25A-086 (3) i
mass save COKTRACTi IR
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PERMIT AUTHORIZATION FORM
I, Cynthia Nolan ,owner of the property located at:
(Owner's Name,printed)
21 Crosby St Northampton
(Property street Address) (City)
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.
X �..-.
Owner's Sig re
Date
FOR CSG OFFICE USE ONLY
Conservations Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
Elff O
Ol
Ruirt ic:rLinetlydy
Rev.12132011
The Cosy monwealtli of Massachusetts
Department oflndustrial Accidents
Office of Investigations
c 600 Washington Street
Boston,,CIA 02111
,wK www.nmssgov/dia
Workers' Compensation Insurance Affidavit: Builiders/Cola tractors/Ill lectricians/Pluxabers
Applicant Information Please Print Legibly
NaMe(Business[Organization/IndividuaI): /W/r/,* t l�wf / �F�✓
Address:
City/State/Zip:Ji0.or!,Q 191.- 4"/A0 V Phone.#:Are you an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with /J_ 4. [] I am a general contractor and T
6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
listed on the attached sheet. 7_ Q Remodeling
2.❑ I am a•solo proprietor orpartner- These sub-contractors have
ship and have no employees 8. ❑Demolition
working or me in an capacity. employees and have workers'
g Y F t5'• 9. Building addition
[No workers' comp.insurance comp.insurance.1
required.] 5. Q We are a corporation and its 10.Q Electrical repairs or additions
3.❑ I am a homeowncr doing all work officers have exercised their 11.Q Plumbing repairs or additions
myself. [No workers'comp. right df exemption per MGL 12.❑Re frees pairs
insurance required.]f c. 152,e 1(4),and we have no
employees.[NO 1TJO11CeI3' 13. Other V
comp.insurance required.]
*A.ny applicant that checks box#I must also fill out the sectica below showing their workers'compensation policy information.
t Homeowners who submit this of davit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have
employees. If the sub,cantractors 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 Job site
131fDf'JJ1atIOl1.
Insurance Company Name., ' lee,
I m
G=L "i
Policy#or Self-ins.Lie.#: /� ,Z 960 gds, 3"lo rY/' Expiration Date:
Job Site Address: -\ City/State/Zip: I
Attach a copy of the workers'compensatiotl palley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A,of ML GL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
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
Investigations of the DIA for insurance covers e verification.
I do here b certify under thepa' adpenalties ofperju that the in/ormationprov ed above is true and correct
Signature
Phone -- �--
Official use only. Do not write in this area,tb be completed by city or to wit offletal. ,
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
`#
6.Other
Contact Person: Phone#:
City of Northampton 212 Main Street, Northampton, MA 01060
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:
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant \ 'S
{
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable £
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Registered Home Improverxient Contractor:` Not Applicable £
Company Nam Registration Number
Pv
Address _ Expiration Date
TelephoneJ
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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[ )
Brief Description of Proposed -1 r- .. . o
Work: t h � A Q t
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 oIr addition to existing housing,'cornplete 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 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 and rthe p 'ns and penalties of perjury.
n ame
Signature of Owner/Agent Date
`
/
Section 4. ZONING Ail Information Must Be Compteted. Permit Can Be Denied Due To Incomptete Information
Existing Proposed Required by Zoning
This column to be filled i0by
_g epartment
Lot Size
Setbacks Front
Rear
Building Height
Bldg.Square Footage 0110
Open Space Footage %
#of Parking Spaces
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONTKNOM 0 YES 0
|F YES, date issuedj �
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONTKNOYY 'E�
_�-
IF YES: enter Book Page and/or Document#
�� ��
B. Does the site contain a brook, body ofvvaterurvvetiands7 NO �3� DON7KNO\9 �~� YES �_�
IF YES, has permit been or need to bp obtained from the Conservation Commission?
Needstobeobtained x—
� Obta�ned »—� Date |ssued.
'
�-� �~� '
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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradin uUon.or@|ing)over 1ooaorioit part ufa common plan
,
that wiUdisturb over 1 acre? YES 0 NO �k
IF YES,then o Northampton Storm Water Management Permit from the DPW iu required.
'
_. _ , ` Department use only
,
CI1..I of Northampton
Building Department Ctirl3 Cut/Driuewey Perrrst# t 4 t
212 Main Street Sewer/S'epticAvaiCablllty
SEP 1 2014 ��!
6 Room 100 Water/VlfeilAva�lablllty
ampton, MA 01060 Twa S2fs of S#rtctural Plans r
Plumbing a -5 7-1240 Fax 413-587-1272 Plof/Site,Plans
14
Northam ton,
A 01 o6p Other2Spec�fy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
This section to becompleted by office
1.1 Property Address:
-
Zone Overl aylstrld
Ew
El.m St District CB District
SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current��"'�'Uu�C._ s.� y yc
Telephone
Signature
2.2 Authorized A ent'
ame(Print) Current Mailing Address:
'"re (� p�
Sig a Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed 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
6. Total=0 +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-2015-0303
APPLICANT/CONTACT PERSON URBAN& SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413)732-3922
PROPERTY LOCATION 21 CROSBY ST
MAP 25A PARCEL 086 001 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 ATTIC INSULATION&BASEMENT BAND JOIST
New Construction
Non Structural interior renovations
Addition to Existin
Accesso 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
INFORN�QnON 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
Demolition Dela
Signature of wilding 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.
21 CROSBY ST BP-2015-0303
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A-086 CITY OF NORTHAMPTON
Lot:-00 L PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-0303
Project# JS-2015-000570
Est.Cost: $3495.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. ft.): 13198.68 Owner: NOLAN CYNTHIA
Zoning: URB(100) Applicant: URBAN & SONS INSULATION CO INC
AT. 21 CROSBY ST
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON.9/17/2014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION & BASEMENT
BAND JOIST
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 9/17/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner