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18C-013 City of Northampton � Massachusetts A ` DEPARTMENT OF BUILDING INSPECTIONS y a 212 Main Street • Municipal Building �r Northampton, MA 01060 Property Address: --7'�a - / 'V/c� —1,f Contractor Name: 12 PISGAH ROAD Address: HUNTINGTON MA01050 City, State: Phone: 4 `e V Property Owner Name: 444 �44 4 Address: 7 E , / City, State: ' ' 1'/ e7 (contractor) attest and affirm that the building I intend to insulate doe� 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 y`' .-- = r' =';" I1it�'sI . ' qf In r:IsSL eyed# xtg �' ► Office Gf Tag = >�51 4FEi ?.zs -60-vion, MA 02 111 i � Wr,rkers' Compensation Insurance da - vit: �?? �3cr3` �cBtrsaciz ;rs, "�iect;iciarrsrPlum�Lrs ?applicant Information Please Prim Leg ibly Name { 'useness /0, *?lTati ^;Z.7P;ii.i-uxl): ry Ni ddr - css: City /state!Lig_ �, .; f, f ;T �' sre ��ou. ar: employ r? Check the a propria � bG,_ ` F r 1 _ ge os Frej ect (required}: ? . _r am a c- - p_171ej er t-..'tiii <�- ; t arm > ;i ` _ �rerco, r i empioyees 0.1111 and/or Puri - time). i> :t�v� s?rj r- sc r- ?is �vr =�.�` i } ti_ F f-�aw co=tuctior_ 2. I am a sole proprietor as vertty;r- 's I- of c ship and have no ctngtcryees WOrk38[ -. - iflF me m -,nv cap'la2i.:- =Z3 i�+zC v[ - =!7?� !'.�_. - •' ry n_t RY ?ii.3*I`•S 2C�L�LtiUn , [No workers comp. i1zsiuz ce � y - gtti - 5 . Q' 'v ar° Sam a sd s l i ? -3 t; 'ze ca? : or ¢dciizious ;_ Q i am a homeowner doing all woz o - by c e:�re s ri==m 1 i i -Q Pharr -bia` repairs or addifions n sef` + o vvork ers' coma- ^wi=t ci e ptian as = ivt`{r ; r ` Y N ._.Q Zna_ raaai_s S 1 _e 4� r s 4 - -- 31:i e avt 7u ( p. insurance required., � # Arty applic.:nt tha€ chmks box #1 ti usr ais3 Romconixe. -s Lvno sub. -mt this andavi - t i i-d—vas :a.n• —aa:5 --iF wv%rk t'r-- hiz-- r„aractees raa er?__ a nc:;• affidavit - ndkeling suet:. =Contractors thzE ehcck this box matm- attccbcd 2n add <ac:_.3 sh y-t s_ ,aZ2 am tf -:h_ az sv _e s,; --V - ar not fhc> - endtics have empioYCes. IiShc sttb ci, tncto s newt rssii,o3 61, ;;mss f ain art errcjrfq er tiaar s pravtt>?er_g tcvrker e€rmpe% _t irsiY ?ms . v :r a, arc Hari• s rke Pa'icy- and jnb rite WP forflAtIdon. t .r" insurance Company Marne: trolicv 3 or Sel -im- Lic. ' s 1� .}' #' . r �! - _ ir,?iiD �t Y . I -`• 1 .lob S ite Ad'dras�: A$tta Ch a ciapy at t e Ivor kimrs' S:ompens peon= =i= €tecl-gx' a is-en page f6ha Yip=3o tim pa-icy number and expiration datel - Fai?uxe to secure cavcrage as requimd Miser 5e^.:uizsa I-S o MGL c- 1 52 ca. i "'t. to the im osidon iii cizFIE?'Iial venaltie's of a fine Lip to s 1,500 -00 atncV r one-y ai rrsonmw> as Ivel I as civi comities ' corm- of a ST OP WORK OR k1? and a line of up to S25G.GG a da } against the violawr. Be t .z. a �-ss3 £}_ V s a _cement may i:e =o= nvardred to the 0?3cc of Fnvestieations of the DLA for insurmnc= co. - c�r:*--e verificatior, I do harabp cErff:6 under the pairs and pegaMAY of pei jury thaf tY`te ii : Lrrar ar vn pr aside. abrae. is trine and correct Sienatu_re. -lac: _ {t{ f?ffieial tcse- 0; Din not :> : .R ,thy Qfrn, ra _vrrr eie c = "ty rrr r;rrs z a F'ci�t 04 fIr of Town: issming Aull orit - y (circle one' 3. Board of health 2. tRuilding Depart. 3. Cir?lsti n? Cfes`i =1_ EllrD -lim! 5. Numbing inspector G. Ether SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Superv Not Applicable ❑ v p Name of License Holder /a d License Number 2Z/-Z Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name HOME ENERGY SOLUTIONS Registration / Number 12 PISGAH H UNTING ON, MA pD 5 Address Expiration Telephone 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 will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... No...... ❑ 11. - Home Owner Exemption 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 108.3.5.1. 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 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors t] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [Oj Other [ Brief Description of Proposed >f Work: d P/ a > vts C .� oe Alteration of existing bedroom Yes No Adding new be oom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. If New house and or addition to existing housin g. 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. 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 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 City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property HOME ENERGY SOLUTlONS hereby authorize 'Ann rX to act on my behalf, in all matters relat rize y this building permit app i TON, MA 01050 Signature o Owner Date We Xz as Owne uthorized ge ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my no edge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owne gent 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 Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved p arking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ® DON'T KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW © YES i IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW ® YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 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 0 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 ® NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. _ - Department use only E�EIVED City of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability o Crrows N hampton, MA 01060 Two Sets of Structural Plans 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 Property Address This section to be completed by office A/W ��� j� �., Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Re / cord : IC-c Name (Print) Current Mailing Address: kz Telephone Signature 2.2 Authorized Agent: ,Q 1 ,Q A vl K / MOMS E 2P SGAH ROAD $ sL / -/ 1 AC Name (Prin /' HU INGTON, Current Mailing Addres _ -? -� - / -K I SAX t'` Signature Telephone SECTIO 3 - CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) '' Check Number This Section For Official Use Onl Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0421 APPLICANT /CONTACT PERSON JAY BOLAND ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413) 214 -2414 PROPERTY LOCATION 304 HATFIELD ST MAP 18C PARCEL 013 001 ZONE RR(100) //RI THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz 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 101880 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF( ATION PRESENTED: 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 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 Demolition Delay Signature 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. 304 HATFIELD ST BP -2012 -0421 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Bloc 18C - 013 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2012 -0421 Project # JS- 2012- 000665 Est. Cost: $1777.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sq. ft.): 15768.72 Owner: SCANDREA REBECCA Zoning: RR(100)//Rl Applicant: JAY BOLAND AT. 304 HATFIELD ST Applicant Address: Phone: Insurance: 12 PISGAH RD (413) 214 -2414 WC HUNTINGTONMA01050 ISSUED ON :1012512011 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 10/25/20110:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner 10,2v