43-084 (2) icrld, i
PERMIT AUTHORIZATION FORM
I, James M.Tobin owner of the property located at:
(Owner's Name,printed)
27 Dunphy Dr Northampton
(Property Street Address) (City)
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.
X J
Ovdner's Signature
DI�t�Pf l�
Date
FOR CSG OFFICE USE ONLY
Conservations Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
LJ}�0
0
Rev. 12132011
The C'ormnonwealth of Massachusetts L -int Form
Department of'Industrial Accidents
_ Office of'Investigations
I Congress,Street Suite l 0(`
Boston MA 02114-201 s
www.mtass.govidia
Workers' Compensation Insurance Affida-vita Builders/tCou tractors/Electricians/Plug .')ers
Applicant Information Please Print L s:Ably
Name(Business!Qrganization'Tndividuai,. f C(4(L4
�1tv/State/Zia:
Are you an employer?Check the appr,4riate box; -
� Type of Arta,}ect(rectuiz
1.❑ ! am a employer with a- ❑ I am a general contractor and I
—� a loyees(full and/or part-time)."` haze hired the sub-contractors i ! ff New constructiat:
l ? `� 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees I nese sub-contractors have 9, Demolition i
={orkina for me in any caUacity. ejiaple,ees and have workers' �
9. Building addition
No porkers'comp.insurance insurance.,� 7
required. i z are.a coloration and its 1 0.17 Electrical repairs dciit ris
3.❑ i am a homeowner doing all work o43icers have exercised their i + 11.17 Plumbing repairs .ddit:or
myself. o workers' cop . right of exemption per MGL
y p f ( 121-1 Roof renar,:
r:sLrartrx required.}; C. ; 2, 1(4),and we have no
_mpioyees. (No workers` 1311 Other i
—mr).1v st ranee required.] f
.
any applicant that chm' box it must also fit i out the section beio•.v spew>.nE poiiev information.
-:�omcowners who submit this affidavit.indicating thev are doinu ail i:o.,,and thee;hire outside contractors must submit a new affidavit indica such.
:) ontrdetors that check this box must attached an additional sheet showim the name or the sub-contractors and state whether or not tbme entitit nve
,;mvioyces. if the sub-connectors hwe employees.they Trust pru ide their nor6:ems comp-policy numher.
Y am an employer that is providing workers'compensation Msarrantce far m;'enrplorees. Below is the pollen ant ; h site
inforpration.
Insurance Company Name: 21AC C n
'oliev#or Self-ins.Lic.#: �Q(0 or) � Expiration Date:
.-vb Site Address: aq VVL-P► Out,
Attack a copy of the workers, compens4ion policy declaration page(showing the policy number and expira i-d�a`te).
ailure to secure coverage as required under Section 35A of M6L c. 153 can lead to the imposition of criminal pct, ies of
:ire up to$1,500.00 and/or one-year imprisonment.as a ell as=civil penalties in the form of a STOP'WORK ORM and is fine
or up to$250.00 a day against the violator. Be advised that a.copy of this statement may be forwarded to the 0 ffic i
investigations of the DIA for insurance coverage verification.
I do hereby certify under the pa td hies of perj, ,,tdiat ilae irr brmotio3:provided nlaove is true and carr
Siurtature: ~. c r t r
� ( � Date
Phone z (All - I.3 b _.
Official use only. Do not write in dMv area,to be conrpteted by city or Wiwi officiaL j
t City or Town: I'ermit/l icenae#
Issuing Authority(circle one);
1.Board of Health 2. Building Department 3. City/Town Clerk i.Electrical Inspector S.Plumbing Ins.---:tor
6.Other
l
Contact Person: Phone#:
s
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction S ep rvisor: Not Applicable�(❑
Name of License Holder: A-
1�
License umbe
I PIS 2�. p 'D f a ? �l(o
Address T Expiration Date
(. Zr l✓ 1 U
Signature.4; Telephone
9.Re istered Home Im rovement Contractor: Not Applicable ❑
Company Name J J Registration, Number
Address Expiration hDa e /
Telephone
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 buildin2 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 i]
Accessory Bldg. ❑ Demolition ❑ New Signs (O] Decks [Q Siding[I7) Other[a
Brief Descri ti of Pro nosed j ' j
p tf!f_ (�zr/)D�(1 INDtL) cz 1 b.y_ rS r?rq�l'll
Work: /
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
as Owner of the subject
property
hereby authorize
to act on my behalf, inU114fters relative to work authorized by this building r it application.
I i _
Signature of Owner Date r
I, as Owner/Authorized
g f hereby eclare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
n belief.
Signed under the pains and peries of perjury.
Print Name
=NERGY SOLUTIONS F
,
Signature of O 54d' 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:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW & YES Q
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 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, ex vation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
(� �} I Department use only
!, City of Northampton Status of Permit:
0� Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability.
Room 100 Water/Well Availability,
0� °'�umbin9&as app°° � rthampton, MA 01060 Two Sets of Structural Plans
�rtham to one 413-587-1240 Fax 413-587-1272 Plot/Site 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
d q n w(, ADclvt Map Lot Unit
n' (n R v i o t�,'v Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
I O Uri Dho OKI iY,
Name(Print) / Current Mailing Ad res :
( Telephone ,� e"
Signature
2.2 Authorized ACIent.
Name nnt) Current Mailing ddress:
Signature I'' Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
—completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical V (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 Q `�
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0788
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON01050(413)214-2414
PROPERTY LOCATION 27 DUNPHY DR
MAP 43 PARCEL 084 001 ZONE
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&AIR SEAL
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
INFORMATION PRESENTED:
proved 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
De lit' e I a
e7
Si ature of Building ici 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.
27 DUNPHY DR BP-2015-0788
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mqp:Block:43 -084 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-2015-0788
Project# JS-2015-001533
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq.ft.): 59677.20 Owner: TOBIN JAMES M&MARYJANE MIZE
Zoning-: Applicant: JAY BOLAND
AT.• 27 DUNPHY DR
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON.•211112015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION & AIR SEAL
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 2/11/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner