building permit ap on.
Signature o Owner Date
I � ' as Own Authorized
gen reby d lare that the statements and information on the foregoing application are true and accurate,to the best of rt�p knowledge
elief.
Signed under the pains and penalties of perjury.
Print Name
HOME ENERGY SOLUTIONSrb IW
�' —
Signature of Owner'AcOMNGTON.MA 010 Ow Date
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 I I
Setbacks Front
Side L:'Y'.....__ 1 R•L----J_ L: _____j R:
Rear i
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 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I Page ? and/or Document#;
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO
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:
i
E. Will the construction activity disturb(Gearing,grading,excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
a ya
C Q W r ' City of Northampton y:
Building Department
212 Main Street
Room 100
Northampton, MA 01060 k �
E1 tric,Plumbing&Gas InsPpa%413-587-1240 Fax 413-587-1272
Northam ton, MA 01066
. •
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section to be completed by office
1.1 Property Address:
O b FI wi ti L e U a j Map Lot Unit;
MA d 1 W j 'Zone "` Over 101 istnct
1:irrt 5t D18trlcf CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
r �C� rB Telephone Sig_ ( � , I'
Signature Q "i "�
2.2 Authorized A ent:
Name(Prinj Current Mailing Address:
j*W&
Signature Telephone
SECTION 3:-ESTIMATED CONSTRUCTIOM COSTS!
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
Kbb-
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building(Commissioner/Inspector of Buildings Date
File#BP-2015-0287
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 96 FLORENCE RD
MAP 22D PARCEL 068 001 ZONE URA(100)/WSP(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
Typeof Construction: INSTALL ATTIC INSULATION
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 FOLLOWING 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
D i De
o dmg Officia 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.
96 FLORENCE RD BP-2015-0287
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 22D-068 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-0287
Project# JS-2015-000548
Est.Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use GroWL JAY BOLAND 101880
Lot Size(sq. ft.): 20778.12 Owner: WILMER KRISTEN
Zoning: URA(100)/WSP(100)/ Applicant: JAY BOLAND
AT. 96 FLORENCE RD
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON.911512014 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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 9/15/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner