23A-221 (4) I I NEW ST BP-2016-1523
GIS a: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:23A-221 CITY OF NORTHAMPTON
Lot: -001
Permit: Building ��/�
Category:INSULATION BUILDING PERMIT
Permit tt BP-2016-1523
Project tr JS-2016-002593
Est. Cost: $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group JAY BOLAND 101880
Lot Size(sq.ft.): 7535.88 Owner: Nicholas Baker
Zoning: URB(100)/ Applicant: JAY BOLAND
AT: 11 NEW ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413)214-2414
H U NTI N GTO N MA01050 ISSUED ON:6/22/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:1184 sgft wall insulation thru clapboards
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: FeeTene:
Date Paid: Amount:
Building 6/22/20160:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
CEI 1 Dem use only
I City of Northampton Status of Permit
2 Building Department Curb Cut/Driveway Permit
` JUN 212 Main Street SewerlSeptic Availability
{I �n � e:;r ovcs Room 100 Watermee Avadty
vicenawnov vnpmw Northampton, MA 01060 Two Sets of Structural Plans
phone 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 PromoteAddress: This section to be completed by office
`ry a`u :5C— 'Qri Map Lot Unit
)r1t OCY- `` In ^ Dr- _,0 ---
•
`-�� Zone Overlay District
'� �^ ! .�•-} I Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
T \C. ►'a 2r I ` -A CO s (10 4 4 Yen(.. ( R\P.
Name( nnt) /'1{rte\ Current Mailing Address:
...0 1 i �j
Signature Telephone %-: ---
L''t" t�`'��
2.2 Authorized Agent:
Nems f' Cutter Mailing d
Sig re Telephone
,SECTION 3•ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building r' Ri( (a)Building Permit Fee
I
2, Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) 65
5.Fire Protection / ( `
6. Total=(1 +2+3+4+5) r')L �1, On Check Number ( (J
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Evading Comnvssionerflnspector of Buildings pate
SECTION 5-,DESCRIPTION OF PROPOSED WORK[check all atwlicabie)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition 0 New Signs [p] Decks [CI Siding[0] Other ICO
Brief Description of Proposed54
WorkSi
�l - A_`� �• -,�
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 addit'on 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. Propos-. quare footage of new construction. Dimensions_,,,,
e. Number of stone '
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 i City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
+kms } �� l -, _,as Owner of the subject
her
hereby be
to act my L i
to on my behalf,in all matt+ rel five to work authorized by this building permit application.
Mr( -cfr
Signature of Owner �(^tA)'}'x�� Date ��
/ t- ,as Owner/Authorized
nt <nby d-_-- - that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
. . I-lief.
Sind under the pains and Penalties of perjury.
Print Name •
�� t G
Sig o er/Agent Date __
RISE ., 60 Shawmut Road, Unit 21 Canton,MA 02021 1339.5024335
ENGINEERING www.RiSEenginaering.com
Ef9G.,,a Et:,d;:t
OWNER AUTHORIZATION FORM
(Owners Name)
owner of the property located at:
(Property Address)
tic�.hmc a. ID to b>
(Property Address)
hereby authorize IN 4'
�- ttn�
(Subcontractor) "-' C I VIE --
_.
an authorized subcontractor for RISE Engineering,to act on my behalf to o. : buing J '
UU.. b
permit and to perform work on my property.This form is only valid with a sir -. , :intact.
? _ .„,
dicau-
Owner's Signatureure
6 P - l 6
Date
SECTION 8-CONSTRUCTION SERVICES
8,1 Licensed Construction eeS��up�ervisor: ` NoLAp lirtab1a❑.-,
Name of License Ftoidar' yam { ��. � c "' � � �.
�' ' 1 \) , License Number
1 .c.> _, rte- "'1 ( GJ
Address • Expiration Date
Pr
Signatureiit, ' Telephone
t-4 lr- r. 6001- 31 3O
... ,. w.• me .,iur..v or: r Not Applicable o...
S. itQ ( O. . / I .rel 1L* O3
Com•an ., Registrati n Numbe
'*dress Expiration
' ry'� � t` ��/_ Expiration Date
'- U I s t` Y i�. 1=1, 32Cr Tlapharre(.11 3-W 1-113( a
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 win result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ? No ❑ffir
11. - Home Owner Exemption
The wtrent exemption for"homeowners"was extended to include Uwper-eccupied Dwellings of one(I) 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 789. Sixth Edition Section 10838.1.
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 faros
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 he 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,Stale and Local Zoning Laws and State of Massachusetts General Laws.Annotated.
Homeowner Signature_ i
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
rte/
Address of the work: � I `6)L7
The debris will be transported by: D,C511 ) C
Lt)
The debris will be received by: LJ v'(2am 1C,W (r
Building permit number:
PP )r tips
Name of Permit Applicant � ��.�. y
Date Signature of Permit Applicant
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