23D-089 (4) r
Property Address: �� '�
Contractor 's
Name:
Address:
City, State:
Phone: J� a
Property Owner r /
Name: � _ do JIc '1 TG� CL�
r
Address: I Ja rnz r `D
City, State: l
I, Jam I` (contractor) attest and affirm that the building I intend
to insulate does 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.
Contract e
Date
Rie Commonwealth QfMassachusetts
Department ofludristrial Accidents
Office of f'.Irt vesiigations
640 Mashfhgtrifr Street
Boston,MA 02_F J 7
www. nass.gov dia
iVoC ers' Compensation Insurance Affidavit: Builders/Contractors/l lectriciansrTlllmbers
APplicaat Information Please Print Le?ib
i1anie(Bssines&Urganization/individuaI): I A YQt L 440 A'�
� J
Address:
r` ;,.Scate/Zip: C� ! t �J5 ' Plllone.#: 14-1�-- 2'L
Are you an employer?Chechjha appropriate box: Type of project(required):
I.Q I am a employer with
h �. I am a general contractor and 1
employees(full and/or part-time).*
have hired the sub-contractors New construction
2.[-1_. I am a sole proprietor or pal wer- listed on the attached sheet. � ❑Remodeling
snip and have no employees These sub contractors have S. Demolition
{
n�oriang, for me in any capacity.' employees and have workers' i
y $ a. F1 Building addition 1
?�o workers'cor:tp.insurance comp,insurance.
i I
f required.] 5. 17 We are a corporation and its 1 O.j lI Electrical repairs or additions i
1. I am a Homeowner doing all work officers have exercised their 11.[�plumbing,repairs or additions
# myself.[No workers'comp. right of exemption per MGL 12. of repairs
1 insurance required.] c. 152,61(x!),and we have no
t employees.[No workers' 13.10 Other!31 S 1R.a_h 6 L
comp.insurance required.,] � f
'Any applicant that cheat's box rt ,rust also fill out the section below showing their workers'compensation poiicv inforn ition.
t rtornemmers who subrrdt this a(fidavif indicating they are doing all work and then hire outside cortra:tor must submi!a new atitdavit indicating
'Cortr_ciors that chat this boa must attached an additional sheet showing the name of the sub-contractors and state whether orric?those entities have
employees. if the sub-contractor have employees,they ruust provide their wor'kers'comp.policy number.
1 am_art employer that is providing workers'compensadefi insurance for m}employees. Below is the policy and job site
Lttj CrlJlaltQti,
Insurance Corrm
any
Narne
policy r or Self-ins.Lic. : k! L U -(�'�t_h 4 t -�( Expiration Date:
.,it)Site Address: �6- KVCt r r-
Cityr/State/Zip-_Td.re r7C
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of NIGL c. 1152 can lead to the imposition of criminal penalties of a
nine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the fortrf of a STOP WORK ORDER and a fu-te
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investi tzations of the DIA for insurance coverage verification.
1 do he fi,under dhepains and penalties ofperjui) that rite information provided above is true and correct,
si?nature:
Prone= AJ 1 G^ X21
i t?zcial use only. Do not write%r:this area,to be completed by=citjt or town ofciaL 1`
t
r' !;
f E
Cl-L"17 or`;'own: 1 ermit-License
I
issuing Authority(circle one):
[ 1_Board of Health 2.Building Department 3.City/Town Clerk. 4.Electrical Inspector- 3.Plumbing inspector
6. O tier
f '
3_ontact Person: P hone#;
i t
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Jd—me
License Number
ddress Expiration Date
Lvo
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
l i)�. f f Htltu v e tom`rJT---
72,ame n Number
Comf Registratio
Address ( ( Expiration bate
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(I) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,pry that the owner acts
as supervisor.CMR 780 Sixth,Edition Section 108.3.5.1.
Definition of Homeowner:Perso (s)who own a parcel of land on which he/she res' r intends to reside,on which there
is,or is intended to be,a one or two TuTily dwelling,attached or detached s res accessory to such use and/or farm
structures.A person who constructs mtwe than one home in a tw ar eriod shall not be considered a homeowner.
Such"homeowner"shall submit to the Buil Official,on rm acceptable to the Building Official,that he/she shall be
responsible for all such work performed under t din ermit.
As acting Construction Supervisor your pres eon the jo e will be required from time to time,during and upon
completion of the work for which this pe t is issued.
Also be advised that with referenc Chapter 152(Workers'Compensa' and Chapter 153 (Liability of Employers to
Employees for injuries not re ng in Death)of the Massachusetts General La Annotated,you may be liable for person(s)
you hire to perform wor r you under this permit.
The undersigned"h eowner"certifies and assumes responsibility for compliance with a State Building Code,City of
Northampton O nances,State and Local Zoning Laws and State of Massachusetts General ws Annotated.
Homeowne gnature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[
r
Brief Description of Proposed S
Work: W >>Q ���. >L
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.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, I �. as Owner of the subject
property rY1
hereby authorize �✓/ i�� � ��
to act on my alf, in a4 matters relative to work authorized by this building permit appli tion
Ll
iKotule ofoker Date
C ' J\ as Owner/ orize�d
A hereby declare that the statements and information on the foregoing application are true and accurate,to the best o Amy now�e�
and belief.
Signed u er the pains a penalties of perjury.
� YES �t �t S
Print Name
Signa of Owner/Agent 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 ® DON'T KNOW YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW ® YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES ® 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 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability.
Room 100 Water/Well Availability
�` ect1c ham ton, MA 01060 Two Sets of Structural Plans
amp ton,
e 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify '
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION i -SITE INFORMATION
1.1 Property Address: This section to be completed by office
5 o a r"rw r Map Lot Unit
/t (,e �,� Zone Overlay District
U Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\ C 'L /f Os en C�
Nam (Print) hh ee ) Current Mailing Address:
Telephone
Signatur
2.2 Authori ed Anent: /
a eSl�I S U '6- AL
Name(Print) Current Mailing Address. i 1
'Sig—nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building A-fr7 r /� (a)Building Permit Fee
2. Electrical `7' (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 Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0881
APPLICANT/CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESS/PHONE 142 BOYLE RD GILL (413) 863-2128
PROPERTY LOCATION 15 WARNER ST
MAP 23D PARCEL 089 001 ZONE URB 100 /
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL INSULATION&AIR SEAL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 091207
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved 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
Demol' i Delay
Signature of Building O ficial 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.
15 WARNER ST BP-2014-0881
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23D-089 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-2014-0881
Project# JS-2014-001535
Est.Cost: $4746.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. ft.): 12763.08 Owner: ROSENFELD EMILY A&JOYCE ROSENFELD
Zoning: URB(100)/ Applicant: IDEAL HOME IMPROVEMENT INC
AT. 15 WARNER ST
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863-2128 Liability
GILLMA01354 ISSUED ON:212012014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL INSULATION & AIR SEAL
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 2/20/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner