17A-093 /40-?it
PUTICIPOINS
mass save conmeroa
Savatirx v1,0 401,111 SY oftx...4.y -
PERMIT AUTHORIZATION FORM
'T E/2-0\-( ()n il/Z , owner of the property located at:
(Owner's Name, printed)
c iz,1'n (AA- ,ot ;oi
(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 Signature
M/5/0
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: Not Applicable ❑
Name of License Holder: /
DI 2Os
le) P) Number
S o ��h � c License D-7
e s
Expiration Date
Addr
( 3rd 0:c6
Signature Telephone /
• elliigNie
9. Re ere Home Improvement Contractor:
9/V CO Not Ap lic,a^ble
Company Name ( Registration Number
)SO C-h leoa d j 0 D. S
Address Expiration Date
,T-1,44\ ---pn MA D I OCD Telephone 6//3 4L/ -di/ft/
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 buildi 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.
Defmition 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 0
Accessory Bldg. ❑ Demolition El New Signs [0] Decks ED Siding[0] Other[D]
Brief Description of Proposed 6r r 042141 0��44+) /� ,/� �� e Work: c� , (�/x 1.x (.c.� r s < C
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. Numker of rooms in each family unit: Number of Bathrooms
ti
c. Is there a garage attached?
d. Proposed Square footage of new constr .ction. Dimensions
e. Number of stories? --.,,
f. Method of heating? `�_ i -'laces or Woodstoves Number of each
g. Energy Conservation Compliance. Massch. k Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is constructio• 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 Ta-OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I ( Q-((L u 1 as Owner of the subject
property 1 `(
hereby authorize , CJ)&W,
to act on my behalf, in all matt rs`relative to work authorized by this building permit application.
�`
Signet.e of Owner Date
I, \Q (50)&4-d t-141; S S , as Owner/Authorized
Agent hereby eclare that the stateirnents and information on thr� L-61
r going application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and pe f alties of perjury.
1 Prli NI a/AC
Print Name I
..--.x. i 1 DJ-) i I
k' • a
Signature of Own- '.'.e Date
Department use only
City of Northampton Status of Permit:
"' P., Building Department Curb Cut/Driveway Permit
v y` '"} 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Csi
M , , Northampton, MA 01060 Two Sets of Structural Plans
"c. 1l1 phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLI•,TION 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
ry(
&ia.i•cc v(E 1 �i Map Lot Unit
�Y Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-re.( ' .a rr C�Lftd cJ(.E ,S- . . �t/ncz, r'
Name(Print) Current Mailing Address:
al ' Chi. i Telephone ` �f c c
Signature pl -� � O �J
2.2 Authorized Aient: r I
Ait, 4D -fr*-)a. -0.tali. A -AA A tla-100__S
Name(Print) Current Mailing Address: f1 ) J
41 erdimoc t4/3-D( Lf- i/(L(
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ) Cg Db, 60 (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 A it , ,C;
6. Total=(1 +2+ 3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0665
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 24 GRANDVIEW ST
MAP 17A PARCEL 093 001 ZONE RI(I00)/URA(100)/WSP(58)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out gL q
Fee Paid i�
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
INFO MATION 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
_ 41K /`°7- r:—/f
Sign e 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.
24 GRANDVIEW ST BP-2014-0665
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-093 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-2014-0665
Project# JS-2014-001142
Est.Cost: $1800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq.ft.): 11630.52 Owner: CARR CHARLES J&TERRY A CARR&CHRISTINE M CARR
Zoning:RI(100)/URA(100)/WSP(58)/ Applicant: JAY BOLAND
AT: 24 GRANDVIEW ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON:12/5/2013 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 12/5/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner