29-060 (4) - City of Northampton
SAS 3'!C
Massachusetts hw " f<<
DEPARTMENT OF BUILDING INSPECTIONS y as
212 Main Street a Municipal Building tis
Northampton, MA 01060 SSW 3��~
Property Address: rk,• f rrGt C
Contractor
Name:
Address:
City, State: C ' �i , �"r-I- Q I
Phone:
Property Owner
Name: i<)�-41) Lee" k-n'
Address: t'_3 q i I M I.-\ d -E' 1 y-a C,,e_
City, State: ) Y-2 fT e Q J Q
I, 1 (5 �`yS (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
C
Date / 0 jail
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
(Property Address)
riJ cc'
(Properly Address)
hereby authorized�-- G�`(Q < �l2 G
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.
i
Owneei Signature
Date
i
i
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder: J6//'t lam(°S I /% 00
License Number
G4 / C-)J/C,>
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
dresS I J Expiration Date
`�- Telephone W N 3
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the built rmit.
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( 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 fa ' y dwelling,attached or detached structures aSgg5suy to such use and/or farm
structures.A person who constructs mar , an one home in a two-year er" s all not be considered a homeowner.
Such"homeowner"shall submit to the Building icial,on a form acce c to the Building Official,that he/she shall be
responsible for all such work Performed under the din e
As acting Construction Supervisor your presence on the j o ' 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 orkers'Compensati and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death)o e Massachusetts General La Annotated,you may be liable for person(s)
you hire to perform work for you under thi ermit.
The undersigned"homeowner"certifie d assumes responsibility for compliance wi the State Building Code,City of
Northampton Ordinances, State and ocal 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 1:3
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[
Brief DescriP+'on o,{Proposed C e- hntf_L 0.1 r t'v"+ 1:-�1 i - ia'' C J u vK , � C��� �j rQ,�
Work: hU� 1- `1 YPn�}��(L1 E►, C.{uq. S' c� _��6 7 ✓2 Sr ld�, l�- iQ l F(� S�/I S
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. 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
1, k/0 ee h 1�1 LG] as Owner of the subject
property
hereby authorize " it
to act on my behalf, in all matters relative to work authorized by this building permit application.
(qq
Signature of bwner Date
S as Owner/ uth
ereby declare that the statements and information on the foregoing application are true and accurate,to the best of y knowledge
and belief.
Signed under the pains and penalties of perjury.
J�u ) F/I-�
Print Name
ov/'_�oll
Si ure 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?
Aft
NO W DONT KNOW ® YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES ® NO Qf
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,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.
`� L�M E Department use o*
ity of Northampton Status of Permit:
uilding Department Curb Cut/Driveway Permit
OCT 312014
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Electric, Plumbing&Gas inspectiq4tirthampton, MA 01060 Two Sets of Structural Plans
Northampton, MA 01060 4 14 pi -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 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
&3 t—mCC_ Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: �"
ka*Jeen �Lr n q 1 YlC p-�
Name(Print) Current Mailing Address:
Telephone r�3W- 9
Signature
2.2 Authorized Agent:
Name Print) Current Mailing Address:
Signa a Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 3 Vol, (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= (1 +2+3+4+5) �3 (Y�„ Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0512
APPLICANT/CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESS/PHONE 142 BOYLE RD GILL (413)863-2128
PROPERTY LOCATION 63 GILRAIN TER
MAP 29 PARCEL 060 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid ke IV
Typeof Construction: INSTALL INSULATION&AIR SEALING
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
INFOR ATION PRESENTED:
oved 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
olit' Delay
A4 l _
Signature of Buildi 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.
63 GILRAIN TER BP-2015-0512
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-060 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-2015-0512
Project# JS-2015-000963
Est. Cost: $3406.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. ft.): 14418.36 Owner: LONG KATHLEEN F
Zoning: Applicant: IDEAL HOME IMPROVEMENT INC
AT. 63 GILRAIN TER
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863-2128 Liability
GILLMA01354 ISSUED ON:111412014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL INSULATION &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 11/4/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner