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30C-034 (2) OWNER AUTHORIZATION FORM (owneft Mm--) awwafftpfawv Eooated at car S6�� hoftymmwft 0.4- r (su DEC 2 m aged stdmtradorfor ME Egbm tg,to ad on toy a pm*and to porn work an my p uMV. OL • owns sire Dete SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Appl ble ❑ Name of License Holder: 7—d s lo- m Afsst C X =yd License Numb r 54o1 ST• �J�D�G, tits o �� 2 Addres z Expir i Dat -322 -3/i/ -Signature Telephone 8.Realletered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Numb r 2y2 `S'u��D�K ST. o�l�orr , d�o� Ad ress // Expira TelephonL t3 oo–3--&--sal 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 build! 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 ❑ New Signs [O] Decks [M Siding[O] Other p �4U2(ZJF"T/DAl Brief Descrptia LftrT/l/Al7�ff 7'e., �O��L,dt� GGZInAC.UsE /l/ 79 Work: ::Jr // Alteration of existing bedroom Yes o Adding new bedroom Yes Attached Narrative Renovating unfinished basement Yes o Plans Attached Roll -Sheet 6& If New house and or addition to existing housing, complete the following: a. Use of building : One Family�-fwo 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, �S IK 'Sr /j'/rC�lQ/ as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. /. &574pg�Ai/r u -fee 2 2> Signature of Owner Date I, �DM_`RossM ASSL 69 as Owner/Authorized Agent hereby declare 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 penalties of perjury. uss;-MAsSL.ng Print Name 7/z5 2 Sign re of Owner/Agent 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 Q DON'T KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW O 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 Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O 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 O NO 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 © NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. [3epartment use drily City of Northampton tifPE� t Building Departmentwtk% l3r►vey,frr� 212 Main Streetrlt �� ' z 2015 Room 100 WattVltetfA�++d►tltity orthampton, MA 01060 Prts Electric. Piu lPfMr31'Dr4 3-587-1240 Fax 413-587-1272 Plot1S Plant t�onr �J60 ' _. 0� 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 �17- Map Lot Unit ��✓'7''`v A. Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,5Me S 7- *4 R71 XI oem-rs /0,/z: Rh Name(Print) �T ^ ,r�I'� � �/��,(� Current Mailing Address: AMP r I AK ` w Flue•- \ Telephone Signature 2.2 Authorized Aaent: - �W S `Rass,u�ss : /Z <S'�r�=0�k 5 i AM�/�,�� Name Print) Current Mailing Address: yra -322-3111 Signs ure 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 (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 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0836 APPLICANT/CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE01040(413)322-3111 PROPERTY LOCATION 399 BURTS PIT RD MAP 30C PARCEL 034 001 ZONE SR(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 92540 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: 4ZA—pproved 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 45 Signature of Building Mkial 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. 399 BURTS PIT RD BP-2015-0836 GIS#: COMMONWEALTH OF MASSACHUSETTS MW:Block: 30C-034 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-2015-0836 Project# JS-2015-001618 Est. Cost: $2400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group ENERGIA LLC 92540 Lot Size(sq. ft.): 40728.60 Owner: ST MARTIN SHANE Zoning: SR(100)/ Applicant: ENERGIA LLC AT. 399 BURTS PIT RD Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322-3111 WC HOLYOKEMA01040 ISSUED ON:31412015 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: FeeTvpe: Date Paid: Amount: Building 3/4/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner