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22D-113 (2) OWNER AUTHORIZATION FORA Ci, U (Owners Warne) owner of the property located at C> A-3 �>(Property Address) � (Property Address) hereby authorize —• (Subcontractor) an authorized suboo It! r for RISE Engineering,to act on my behalf to obtain a buikft permit and to perform work on my property. Owner's s4natum 4- Date RAI nrT 9.d 9111E yo. .r���s�4;:8.��•.rr,�e'��i::Fi:a'•J�':yw° lrv��Zr'i.iu - In We '-l�`•E, -`'is e:c...._- _ 'r 'r O is' ::�lt�+.S�r��..'.'�r '✓43.."i.`-ss+.'-S.-rivtr.^t`�•.L::•i iliz.+e:r.:.''.t':.w _.o ✓.... .. t�:Y iciY.. �� �)�A,'r.iF�,,'1•,9�°^_lixk�'ir*�Z�`..7SuS^_ (� // � (j�'�,� [//\\\J��' l;•4`�.��l�Ua:aZ2'aF.1`,S`"._a-11i n1C.i./ciu'.':�t�-`:)• �f•1��x..sa=.{..cl�r�.o.-1.LA..� rk ► -52 � Y i•�V+}w��.�•'�"'� .�L�i!,'i. •..:Zvi._.. '''_' .'i5:. 'l..t , .:_." � - 1 !.tJ•' .-. : r= Tt:u: .._ �.. . _.:r..._...'._ii:..:_. �a-. .' �+,•• :�i.l�:a ��=:{Stt '?..: 1 i tom:.:^i.:�?7.1I)a.: ;' •. .. _ z:-'et. V i t r"i rr;•ag y u).i?Cateih.SLL"JT�Cw:l�it. 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SECTION 8-CONSTRUCTION SERVICES 7 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: � License Number ISc a� 1a ��� tJ Address V� Expiration Date Signature z, Telephone 8.Registered Home Improvement Contractor: Not Applicable ❑ Co pang Name Registration Numbef pr �-� PC---,C4-d, 10 I D4 Address /� Expiration Date P( �� 1/�� Telephone r 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 buildine 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 ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [r-3] Decks [C) Siding[[I] Other[O] Brief Description of Proposed /�,A� Work: GL l Alteration of existing bedroom Yes ✓No Adding new bedroom Yes No 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, d a u A u OLo (,,c as Owner of the subject property hereby authorize = :: to act on my behalf, in a ma ers rela ive o w authorized by his building permit app ication. Signature of Owner Date I,�ev � 601 &0c] as Owner/ o�rize ecl a th t the statements and information on the foregoing application are true and accurate,to the best of my�wledge belief. Signed under the pains and penalties of perjury. rev � A-0 _A . Print Name If Signature of r/A 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 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: -T volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW � YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW (E�r YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® , Date Issued: C. Do any signs exist on the property? YES 0 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 © NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading,excav on,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO (3 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. -- Department use only 2014 �!LI�! City of Northampton Status of Permit NOV 6 uilding Department Curb CutlDriveway Permit 212 Main Street Sewer/SepticAvailability &Gas Inspections ROOM 100 Electric,Plumbing WaterMell Availability Northampipn,MA 01060 orthampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 PlottSite Plans 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 60 4 W 1 5 &r-&k, r Map Lot Unit Zone Overlay District Y C' Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: l -z� Name(Print)a¢ye�aa q Current Mail' Address,Au, 2--' 7 0 1�. Telephor Signature 2.2 Au orized A ent: nn D kv Name(Print) J Current Mailing ss: .1 AL.-- L1011 ALALW(.1 t4 3- teo -311 � Signature Telephone ti, yECTION 3-E v STIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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=0 +2+3+4+5) Check Number d This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0535 APPLICANT/CONTACT PERSON JAY BOLAND ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414 PROPERTY LOCATION 60 AVIS CIR MAP 22D PARCEL 113 001 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 INFOJkMATION 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 Demolition lay nature of B din f icial 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. 60 AVIS CIR BP-2015-0535 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:22D- 113 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-2015-0535 Project# JS-2015-001008 Est.Cost: $1200.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sq.ft.): 24175.80 Owner: WEGA CLAUDINE Zoning: URA(100)/WSP(100)/ Applicant: JAY BOLAND AT: 60 AVIS CIR Applicant Address: Phone: Insurance: 12 PISGAH RD (413) 214-2414 WC HUNTINGTONMA01050 ISSUED ON.11/10/2014 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 11/10/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner