31A-168 (2) • F
Property Address:
Contractor ; `\C 1
Name: \
Address:
City, State:
Phone:
Property Name:
Owner
Address: �v� ,!' �
City, State: \
(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.
Contractor signatu
Date
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The state of Massachusetts allows the homeowner the right under 780CUR 108.3.4 to
act as his/her construction supervisor. The state defines"Homeowner"as, "Person(s)
who owns a parcel on which he/she resides or intends 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."
The building department for the City of Northampton wants person(s)who seek to use
>rst uc ion su_ " `*to-be aware that
the home owner exemption,-to ad-as their owff co pervrsor,
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the-building department be called to
inspect work at various stages,which include foundation/footings(before bac II&
sonotube holes(before pour),a rough building inspection(before work is
concealed).insulation inspection(if reanired)and a final building inspection.The
building department requires these.inspections before the work is concealed, failum to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical,phunbmg&gas)-the
homeowner will be-responsible to make sure that the trades hired secure their proper
"-ts in conjunction to the building permit issued,and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
1, understand the above.
.(Home owner./resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued tome.
Date
Address of work
location
s T
The Commonwealth ofAfassachusetts
Department of Industrial Accidents -
Office oflnvestigations
600 Mdshington Street
Boston,AKA 02111
www mass govtdia
-Workers' Compensation Insurance Affidavit:.Bntiders/Contractors/Etectricians/Piumbers
Applicant Information Please Print LegIN
Name(Business/or onam&viauat)
Address.�� \,;�;L�<T) .,S—k r
City/StatelZip�S��'Lil� A-4 � �. Q�-Phone.#:
Are you an employer.-Check the appropriate:box~ Type of project(required)_-
1.R I am a Employer with 1 4.. [] I mm a genet contractor and I
Io-yees{fitil and/ part-lime).
s have hired the sins-contractrns 6. ❑New arnstru�ction
2-E] I am a sole proprietor or partner- listed on-the.attached sheet: 7. 0 Remodeling
These sub-contractors have
- shi�r�have rm�yees -, -8. F1 Deiao2ikiom -for me m
co W06=7
workeas'.
� ' on
ENO wDTMS-,eomp-ffi=zwe - _.�C13n]p.inc�ira„cr#:; -. - i0.� -
j 5. ❑ We are a corporation and its Etec�ical repass or additions
,3.E1 I am a homeowner doing all work officccs Isavz etitised then 11.Q P2embiag repairs or additions
mysel�[No 'COmp right of excrokaii per MGL 12.0.Roofrepairs
insurance rti�oirefl f - 0: 152,§1(41-and we have no
employees:[No works' 13_ Other
y. #1 L L�coumyp.msazay=reTilire&I
i1►ny appt�at ghat clsecks'b= -maEAw t�oa�.�m bdow+lalwQg RGi/:
ftt,,."`•JS.00DwwIIeSSwhOs&x&thisambiL gdwyxm deiwallvmka®dtvCIIbireodSi�C0�9C Sm115tsubmftamw!aTdavit*b&csfIIg=& .
'l.OAt<aGtO[S lbat CbCCIC this boa mwt.attacbed w additional Amxt sbow=g the name Of d1 C S bCMWAa 5 wd bave
e�Pb 'kdwsut,. cloy bxie=Wkyemtbcymiwpvn&*=wmi=eco,.q,.poridyxumbcr.
f aw an mphyer that iaprovWj .-workers'compemadon&su ancelbr ivy ewplayees Bdaw is the policy cnd job-s&,e
iuforraarBoas.Insurance Company Name
Self-ins. r
Eagnration Date:Policy m y .
Job Site Address LC" 1'�.` 'I 't-�►�� � Cit t3trJLip�t
Attach a copy of the workere''compensation policy dedaration pages(showing the p9rtcy ntnnber and ea station date
Fait are.for secure coverage;as egtiiii = r oa 231 of11�G'T`c 1�2 caa lead to a nm 'of c. pcaa ies of a
fine tip to$1,500.00 and/or c._yea=.imp sow'as well as civil penalties is fe foam ofa ST'nF WOI�C3RD�R a3o#-a fine
of tap to$250:00 a.dag agakt tha-violator.So advised that a co P3.of this siat fuk
enent may be vart+ded td
tie C}fi ce.of
sous of tb-0 DD r _. -vrrificah n _
for nnsmaticc exfvacacee
c� ify. - par s;a pe al of 't &Ike&forxuzdm prorrded �t� aadr�riecl
Phone#k � .. .
_Ofrdd use only. Do not write at this area,to be c_en* _ by a5;or towns offrcW
City or Town. PermitUcense#
Issuing Authority(circle one):
1.Board of Health Z Building Department 3.Cityt'fown Cleric -4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTIONS CONSTRUCTION SERVICES
8.1 Licensed Construction Suoerviso_r. Not Applicable ❑
Name of License Holder: L, \4 �f � V7-C�
Ucense Number
Address Expiration Date
Signature Telephone
fl ;049 9 SA _ " .yam" .r. Not Applicable ❑
*—Vi ARMAN&W ComDany Name Registration Number
Address Expiration Date
Telephone� �
SECTION 1Q-WORKERS'COMPENS/tTI�M.INSU ICE FiDAV c
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...... Cl
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 10835.1.
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 Budding Official,that he/she shall be
responsible for all such work performed under the building permit.
As acting Construcdon Supervisor your presence on the fob 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-DESCRtPTIOwoFPROPOSED WORK(checkattaciplicabte).
New.House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Ca Siding[d] Other[o]
Brief Description of Proposed --
Work: �Z'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION Ti OWNNr_R AUTHOttt?J4 l k ]F 1 COMPE:ETED VlfklEl+l
OWNERS AGEwr OR GONTRAC7 OR APPt M FOR$UII.DING PERMIT
I — 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 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 by Zoning
This column to be fined in by
Building Department
Lot Size
Frontage i
Setbacks Front
Side L:= R:= L:= R:= I
Rear
Building Height Q
Bldg.Square Footage % t--#
Open Space Footage %
(Lot ama minus bldg&paved
--
#of Parking Spaces :---f
Fill:
s
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ; Page and/or Document# x
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 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 0
IF YES, describe size, type and location: I
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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
„tS�Iil g Uepartmenf � .a
212 Main Street
R6om 100
Nor587a�o MA 01060
- rn,
0 Fax 413-587-1272
l�
r: ac
ICARIt T UCT TER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIOFt'_1,91.M INFORMATION
1.1 PrLoo�e,rty Address:
This sectiorrto:be completed by office:
Map-
'o
Dstcl`
R
SECTION`2--PROPERTY OVM904IPfAIIt I[O�t1�ED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
(Print) Current Mailing Address:
[Name
ignature Telephone
:SECTION-1 ESiilMATED GON18”, IC ,O I GOST5
Item Estimated Cast(Dollars)to be Offida{u se Oti)y
completed by unit applicant
1. Building (aJ Hilii h Perrrtif Fee -
2. Electrical (6)Estrrrtae+d Total Cosf of
�_Cottsti action from 6
3. Plumbing Hgtidtng Permtt ee .
4. Mechanical(WAC)
5. Fire Protection
6. Total=(1+2+3+4+5) V Cliedi Num- r
- This Section F60111116lal Use Ordy
.Date
Building:Perrnit Number. Issued
Signature:
BtrOding Commissionerllrtspector:4f Btpkiings Date
File#BP-2014-0940
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413)732-3922
PROPERTY LOCATION 74 MAYNARD RD
MAP 3 1 A PARCEL 168 001 ZONE URB000V
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 41 1 �i
Fee Paid
Typeof Construction: AIR SEALING
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included•
Owner/Statement or License 101877
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION 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
ela
Signature of uil g 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.
74 MAYNARD RD BP-2014-0940
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 A- 168 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-2014-0940
Project# JS-2014-001631
Est.Cost: $680.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. ft.): 7492.32 Owner: BRUNSWICK RICHARD P
Zoning:URB(100)/ Applicant: URBAN & SONS INSULATION CO INC
AT. 74 MAYNARD RD
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON:311212014 0:00:00
TO PERFORM THE FOLLOWING WORK.-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 3/12/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner