17A-039 (3) City of Northampton 212 Main Street, Northampton, MAO 1060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: 2)L. Q �k
The debris will be trans `U4x--
Th transported by:P
:
will be received b
The debris Y
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
The Commonwealth of Massael'ausetts
Department of IndustrialAccidenis
{ Office of Investigations
G 600 Washington,Street
Boston,J11A 02111
`^ jimmmassgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/.10lulmbers
Applicant Information Please Pfmt Legibly
Name(Business/Organization/Individual): �/�.}!�" f ,J
Address•
City/State/Zip:t�d�.,�l/� n3 l'/!n�'° Plione.#: '/ - 5'22
Fyou an employer?Check the appropriate box: Type of project(required):
I am a employer with ,/�3� 4. ❑ I am a general contractor and I r employees(full andlorpart=time).* have hired the sub-contractors 6. ❑Itiew construction
I am a"sole proprietor or partner- listed on tho-attached sheet. 7- ❑Remodeling,
ship and have no employees These sub-contractors have g, ❑Demolition
wor'kin for me in an capacity. employees and have workers'
g y p t3'• t 9. ❑Building addition
[No workers'comp.insurance cornp.insurance.
required.] 5. ❑ Wo are a['`� corporation and its 10.❑Electrical repairs or additions
3.El am a homewmcr doing all work officers have exercised their I1.❑plumbing repairs or additions
myself. �o workers'comp. right df exemption per MGL
_ 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees.[No workers' 13.V9 Other v
comp.insurance required.]
-'A.ny applicant that checks box#1 must also fill out the section be'ow showing th:ir workers'compensation policy informnation.
t Homeowners who submitthis affidavit indicating they are doing all work and tken hire outside contractors must subrrat anew aftidavitindicating sucI
$Contractors that check this box must attached an additional sheet showing thename ofthe sub-contractors and state whether or not those entities have
employees. rf the subcontractors have employees,they must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and fob site
i�zfornrattort. /y�
Insurance Company Name: / lG��`i✓2L' —�+
Policy#or Self-ins.Lic.m: 1//�1,Z&V Rye,,5 �3flo �Y/i Expiration Date: C1I'"
Job Site Address: ` \ sR�s � '
Attach a copy of the workers'compensatioli policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties is the form of a STOP WORK ORDER and a fire
of up to$250.00 a dap against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLL for insurance coverage verification.
I do hereby ee�riify under the pains•and pe altles ofperju that the information provlded above is true and correct
Si natur \ Date: .� '
Phone
Offccial use only. Do not write in this area,to be completed by city or foiva official. .
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person: Phone 4:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9 Registered Home Imarovement Contractor _ . ....? Not Applicable £
Company Name Registration Number
Address Expiration Date
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(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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [I]] Decks [Q Siding[❑] Otherx]
Brief Description of Proposed
Work: IC--
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 an- addifth to'exi 6,-C 'housing, comble#e the followinq':
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
--4,c d dr 1 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 urLder the p ' s and penalties pffperjury.
Sint Name D\ C-
�11g-rlldure of Owner/Agent Date
'
,
Section 4. ZONING AIL 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 L
Setbacks Front
Rear
Building Height IF
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved L--j
#of Parking Spaces
(volume&Location)
A. Has aSpediPermit/Yahamce/Finding ever been issued for/on the site?
�� YES ����
NO �,�� DONTKNO� \V «��
|F YES, date issuedd
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �� D NT«~� u KNOW 0 YES
IF YES: enter Book Page and/or Document#
�� ��
B. Does the site contain abrook, body uf water orwetlands? NO «���� DON7KNOYY �~� YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �~t Obtained �-� Date�~� �_� ' .
C. Do any signs exist on the property? ��? YES v�� NO �^��
�
IF YES, describe size' type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location: v
E Will the construction activity disturb(clearing,gradingexcavation,orfi/Ung)over 1 acre orixh part ufa common plan
,
that will disturb over 1 acre? YES 0 NO 0
IF YES,then o Northampton Storm Water Management Permit from the DPW is required.
4
:
City of Northampton 4 '
---" !' Status of Permit,
1. t
{w uG 2 5 214 Building Department GUrI�CutwDn�cewayPerrrt�#
\U P
212 Main Street Sewer/SepticAvaira`611�ty '" h z
as�nspeot1O�S Room 100 Water/UhtelfAvailabillty
Piumb'n9 �1p60 orthampton, MA 01060 Two s8ts�of Structural Plans
electr,NotthumptOn
phone 413-587-1240 Fax 413-587-1272 P[oflSite Puns I
oUier Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thts section fo be completed y ice
1.1 Property Address: ,... b off
Zone Overlay Dstrtct
EIm:St ❑istrnct CB D,istnct
SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Curffe�t�3Lli Add s cp��
" �- i�+ Telephone
Signature
2.2 Authorized A ent:
Name(Print) Current Mailing Address: f?�
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit 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 it 00 O-C
6. Total=(1 +2+3+4+5) Check Number 1 fir
This Section For Official Use Only
- Date
Building Permit Number: Issued:
Signature:
Building Commissioner/inspector'of Buildings Date
File#BP-2015-0222
APPLICANT/CONTACT PERSON URBAN& SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413)732-3922
PROPERTY LOCATION 200 BRIDGE RD
MAP 17A PARCEL 039 001 ZONE RI(100)/URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 4!5f 5
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory 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
INFORMATION 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
molition Delay
10011 ���
Signature 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.
200 BRIDGE RD BP-2015-0222
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-039 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-2015-0222
Project# JS-2015-000419
Est. Cost: $2567.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. ft.): 11717.64 Owner: LAWRENCE-RIDDELL MICHAEL K& LAUREN C LAWRENCE-RIDDELL
Zoning: RI(100)/URA(l00)/ A�nlicant• URBAN & SONS INSULATION CO INC
AT. 200 BRIDGE RD
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON.812612014 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 8/26/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner