11A-012 47 LEONARD ST BP-2019-1030
CIS 0: COMMONWEALTH OF MASSACHUSETTS
Map:Block: I I A-012 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TTOTTHE
TGUARANTY FUND
D((MGLL c.1144/2�A))
Category INSULATION BUILDING 1LDI \ V 1 ERMI 1
Permit# BP-2019-1030
Project# JS-2019-001688
Est.Cost$4896.00
Fee: 565.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group URBAN & SONS INSULATION CO INC 106062
Lot Size(sp.ft.): 43560.00 Owner.- EMRICK JOEL C&MARY LEE
Zoning: URA(100)/ Applicant: URBAN & SONS INSULATION CO INC
AT.- 47 LEONARD ST
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON:3/20/2019 0:00:00
TO PERFORM THE FOLLOWING WORK 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: Jy 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 3/20/2019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
` KLUtIVrbPw+fi ?"b
City of Northa pto P it
Building Depa men Curti: Permit '
. ; 212 Main Sir at MAR G 0 2 dy
Room 10
Northampton, M 010 ° nf' Plans
�\ phone 413-587-1240 Fa 41�FFn{ 'mNms P
SM
Specify—
APPLICATION
Pee(b
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION P l(] 3d
1.1 Property Address: This section to be completed by office
MapLot ��a Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Own r R ord:
Joh CawZ\ C \,
Name(Print) Current Mailing Address:
Telephone -c—
Signature
Signature V U T J
222AutA OoNzetl Agent
Name P t) Current Mailing Address:
Slgnatu aTelephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
wm letedb mr-itapplicant
1. Building (a)Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Oficial Use Only
Building Permit Number: Date
Issuetl:
41�fSignature: 3- 20' 26(9
Building Commissioner/Inspector of Buildings Date
a�coo
EMAIL ADDR���9S,,.((__REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
�irtu7 / r[LG/P' (Jr �ZGln& ��/ /
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 Detriment:
Lot Size ......_.
Frontage ............. _
Setbacks Front '
Side L - R: _ . L: R
Rear
Building Height
Bldg.Square Footage
Open Space Footage _.
(Lor area minus,bldg&paved
adari .. ._ _. _.._._._..
#ol'Parking Spaces -
Fill:
rolmne&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DON'T KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW O YES
IF YES: enter Book Page '.. and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW (D YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O ,Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO I&
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
IF YES,then a Northampton Ste"Water Management Permit from the DPW is required
SECTION 5-DESCRIPTION OF PROPOSED WORK Icheck all anolkablel
New Hoose ❑ Addition ❑ Replacement Windows Alteration(.) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs (O] Decks [p Siding Olher[II]]
Brief Description of Proposed
Work «
Alteration of existing bedroom_Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ea. N New house and or addition to existing housing, complete the Mlowina:
a. Use of building Only Two Family Other
b. Number of rooms in each family unit. Number of Bathrooms
c. Is there a garage attached?
J, 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?
Il 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? 3�j,, Yes No,
I. Septic Tank_ City Sewer_ Privalewell_ City water Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owne§of the sublproperty
egt
hereby authorize V\� �'�+\�S ^ `_'�' `v �D `\1 `���� y \ \\\�
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Data
\ \\
hi
�\ � \ he Owner/Authorized
Agent her by 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 and p ties of pepu
O
P me
Date
Signature of Owier/Agent
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /' \N 1 Not Applicable ❑ D'�1
Name
oof.Umnse,Holtlar[:�l-��--
LicenseNum\d-� � � 1
Alo ess Expiration Dale
Signature Telephone
9.RealoWred Home, m f i r. Not Ap Ilcable ❑
NlCZ�4
Company Name Registra on Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L, c.152,§25C(8))
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...... ❑
I
City of Northampton
Massachusetts
u
s
DEPARTNFNT OF BDZLDZNG ZNSPECTZONS
212 Main Street a Municipal Building
c°
xorueeptnn, em olaoo
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 cnuacted with a corporation or LLC,that entity must be registered
\5
Type of Wm--- rV,.S� l`� Est. Cost:
Address of Work: `�l
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 HOME 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:
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
Massachusetts
c
i
DEPARTMENT OF NOLLDING INSPECTIONS A F,
212 Main Street a Municipal B iltling
Northampton, Ma 01060
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 a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.R5, 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 person(s) you hire to perform work for you
under this permit.
__ City of Northampton
s s
+�' Massachusetts
( DNFANT T OF BUILDING INSPECTIONS ,Ykr
212 Nein SCrae[ Municipal Building
NorthwptOn, !W 01060 Yy"yj\0
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 print 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 Applicant or Owne
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 C \ Please Print Legibly
Name(Business/Organization/Individual): .�J�N-S
Address:3�s
City/State/Zip:SY''L- ) %,�\'4�, Phone #:
Are you an employer?Checktheappropriate box: Type of project(required):
l.� ',`I am a employer with� 4. ❑ I am a general contractor and I 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. T 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10. 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. [No workers'
Other—
comp. insurance required.] 13.® Other
*My 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.
iCmdu caul that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workerscomp policy information.
I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site
information.
Insurance Company Name: lit �L
Policy#or Self-ins. Lie.#:'S(j\MZ�_eO�ROS>,_ 55 {Expiration Date:`
Job Site Address:
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 a 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 hereby certify under td penalties ofperjury that the information provided above is true and correct.
Sumant en. Date' \-a,
Phone#:
Oficial use only. Do not write in this area, to be completed by city or town of
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)name(s),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 retumed 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 per-mit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"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
Fax# 617-727-7749
Revised 5-26-05
www.mass.gov(dia
Propertyaadrosa: h� -�1�al PISP s�
Conuad"
Nam
city, state:
Phone:
Maine: Owner � 1C, 1L
city,state: l� O` 5
(contractor)attest and aNam that the WkUng I etterd
to insulate does not have arty open air(knob and tubejwing ffi-the spaces to be atatdaffid and
ttrat I have provided the property owner with a copy of the affdaw2
Contractorstgnattrre p .
Pate.
XI
OWNER AUTHORIZATION FORM
I, Joel Emrick
(Owners Name)
ovmer of the property located at:
47 Leonard Street
(Pmperty Address)
Leeds, MA 01053
(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 property.This form is only valid wHh a signed contract.
Owner^ Signature
ff C/
57—
Date —Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton,MA 020211339-502-6335
v .RISEengineering.com