32C-121 (7) • alin't
mass save COIIMACTON
PERMIT AUTHORIZATION FORM
1, Jon , 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.
Owner's Signatu
L/cy
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
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 1 Not Applicable ❑
Name of License Holder: 3 �L.D 1�t\
License Number
1a -� S :--6,-K.„-tin c-6 lr1A 6I65) i Cpl 2 O
Address v? l Expiration Date
< v
e; 413 - (�(o?- 3 u
Signature '.',.2-','"/ 0 ' Telephone (
p � �1 Di I /14
9. Req'stered Home Improvement Contractor: Not Applicable El LZ r1Qa l� v a� S (12 4 LeO 3
Co an Name Registration umber/ t.) &(1 --2,
IC — 1 3...r fr\' -g00_01 fit("1_47nyY\OM .bi 0,St)
Address Expiration Date
y P Telephone 7(3`6 -7"
6 Qi F
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 I3 No ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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) Er— Roofing ❑ ,
Or Doors D
Accessory Bldg. ❑ Demolition El New Signs [O] Decks [[] Siding [0] Other[0]
Brief Description of Proposed JJ �
Work: q
�r
�- ( Csv� �* CLC Y.s.e' -ACC
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
, as Owner of the subject
property
hereby authorize J /3D I - ( u ► EI'1j SCI J
to act on my behalf, in all�rs relative to work authorized by this building permit I ation.
C
Signature of Owner Date
( r,I, r , as Owner/Authorized
Agent hereby de are 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 �
` 4**. Date
�r r/ (�'; I -77, Department use only
� (�� �'' City of Northam• j Status,of Fiermit:
Building
r , g Curbrqut! riveway Permit
1
I 1 OCT 0 212 Main St=-t ` Li(' p
�,,� � 5 � �� � • S �(}� Sew��l$ •tic Availability
, 1 Room 100 Efg r Watea-th-II Availability
I Northampton, M' 0 I UItPI'"mbin T.vot Se of Structural Plans
Electric, Plum ri g 8 I r.c,n0N5 rtha 9`� Gs in.._c
North n -ror r^ ,,: none 413-587-1240 Fax 413- : -- :. aaq or,;,;oi#1-i•_ Plans
Other •ecify
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
o ' 4- {-Gz..-�!—d Map Lot Unit
71(7 Hi A- j--. (Y1161- o 6(''''s3 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ff
Name(Print) Current fling Address
CaTitthaf Telephone
Signature
2.2 Authorized Agent:
(5b{k
Name(Print) Current Mailing d ess: D t O}
`" , r3-661 3136
Signature „ ag Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /" C V/� r) (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 tp?g— (
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0463
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 20 FRUIT ST
MAP 32C PARCEL 121 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out E E rte"
Fee Paid �J(Yd Vv
Typeof Construction: INSULATE&AIR SEAL ATTIC
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 LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ORMATION 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
dieyrZ
Sig anature 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.
20 FRUIT ST BP-2014-0463
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 121 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-2014-0463
Project# JS-2014-000801
Est. Cost: $600.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq.ft.): 10497.96 Owner: DAN JEFFREY A&TALA R ELIA
Zoning:URC(100)/ Applicant: JAY BOLAND
AT: 20 FRUIT ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
H U NT I N GTO N MAO 1050 ISSUED ON:1 0/1 7/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE & AIR SEAL 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# 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 10/17/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Louis Hasbrouck—Building Commissioner
f