29-386 PARTICIPAIVIS
mass save COMACTOR
Niatita
PERMIT AUTHORIZATION FORM
I, g f L/ , owner of the property located at:
(Owner's Name, printed)
(Property Street Address) (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.
Owners Signature
`l
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 Data
Rev. 12132011
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 1t Not Applicable ❑
Name of License Holder: \a-
License Number
1a o, SQ.�, f 01 2 C)
Addr Expiration Date
OS)-n \MA- o o 3-146n- 3175D
Signature ) Telephone
•
9. Registered ome mprovement Contractor: Not Applicable ❑
C• •an Name Registration Number
J
Ad.ress 1 Expiration Date
/ ■ , I • Telephone q13-We), 31 1 0)9-69 0
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 Exemntion
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 ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding[Dl Other[01
Brief Description of Proposed ri
Work: pc() u,1 d„ ,tf 4th L- t` lao r I a tY oz' 11() ;
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 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
I, di /,, I . as Owner of the subject
property
hereby authorize 't b „'� �1 O�\
to act on my behalf, in all matters relative to work a o zed by this building permit application.
1 ei( j c
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 and penalties of perjury.
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required Zoning
c0,Iumn to he filled in 1)1\
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R. L R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage 0.0
I Ia-f area inums bldg&paled
parking i
#of Parking Spaces
Fill:
f t okmie&Locath'n)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW C� YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES (J NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO O
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 O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
� (,'�� City of Northampton Status of Permit:
Vt0 Building Department Curb Cut/Driveway Permit
2,212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability
4-P7:0,6.7.__ No ampton, MA 01060 Two Sets of Structural Plans
M° 7-kl4L vN'phonne 13- 87-1240 Fax 413-587-1272 Plot/Site Plans
(A, 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
36 Bra o k t )0c . r t 04- Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 O er of Record:
n W � � ( ( 3L, 5rvolcsopo� Driuc cIorer\«
Name(Print) Current Mailing Address: /
cciudo
Telephone ;r 1 3._5-- q,.... 5 S 7
Signature -j 75
2.2 Authorized Agent:
ifr \ at)id-4 i ,
'� � 5-� �� �I �, ,ov Name Print} Current Maili
ddress:
I ;.rte 9"% 4I —("Li) • I 3 b
Signature '' "A+ -41 Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS I
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) Check Number 7.5-5 _ 6
This Section For Official Use Onl
Building Permit Number: Date
Issued:
Signature:
Building Commi•sioner/Inspector of Buildings Date
File#BP-2013-1004
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 36 BROOKWOOD DR
MAP 29 PARCEL 386 001 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 756
Typeof Construction: INSULATE ATTIC/AIR SEALING
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 F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
N 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
deo)• Delay
l/
Signatu"Ir-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.
36 BROOKWOOD DR BP-2013-1004
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-386 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-2013-1004
Project# JS-2013-001680
Est.Cost: $1000.00
Fee:$55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq.ft.): 26179.56 Owner: LOBDELL ROGER G
Zoning: Applicant: JAY BOLAND
AT: 36 BROOKWOOD DR
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON:5/1/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC/AIR SEALING
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 5/1/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner