38B-041 (2) IEDGEWOODTER BP-2017-0767
c�Is#: COMMONWEALTH OF MASSACHUSETTS
Man:Block:388-041 CITY OF NORTHAMPTON
Lot:-QOl PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-0767
Proiect# JS-2017-001279
Est.Cost: $1597.00
Epp $05.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 106062
Lot Size(s4.ft.): 3223.44 Owner: Rachel Schneider
Zoning: URB(I00)/ Applicant: URBAN & SONS INSULATION CO INC
AT: 1 EDGEWOOD TER
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
S P R I N G F I E L D MA01104 ISSUED ON:12/12/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:ATTIC SLOPE INSULATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector or 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: Qth 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 12/12/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0767
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO FNC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413)732-3922
PROPERTY LOCATION 1 EDGEWOOD TER
MAP 38B PARCEL 041 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid •
Tvoeof Constructio : ATTIC SLOPE IN A L7f�,4
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildipg PI-ns ncl ded:
Owner/Statement or License 106062
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO$MATION PRESENTED:
eV-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 PemtftVariance*
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
Signa n • of Building Official 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.
.i 2) 041
raM6Am-etxV'osaronl` rh
City of Northampton Patel �rt ntr. m.
ilding Department rn ,,� s v�r`` �
212 Main Street Sgn'erlEep or,41 ilrf 1;a °" `" iM
r, i Room 100tleTe'Svali'6I�it I OW x ` "- "` "3
/ < tiV �z Northampton, MA 01060 51i e ric -a - ".a
� ;"p •no 413-587-1240 Fax 413-587-1272 �d OS Pons �' ., a1 €-. s';'
O er`sec` i;55'5TAAL .,
i • -PLIC, ON TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1:SITE INFORMATION . "aI
1.1 Property Address: red t,ThrSsec ori{¢,6wc pie `d h oH•[<e _-•,f
r ='± w., "� _kyJntk lY£+
Zore {4veray- D(sfri "
aerro rstiEs zglerstC�i" : MF,�
SECTION 2 PROPERTY OWNERSHIPtAUTHORRED.AGENT .I
2.1 Owner of Record:
Name(ening Current Mating Address: C 1 i c oil
Telephone
Signature
2.2 Authorized Agen
YL\\X _333,, S }_._\C -(k1)'
Name Pr t)�\ Current Mailing Address:
q
Signatu -�y \ Telephone
SECTION 3-ESTIMATED CONSTRUCTION O5T5.
Item Estimated Cost(Dollars)to be - Official Use Only
completed by permit applicant .
A Building (a)Building Permit Fee
2. Electrical (b)Estimated Tot®rCost of
Constriction from(61
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection 90
S. Total=(1 +2+3+4+E) t/5L� - 15 Check Number 7'7.0,7 j
This Section For Oficial Use Only
Building Permit Number Date
Issued
Signature:
Building Commissienerflnspector of Sugdings Date
Section 4. ZONING Ali tnformatian Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This colwnn to be filled in by
Building Department
Lot Site I —i I —I I I
Frontage L. _i J L_.. _
Setbacks Front 1 I L__1
Side Lir-1 Rif I L: !
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) E Roofing C
CD
Or Doors CIAccessary Bldg. tD Demolition ❑ New Signs (CI Decks 11 Siding LiEll, Oth r[
b
Bdef Description of Proposed / it A
Work: "P-T`T 1 G- j—"Cu`41�.+ q.�J\i���'Q
Alteration of existing bedroom^Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa ifNew hous&anii-tlradditiorrYo extstinet:heusrnq, compfeta the foflow(tia:
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
f. Method of heating? Fireplaces or Wocdstoves Numberof 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. 0ocdpiain 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 TankCity Sewer Private well Clty water Supply_
SECTION Ta-OWNER AUTHORIZATION-TO
BE COMPLETED WHEN
OWNERS AGENT OR-CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ,as Owner of the subject
property
hereby authorize S--e,tz i-lV -*iS
ea- -iS n1Rs,\-b51
to act on my behalf,in all matters relative to work authorized by this buildina permit application. ll
Signature of Owner Dale ><C}
I, `V w..h V t--A\ \ - , as Owner/Authorized
Agent hereby declare that the statementsand information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the patifriand pengl es of perjury.
'ant Name
Signature of Owner/Argent Date
SECTION 8-CONSTRUCTION SERVICES
8.t Licensed Construction Supervisor: r/y� \� {NN�oottApolicable £
Name of License Holder:. 41 i te-� 1 C4� ` D __
Ucense Number
'- '5CeeS ter lell s LC (0\1%1\-- la— \' ..— el
Expiration Date
Synafine Telephone
9
:Registere tomein rovenie� i ratMr: ._ ' _. _' Not Applicable £
fir. ../'termiligsbi \ -9'k--k CS
Company Name Registration Number
Address Expiration Date
e3Telepho1 -1- JPE"
SECTION 10i WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§250(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 Yesyl... £ Na.,.,, £
} = ktati eOwuer<ttrienlitian.
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.CMR980. Sixth Edition Section 108.3$.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 strictures 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.
The Commonwealth ofMassachusetts
Department of Industrial Accidents
FS= Office of Investigations
600 Washington Street
IFS= l Boston,MA 02111
4'-..>"� www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please
se PrintLegibly
Name (Business/Orgtniaton/ndividnat): , S _ \.\S\�N,T(VA
-
Address:CpqS
%Ilia
City/State/Zip: blit Ilk\\s.% Phone#71 ] (:::k5.9.6a-,""
Are you an employer? Check the appropriate box: Type of project(required):
1 I am a employer with y 4 4. 0 I am a general contractor and 1 6. Q New construction-'e employees (full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees Thew sub-contractor have 8. 0 Demolition
working for me in any capacity. employees and have workers'
9. J Building addition
• [No worker' comp. insurance comp. insurance.:
required.] 5. 0 We area corporation and its 10.0 Electrical repairs or additions
3.0 1.am a homeowner doing all work officers have exercised th.cir 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MCGL i2.—
Roofrepairs
insurance required.]t c. 152, §1(4),and we have no —
employees. [No workers' 13Other4LS\' TT f b N
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tAo meowners who submit this affidavit indicating they me doing all work and thea hire outside contractors must submit a new ai:5davit indicating such.
:Contractors that check this box must attached an additional sheet showing the name 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 is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name_ i*,, C V % r
.
Policy#or Self-ins.Lic. #4M'z dos O&cb°yjtb 1\ Expiration Date: 1,—
i — ` - -
4 t boi
Job Site.Address:\ t `CC-1'4 it0C 1 `a Cityi5tate/Zip' -(hl..E 1"4tiA
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
the 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 fait
of up to$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Ido hereby cerSfy unit, aa:•• and pena -',s ofperjuiy that die information provided above
`;i��t"true and correct.
Sin.ature: �s,� � o�y� Date: A\95'.Y,',..) t
tcas
'hone 41: D-" *J
• C d—„a. ,
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License 4
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3. City,'Towu Clerk 4.Electrical Inspector 5. Plumbing Inspector
•
6. Other
Contact Person: Phone 4:
City of Northampton
-'-F Mas$achase_tt=
(F
g.t
) r S S a it DEPPRTfZNT OF HOILDTNG WSHECTI@1S n. 7
t,t! _T., 7 212 Mall Street • Municipal Building
,, Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner . Assistant Commissioner
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 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 home owner."
The building department for the City of Northampton wants any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, 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 permits 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
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 •
•
•
0
City of Northampton 212 Mair, Sfreet, Northampton, MA 01060
Solid Taste 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 MOL c 111, S 150A
Address of the work: A t 5E..
The debris will be transpoled by: Rit
The debris will be received by: S---<e JAL\ C
Building permit number:
Name of Permit Applicant � \�
Date Signature of Permit Applicant
Property Address \ Era-t_2. 0 t-R
Coacior
Name: v\ i"T\WOt
Address: ;
3�S � .� S
Sc.')
``— -
City, State: S �Q f
Phone:
Name:
Owner (� -Sc \ Sc\A"C.-WY2
Adds;___ _ _ \r' ��?--' --------_._.-----------
city state: O lo\u:. ' Nam e 0\t
I, \[', a (contractor) attest and aWnm that the building I intend
to insulate does not have any open-nr .b and tube)wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavit.
Contractor signatu -
Dai \\ ��
RISE60 Shawmut Road, Unit 2 I Canton,MA 02021 1 339-5024335
ENGINEERING- www.RISEengineerin9.com
FHkkncv=..o:cac
OWNER AUTHORIZATION FORM
R ACEI E L 5cfhv4-r
(Owners Name)
owner of the property located at
I f kDcob IW.
(Property Address)
c�(Property Addresss)),�, (-.11
1 `\
hereby authorize \� 1� 'C ttrOt �YN5�1 \AS1 1tIA
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
Thar Permit will be secured by the insulation contractor, at no additional cost. It is the homeowners_
responsibility to close out this permit by contacting their municipality at the completion of this work.
Owner's Signature
1 nI 01 (x,
8.7016