31A-108 OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
(Property Address)
6� Lc�� ,t;kW
( roperty 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.
5;-vn1<i ignature
Date
i
OWNER AUTHORIZATION FORM
(Owner's Flame)
owner of the property located at
-7 $
(Property Address) �\
( roperty 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.
Own s ignature
'�— !19-1 '-� .--
Date
Yt The Commonwealth of Massachusetts
'= Department ofditdustrial Accidents
__:J"! i Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le6jb1
Name (Business/Organization/Individual): 4 -S
Address
City/State/Zip: � 1 Phone #. __S
Are you an employer?Check the appropriate box: Type of project(required):
1 I am a employer with._ 4. ❑ I am a general contractor and I
employees (full and/or part-time).
* have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
These sub-contractors have
ship and have no employees T 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. Building addition
[No workers' comp. insurance comp. insurance.$ ❑
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.F-1 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13aOther
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the nanie of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that ispi-oviding workers'competlsatiott insurance for my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
Policy#or Self--ins.Lic.#:��•��.�Q �� �j�Q� Expiration Date:
Job Site Address: 1 � 1 City/State/Zip_CA I V VA
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do her certify under the pa' d penalties of perjury that the information provided above is true and correct.
Signature: 1v." ' Date:
Phone#- .�
Of use 01111. Do not write in this area, to be completed by city or town officiaL
-City or Town: -- - - Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Version 1.7 Commercial Building Permit May 15, 2000
4
SECTION 10-STRUCTURAL PEER REVIEW(780:CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes a No 0
SECTION 11 OWNER AUTHORIZATION'=TO BE COMPLETED.VHEN1.
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Signature of Owner Date
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.
d under the pains enZiies
of penury
ntN@me
�... _
Signature of Owner/Agent Date
SECTION 12-CONSTRUCTION:SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
_ .. __. ....�. __..., .........
Name of License Holder
License Number
Address Expiration Date 4
.Signature Telephone
SECTION 13-WORKERS'.`,COMPENSATION INS URANCE'AFFI DAVIT;(M.G.L.:cA 52ji 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 0
Version 1.7 Commercial Building Permit May 15,2000
FCONTS'TRUCTION ON 9-PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF EKLOSED SPACE)
9.1 Registered Architect:
Not Applicable ❑
Name(Registrant):
Registration Number
Address
Expiration Date
i
Signature Telephone
9.2 Registered Professional Engineer(s):
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
.. .._.._..._._. _ _.._.
Name Area of Responsibility
.......
Address Registration Number
i
Signature Telephone Expiration Date
T...-..... .,.,. _ ..,
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name:
Responsible In Charge of Construction
�..
Address
Sign ure Telephone
Versionl.7 Commercial Building Permit May 15,2000
8. NORTHAMPTON ZONING-
Existing Proposed Required by Zoning
This column to Gee filled in by
Building Department
Lot Size
Frontage _.._...r_....._. ..... ._........ . . ...,.._... _
Setbacks Front
SideL._._. ..m 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 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 ' Page and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW C) 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 0
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 Commercial Building Pen-nit May 15,2000
0
F ION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
C FEET OF ENCLOSED SPACE
r Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other
Brief Description Enter a brief description here.
Of Proposed Work: E.
SECTION 5-USE GROUP AND CONSTRUCTION TYPE
USE GROUP(Check as applicable) CONSTRUCTION TYPE
A Assembly j0JF-1-1 ❑ A-2 ❑ A-3 ❑ 1A ❑-4 ❑ A-5 ❑ 1 B B Business 2A E Educational 213 F Factory ❑ F-2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 38 ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility ❑ Specify:S eci ._...__.,___.....�......_.._.._.__._...��,_..:._ .__...__.... .__....__
M Mixed Use ❑ Specify ,
. . .....
S Special Use F-1 Specify ..... _.., . ._,.
COMP LETETHIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS-AN D/OR.CHANGE IN USE
Existing Use Group: Proposed Use Group,
Existing Hazard Index 780 CMR 34):,._.._. Proposed Hazard Index 780 CMR 34)
SECTION.6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor(sf)
1s 1st
2nd _._._.._... _......,.:... _ _.. . ..._.. .. __... 2nd
_. _._. .
3rd 3 d
th
Total Area sf
( ) Total Proposed New Construction(sf)
..........
Total Height(ft) j
- ---- - Total Hei ht ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone••Information: 7.3 Sewage Disposal System:
Public E] Private E] Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building Permit May 15,2000
Departme t use,only
��- City of Northampton Status of Permit;
Building Department curb GU'ffDnvevvay Perrrit.5
212 Main Street Sewer/SepticAvatlabrlity
p-f587-1240 Room 100 Water/Well Availabi i y JUN hampton, MA 01060 Tw Sets of Str6ctura.1PIanS
zp�one� Fax 413-587-1272 Plot/Site Plans
Electr'f to� :;r,_� Other,4666-
r � G�
APPLICA &w 4b 1 ' ,REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Propertv Address:
_..._...._. _ ..... ___._
s ap Lot Unit
Zone Overlay District
- --- Elm St:District CB District`
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:_
Name(Print) Current Mailing Address
. - ._-_.. _ -.-
.
Signature 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=0 +2+3+4+5) f Check Number
This_Section For'Official Use Only
Building Permit Number Date
Issued
Signature:_
Building Commissionerlinspector of Buildings Date
File#BP-2015-1294
APPLICANT/CONTACT PERSON URBAN& SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD01104(413)732-3922
PROPERTY LOCATION 78 VERNON ST
MAP 3 1 A PARCEL 108 001 ZONE URB0001/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building,Permit Filled out U4 r
Fee Paid V-7 Vr
Typeof Construction: INSTALL ATTIC&BASEMENT INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101877
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9A�IVIATION PRESENTED:
r 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 o " n y
Sign of wilding Qff ial 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.
78 VERNON ST BP-2015-1294
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A- 108 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa: INSULATION BUILDING PERMIT
Permit# BP-2015-1294
Project# JS-2015-002381
Est. Cost: $3989.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. ft.): 2657.16 Owner: QUINN JAMES
Zoning: URB(100)/ Applicant. URBAN & SONS INSULATION CO INC
AT. 78 VERNON ST
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON.611612015 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC & BASEMENT 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 6/16/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner