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43-151 172 GREENLEAF DR BP-2018-1148 GIs 9: COMMONWEALTH OF MASSACHUSETTS Mav,Block:43- 151 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cateeorv: INSULATION BUILDING PERMIT Permit BP-2018-1148 Project JS-2018-002068 Est. Cost:$5940.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor., License: Use Group: URBAN & SONS INSULATION CO INC 106062 Lot Size(sq. ft.): 47175.48 Owner: HUGHES KRISTIN zoo Applicant: URBAN & SONS INSULATION CO INC AT. 172 GREENLEAF DR Applicant Address: Phone: Insurance: 385 LIBERTY ST (413) 732-3922 WC SPRINGFIELDMA01104 ISSUED ON.5/4/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.ADD INSULATION TO ATTIC 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 4 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 sienature: FeeTyDe: Date Paid: Amount: Building 5/4/2018 0:00:00 565.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner her Departmenf use only. ton p Suis of Permit � .> Building pa Curb ment CuCut/Driveway Penni - 3 "m St aet Sewer/Septic Availability Roo 10 Water/Well Availability r' M 01060 Two Sets of Structural Plans Fa 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION t-SITE INFORMATION 1.1 Property Address: I7 /,!57/Thhiissection to be completed by offi �i�C.lF A \ \� Mapes Lot � Unit \A1-�I"^^^1�tNtt Zone Overlay District Elm SL District. CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner Rem ` \ l \S�lr\ CSS '11,1 a C"s (2ItA� R Name(Print) Current Melling Address T"I phone Signature 2.2 Authorized A en ` r, Name(Print Current Mailing Atltlmss: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a)Building Permit Fee 2. Electrical (b) Estimated Tolal Cost of Construction from 6 3. Plumbing Building Permit Fee /r 4. Mechanical(HVAC) 00 5. Fire Protection ` 6 Total-(1 +2+3+4+5) J L Check Number y� This Section For Official Use Only Building Permit Number. Date Issued Signatur . Building Com ssianermrepector of Buildings Date EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) a. Q9VOCIEr1 Sectional. ZONING All Information Must Be Compl?ted. Permit Can Be race F.eTo I�ncodmyplyete Informatio Existing Proposed f R fAld�ndin fi M ' Budding Depemnwl _...__ .. .. 0110 MM In T4 Lot Size n-r.:c 11u'a1 Frontage Setbacks Front - Side L R: L R: _..... Rear Building Height Bldg.Square Footage """ % Open Space Footage % (Lot arcs minus bldg&paved .. Parricurg) #of Parking Spaces -- Fill: (mlume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DON'T KNOW � YES O IF YES, date issued: IF YES: Was the permit recorded at thetttR��eeggistry of Deeds? NO O DONT KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW OiDN YES IF YES, has a permit been or need to be obtained from the Conservation Commission? �''1 Needs to be obtained O Obtained , Date Issued: C. Do any signs exist on the property? YES © NO CY IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO IF YES, describe size, type and location: E. VuII the wnstmclion activity disturb(clearing, grad ng, excavation, or filling)over i acre or is it part of a common plan that will disturb over t acre? YES © NOIN IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [m] Decks [0 Siding[1-3] Other BrieWo Descripticn of Proposetl ��7 S TW�� —T-z5 iI� (_ Alteration of existing bedroom_Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Be. If New house and or addition to existing housing, complete the following. a. Use of building One Family K 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. Masscheck Energy Compliance form attached? h. Type of construction Is construction within 100 ft.of wetlands? Yes No,. Is construction within 100 yr. floodplain_Yes_No I. 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, as Owner of th to t property hereby authorize�_�]y- � 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. Signed under the pains a enalties pfber�ury. e Print Name n� Signature er/Agent Date SECTION 8-CONSTRUCTION SERVICES , 8.1 Licensed Construction Supervisor: No(t A�pplica(bl�e ❑ Name of License Holder License Number 1 � Addre \ Expiration Date Sig ature Telephone 9.Repaiystteered�Ho`me Improv m nt Contra`ctor, ` Not Applicable ❑ Company Name Registration Number Address Expir �Dat� Telephonl SECTION 70-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 building permit. _ Signed Affidavit Attached Yes..... No...... ❑ City of Northampton Massachusetts FP's' 9fck DEpARTHENT OF BDILDZNG INSPECTIONS � a 212 Hain Street • Municipal Builtling i' n Northampton, MA 01060 AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes. Prior to performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the`reconstruction, alteration,renovation,repair, modernization, conversion, improvement,removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be done by registered contractors. Note:If the homeowner has contracted with a corporation or LLC,that entity must he registered. Typeof WorkESL Cost:S Address of Work:\ Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law(explain): Job under$1,000.00 _Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE ROME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY"FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner. �-,, �t kc)— �� 5L) 1� ���� I ) Date Contractor Name HIC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton s . Massachusetts F t DEPARTMENT OF ROLLDING INSPECTIONS k 212 Main street •� Mmicipal Building Nor ham C� pton, eVA OlOfiO Massachusetts Residential Building Code Section 110.R5.1.2 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. Section 110.R5.1.3.1 Any homeowner performing work for which E.building permit is required shall be exempt from the licensing provisions of 780 CMR 11 QR5, provided that if a homeowner engages a person(s) for hire to do such work, then such homeowner shall act as supervisor. 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 persons) you hire to perform work for you under this permit. City of Northampton Massachusetts ® ` '�. D212 RTMENTBaine OF BUILDING amunini INSPECTIONS 5 212 Hain Street aMunicipal Building Northampton, rw OlOfiO Debris 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. The debris from construction work being performed at: (Please pant house number and street name) Is to be disposed of at: (Please print name and location of facility) Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) Signature of Permit App Ic o caner Date If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. The Commonwealth of Massachusetts Department oflndustrial Accidents 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 Legibly Dame(Business/OOrrgganization/Individual):�� Address:,-( ��� City/State/Zip: _ Phone#� � � "<� Are you an employer? Check the appropriate box: Type of project(required): L'S I am a employer with\ 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a coronation and its required.] officers have exercised their 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [Vo workers' comp. inrance required.] 13.� suOther 'My applicant that checks box kl 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 mew affidavit indicating such - tCommeters that check this box must anached an additional sheet showing the name of the sub-contmeare and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and jab site information. ` Insurance Company Name Policy#or Self-ins.Lic.#:�alrj��Z�nQQ0�p ,6`t��i_�+ 1\R Expiration Date. Job Site Address: �� �1C7�V hi'_ City/State/ZifTl'�Lt��-1b 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 51,500.00 and/or one-year imprisonment, as well as ci%il 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 hereby certify under! s and penaltie. etyury that the information provided above (issttrue and correct. Simature ���' �y _ Date: IL Phone#: - OD— ,�� \ `11 Oficial use only. 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#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)camels),address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are.required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and trader`Job Site Address" the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia a ; - Permit Authorization mass save- Form Site ID: 3353262 Customer: Kristin Hughes 11 owner of th a property located at: (avmer•s ame.o�meal 172 Greenleaf Dr Northampton, MA 01062 Ie:WyMStrettFdd.essl (CM) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. Owner's Signature: Date: FOR OFFICE USE ONLY We have assigned the following Mass Save Home Energy5ervices Participating Contractor to the above referenced project: OVA Participating Contractor Date Name: CLEAResult Phone: 800-480.7472 Email: rnr once u:e only Rev.302015 Scanned by CarnScanner