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35-049 el f twit 4 al PA/MCIPABMG r COIflRACTUR mass save Savings %hauow.noeyanid! Y PERMIT AUTHORIZATION FORM 1 , owner of the property located at: (Owner's Name, printed) c r , L 0 1(- k'. (Property StreeJAddress) (City/Town) 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. MP./ - Owner's Signatur' " 1, 1 2 Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Rev. 12132011 ,..- . .1 . . . . . . • __ ----- The Commonwealth of Massachusetts • 17.1 ...,-.-_•_. __,......_...._0 Department of Industrial Accidents • , rj MS erlintsffivirfav - r e t 43 ‘ - = 7 600 Washincrton Stre 0 ---- - „......„.....0 . 4 7.1 - • , ,,.., : Boston. Mass. 02111 ---.............4.- Workers' Com. ensation Insurance Affidavit: BuildingiPlurabinalectrical .Contractors . Y' 14 y ,,, ro ,- jo*, /, ixortmeirmwanif,4144:0,-;-/Ft-atiL----"fo. ) - '"" '''''' ' , . _ - • - - . .. , • pame: Bryan V. Hobbs Remodeling . - scitt--zss. 346 Conway SL . rea-W-0d. MA 01301 - - - - c ity • st • ate: -...,..: .:311c:me..(tif) — 7 7 5 --- 96 6.6, . . • . - . . , wok, site localion. ffali adcires . sl: . _ . . _ D I ant i homeowner text ail work myself. • Project Type: 1 1 New Const emodel . . 0 I am a sole or ovnetor - and have no one working in any CaDaCirsr. 0 Builefr Aildition WY A WIrlie/' ..altZfr4EVEN,ZAP , > . 11FAVANWffistrig . v ,3 . . - 114 .1 _ am an ernployF pro wark.we compensation ibr ..71:‘,1 ezdployees workhatz on ths.job. . . . ... itirciiiiiii' iiejt .:-‘: - --. ._ • • . . - - • ..- . . =- . .- , iiiiii3ii,d. •- -- - - -. - .1 ' - - - . - - - '"' - -' --:3 - * . - ...'" - ---- '"- ..-- • *. ; : i '':-.. - • • "' -. .- ,. '116 Camay St .-. - . • . - .• - -.---- - -- - - ."...i.c/ree•Affeid, MA 01301 phone* - • . - ...'". -- - -- • - :'6 7 .14 3) 77 6 9 i 0 6, - . . ... . . - - . - • . . -.. .- .- - _ , . • . . - irtint-apea co.- . Jo " iii., 4,4 i is __ 1 . olio .4 . ..c - 1 .- - .L . 76.67a .. • 0/ 0 • ...,,? •- '„..semearow,r,ftArwyfaesee(figozfarmiwize , , . • 4 7,, 4 - 0 i am a solo proprietor, general contractor, or homeowner (circle ;'n0 and have hird the contactors fisted belowWho . - have the following Workers' compensa police4: , - . - . • • • , ail:apart* name: • - . . • . . _, . . . . . . . • .... .•„ ,. , -. . . . . - : - - - - . - . ;, . - - 1 i‘',.::: • - •- a ddiess: • . - . - - - . .... . . • . - . . - - • -. - _ , Dbotie ii: - --. • - . . • . — f --'. -: • '." - - - - ixtiuraiice co. - •:-. .. • • - • - • - - ' - filf://;';,/--.47,v, ....',..•,...74 -..g. ..(;-' 4 ,/07 ' /.7-7-,,,-,7;,-,, --,, ;;/x: , F4r , Mi r ir-SfigtffffuirO4.'4AV, , lsriglEfeAftifMtfe/ar:4 , z•--;',- ...- ....-. , . . . ... , ::"•* - - ,: : • .-, • • ., -‘..--r ,:..,,..,.. - : . ..; , _ . . .... : fiadi-est- .--- • - - . - - . • -- . - . . . ... - . • 'diti': -- :::;-.- ..-. :-: - 1 . •.-:- '• -'• - - ' - - • - - . - - - - - - - - - - - .- ii3Sizr2hce.co; - - ; - . ... , „. . .. 1 - . . • • .. -. tolid;i4.. .--.- . :-..- ' -:. .-.... -.:-..-. .: -L„ .;:,- -;--:. - , teY-'161Iffiff e iffig.,2 ,. ;:0; ,,1'iig'.51%'''',-*gW=7/%A,; Failure to secure coverage as required tinder Section 25A of MGT, 152 tau lead to the instroSitiort af r--1 of a 4ne up to S1.„5DO.01) saltier one years imprisonment as well as civilpenalties iu the form of a STOP WORK ORDER and s rime of.S100.00 a day stgainsr ma. I undeptaad - that a quay of this state/neat may be forwarded to the Omce of Investigationsof the DTA for coverage verificatior.. ... • 1 I hereby ceriihr under theains and penalties ofperfu.rx that the information provided above is true and correct. . .. - - Siguatire blterf? 3..?., ■Sert • . Date Pr. int name r y 4 b ) 1-1- o 1-'6_5 - — • • official Mc only de not Trrili III thi.5 arge tv bc borepietodby city.: town. offiatel . '1 - CM or tovas: pe 0 cheek if immediate response is requir ed . . • . • - rmit/license* OBu - . - . ' . ildiug De.pareut OLice tat xiing Board - - OSeiectanetes Office -. .-::- -.....': .i: • IDPlealth Department . .- 0 Other • -phone t-!; • contact person: ocrasfiseTc.20Z) • . •-.. , . - .- •---, - • . . • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Bryan G. Hobbs Remodeling � 3 � A 346 Conway St. License Number Greenfield, MA 01301 Address Expiration Date / Lj4� , ^ . �. (`/(3) -77 5 Sig re Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ 13” Company Name Registration Number Bryan G. Hobbs Remodeling .7 /.2 / 3 1 3 Address Greenfield, MA Expiration D ate Telephone y/ 3) 775 ? p0 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 build' g permit. Signed Affidavit Attached Yes I 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 D Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [D] Other [fib /ti�hltsPLl'7ER ,b Brief Description of Proposed Work: C ∎ (' 5,4 C ta.'r okotiv holt, a a_t 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 addition to existing housing, complete the followinct: 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 1 , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I of � .1? (� 1M 5 Min 6d; /. 1, r , as Owner /Authorized Agent herby declare that the statements and info on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Na e /3 Signature of wner / nt 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 parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained o ,Date Issued: C. Do any signs exist on the property? YES Q 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 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 Storm Water Management Permit from the DPW is required. — E . .. . . , __ _ - Department use only r t - 4 ity of Northampton StatusofPermlt: i Fie :. uilding Department Curb Cut/Drive y permit, 5 2013 212 Main Street SewerlSeptic Room 100 Water/Well Availability oYr. of sui.o ri�%uarecrio`vs N rthampton, MA 01060 Two Sets of Structural Plans NORTHAMPTON MA 0a • • - • - 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 C, 3 6 0 R Map Lot Unit .F1- ,-y,,C;C ' Ili tt Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: . 4 j (Art.h. - v - 1i- i t 91:3 R 6 -11 f o Name (Print) Current Mailing Ad (4./i 3) 6 Teleph ne Signature 2.2 Authorized Aaent: % rya.ii 6 d b65 r e4rrotiti 1Q ` �s,. T ' - , . Name (Print) Current Mailing Address' 1 .c c 4, 4 (g13) 77 •-944 6 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 Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) d , q t C Check Number /` a OL.) This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0782 APPLICANT /CONTACT PERSON BRYAN HOBBS ADDRESS /PHONE 346 CONWAY ST GREENFIELD (413) 775 -9006 PROPERTY LOCATION 963 RYAN RD MAP 35 PARCEL 049 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ? Fee Paid / v Tvpeof Construction: AIR SEALING & INSULATE WALLS New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building Plans Included: Owner/ Statement or License 83982 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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. 1-413- 13 05..35p Bryan Hobbs 6 6 7.11-,an G. llobbs ;46 Conway Str,:et D IN — GTN - 6 - P - E ----j CT - -: v .: .• , • 4` c ..,- one (413) e. (413) 775-92:7 lio •,,- , .$f , •,. - - 1) L ±8!Ep):_ompnisuiL 2013 N° AMPTON, m 0108 FC ,._,t,C,r,:ti9, 1 " .'",''' le., L'f.;;'4,--- '''''*' • ''.. . ' .■','/ --- s , i i ^-a pktrk K 01 , 1• 4 IT'''''''' ,,-, A. 1 - .3 V...))/,, :F261..24 jfiej ..' ;P A i - . • .,/r- I , . , ,.....",.. : . . - ; , .- 1