38B-131 (3) OWNER AUTHORIZATION FORM
TIE
(Owner's Name)
APR 222015
owner of the property located at
(Property Address)
0
(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 prope
L
Owner's Signature
Date
i
OWNER AUTHORIZATION FORM
I,
(Owner's Name)
APR 2 2 2015 '
owner of the property located at
(Property Address)
A% O C6
(Property dress)
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 prope
t
Owner's Signature
Date
I
Property Address:
Contractor
Name:
Address: b
City, State:
Phone: 3 I '"1
Property Own! \
Name:
Address: d�
City, State:
1, ntractor)attest and affirm that the building I intend
to insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavit.
Contractor signature
Date
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines"Homeowner'as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or iwo 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
home owner."
The building:department for the City of.Northampton wants person(s)who seek to use
the home owner exemption-to ad as their owa construddowsup&*isrn -to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the.building'department be called to
inspect work at various stages,which include foundation/footings(before backfill),
sonotube holes (before pour),a rough building inspection(before work is
concealed),insulation inspection(if required)and a final building inspection.The
building department requires these.inspections before the work is concealed,failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical,plumbing&gas)-the
homeowner will be.responsible to make sure that the trades hired secure their proper
"-ts in conjunction to the building permit issued,and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above
.(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to-me.
Date
Address of work
location
T
The Commonwealth of Massachusetts
Department o,f lndustrial Accidents
Office of Investigations
600 Washington Sired
Boston,MA 02111
+ www.nurss.a ovIdia _
-Workers' Compensation Insurance Affidavit:Builders/Contractors/Flectric a.ns/PIumbers -
Applicant Information Please Print L Iv
Name(Business/0q=izarionRndividua1): '
Address~`= - 1
City/Statevzi \ Phone.#:
Are you an employer?-Check the appropriate box: T of o ect r
4.. I am a general contractor and I 3'Pe Pr ] ( e4 =
am a employer with _ ❑ 6. ❑New conshuction
- employees(foil and/or part time)# have lured the s��lb-contractors
2-❑ I am a sole pioprietor or partner= listed on. e attach ed sheet 7. ❑. e $
ship;vd.have no grployees �e have -8. Q Demolition
wo far me in eWlo_yeesapd_bgye workexs'-
r�n$ �qty. _ _inc�aanrr .. "g��
[N&WeArew comp-insuzance i o_ or additions
regna�] 5- ❑ We are a corporation and its ❑ r�
'3.❑ I am a homeowner doing all work rk officers bava excised ttreu - 11.Q Pkiab*- epairs or additions
ti.*of exempdo i per MGL
myselt[No 'comp- F-15i,§1(4.1 and"we have no 12-[3.Roof
. [Id • 13.
_ Cpl - o workers'.
comp-insurance requim ) =
'�3'aPPficant�nt eheda box#1:n aratao fill out the swt iea bdowshowmg emir s'compa wtion Policy dos=
t Homcowaess svho submitthis a$da'-,1ndicaia►g they are demg all wmk and then ham outside sanvactxs mmst submit a new-afftdavitindic:rting sum.
tContYactor that ctxcic#iris box mnmamx&cd an adffid= sleet;bowing the nana:of the subtanaaaas and sent wbedararmc-1 ww=dties have
eu ployem Zthe sob-cnnc>cm#s hire employed t5er MUStP°° 41* coup--PTic Ysumber -
Jam an axployer that bpmvidi>,worken'coixparsadoa b urmtce for-i iy employers Below is the policy god job.-site
information.
Insurance Company Name ��-
Policy#of Self ins.Lic:
• v
Job Site Address:
Attach a copy of the workers'-compensation policy deebrafion page(showing the pgUcy number and expiration,date
Faihae,to secure coverage;as requu °under BeCfroan 23:K of MG2`c 132 can&ad to the ini>posznori'ofc pees of a
fine up to$1,500.00 and/or one-year,imprison'as vmll as civil penalties is the farm of a smp-WORK-QRD R an&-a fine
of up to$250.00 a-day agaf nst the v ohitas Se advised t1mt a copy of this statement maybe fai warded tq tide Ot Ct of :.:
moons oflhc CIA fot'm manse cauerae xcion: - _ --
I do Tier rutder they _ rJury:flrafthe information rrovidedADM6
Phone#k
- - '- use only. Do not write in this area,to be comp- - bp.�or town offrciaL
.City or Town: PermitUceim#
Issuing Authority(circle one):
.-1.Board of Health 2-Building Department 3.City/Town Clerk .4.EIectrical Inspector 5.Plumbing Inspector
9
6.Other
Contact Person: Phone#:
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......CK 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 10835.1.
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 it 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 baildine 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
SECTIONS-DESCRIPTIO* PROPO.S WORK=fcheck.alfaaol caml
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[O] Other
Brief Description of Proposed c .\ C \ hs: _
Work C_ v
Alteration of ebsting bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
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. Masschedc Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. fioodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. WilP.buikfing conform to the Building and Zoning regulations? Yes NO.
I. Septic Tank City Sewer Private well City water Supply
SECTMN 7a OWNER AM1011MAMI I+f O E�Gdi1!*f -WHEN
OWNERS ADEN O CQWl1RA WR—APP.E IEB.Fiflff Ulf.E3jIi S ERMl7-
1 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
t as Owner/Authorized
Agent hereby declare that the statements acid information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
?wed under �pa�in�s a Ities of perjury.
Print Nam
Signature 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 Departn-n
Lot Size
frontage i
Setbacks Front
Side L:= R= L:= R:=
Rear
Building Height +�
Bldg.Square Footage Ila
Open Space Footage %
(Lot area minus bldg&paved _a!
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES Q
IF YES, date issued:1 �
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I Page Document#
F
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained ,Date Issued: I M
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 0 NO Q
IF YES, describe size, type and location:
E. Will the construction ad"disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
dullaing Department L" T
212 Main Street
D
--��(rte Room 100
rthampton, MA 01060
JUN 12 ZO�ton� 587-1240 Fax 413-587-1272
Electric, rt UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
q o
Nort
SECTION 1_sITE INFORtYInT1oN:.
1.1 Proaerty Address: This section to be completed-bvv offlce
p Lot 17n
`�one � Oj�Distnct
SECTION 2 PROPERTY OWNERSHIP/A1fiHa1tF�EQA6ENT.
2.1 Owner of Record-
Name(Print) Current Mailing Address
Signature Telephone
2.2 Authorized
3 --\ r
Name(Pri Current Mailing Address:
Y
i ature Telephone
SEGTION 3 ESTIMATEDCONTJtIJCTION
Item Estimated Cost(Dollars)to be - t?Ificiaf Ilse W.
completed by rmit applicant
1. Building
( �BLi�ing�?eFritit Fee
2. Electrical
(b),:g ated Total Gist of
_-.Construe ion frori-
3. Plumbing Buitdtng Pertnitl=eess -
4. Mechanical(WAC) -
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This.Section F�iala se Only
Building Permit Number te
r.
Issued:.
Signature:
Building Commisstonerllnspector-uf Hur7dirlgs : Date
File#BP-2015-1295
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD01104(413)732-3922
PROPERTY LOCATION 22 EAST ST
MAP 38B PARCEL 131 001 ZONE URB000)/
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 101877
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I MATION PRESENTED:
NF
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
Dem Delay
Si re of B dmg ficial 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.
22 EAST ST BP-2015-1295
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B- 131 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv: INSULATION BUILDING PERMIT
Permit# BP-2015-1295
Project# JS-2015-002382
Est. Cost: $3655.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. ft.): 5009.40 Owner: FEMIANO SAMUEL&P COONERTY C/O DAVID R HOLDEN
Zoning. URB(100)/ Applicant: URBAN & SONS INSULATION CO INC
AT. 22 EAST 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 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