31A-297 (2) OWNER AUTHORIZATION FORM
(Owner's Na e)
owner of the property located at
9 9i L�- LIJ
(Pro rty Address)
di
n G L(jG
(Property Address)
hereby authorize C A S
(Subcontractor)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property.
Owner's Signatu e
Date
,. S
CAM
i�
'i
The Commonwealth of Massachusetts
Department of Industrial Accidents
ir WE Office of Investigations
600 Washington Street
Boston,Mass. 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual). I 4t�o Imp_S
Address: VO&A
City/State/Zip: u-ti4l n -kX-)Aft 610,`O Phone#: -( 1 .3—&L ,&J 31 :L
Are you an employer?Check the ppropriate box: Type of project(required):
1.p I am an employer with 4.0 I am a general contractor and I 6.0 New construction
�mloyees(full and/or part time).* have hired the sub-contractors
2. '' I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling
ship and have no employees These sub-contractors have 8.❑Demolition
working for me in any capacity. employees and have workers' 9.0 Building addition
[No workers'comp.insurance comp.insurance. :
required] 5.0We are a corporation and its 10.❑Electrical repairs or additions
3.01 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers'comp. right of exemption perm MGL
insurance required]t c. 152, § 1(4),and we have no 12.❑Roof repairs
employees.[no workers' 13.❑Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If
the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.Below is thepolicy and job site
information.
Insurance Company Name: ryb G ry
i / r
Policy#or Self-ins.Lic.#: L— ` Expiration Date: [t" 2 6('S
Job Site Address: `�1'� �°L 11�� ��l 1 i City/State/Zip: r4oxY �Dr) MA L)i b 0
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 MGL 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains.,q dp alties of perjury that the information provided above is true and correct.
Signature: w • Date: [Z I t 9
v-.
Print Name: Phone#: "Z� -2j" to& Q
Official use only Do not write in this area to be completed by city or town official
City or Town: Permit/license#:
r
Issuing Authority(circle one):
I.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction SuDervisor. Not Applicable ❑
Name of License Holder
License Number
MA o ( 01S al 114
Address `" Expiration Date
3 3 b
Signatur#r !:J. Telephone
9.Rea stered Home Improvement Contractor: Not Applicable ❑
� CC c x�S ) lo�(l�U
Combany Name - Registration Number
Address / Expiration D to
Telephone `7 3'Z
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....... 0-"' 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 buildinE 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 F� Replacement Windows Alterations) E�j Rooflng
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [M Siding[O] Other[a
Brief Description of Proposed �0 . r / I n �, f/ j t L 1
Work: 1J' l..(/�JJ d.V it) (,�G�-( /�G� 1 tT1L L, 1�' ��R"i1 1 n1 t�(jr\ t`c'aIe.SEA J,AL
Alteration of existing bedroom Yes *'�No Adding new bedroom Yes r'�No y)
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If Newhouse 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 a ed?
d. Proposed Square footage of n construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. sscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction 'n 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. ® 6 ►1. as Owner of the subject
property
hereby authorize _I44 bCA'Fkr4 d biq 4a t ' 1!2�� SCI(.f d.A S
to act on my behalf, in all atters relative to work authorized by this buildin p rmit application.
Signature of Owner Date
1, J, as Owner/ ori
e ' ere d are that the statements and information on the foregoing application are true and accurate,to the best of myy n�dge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of, er/y ent Date I I L
D
r.;-= "` Department use only
r ^.�w p Y
I
r�6 1 City of Northampton Status of Permit:
LI �G` 9 zQ14 lJ Building Department Curb Cut/Driveway Permit
j 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
�3hiotte 4 3-587-1240 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
ytmon r� I Map Lot Unit
r(An Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
[1 C
Name(Print) Current Mailing Address:
l� .A— Telephone 'mot 1 '7� �-�j
Signature '( { J
2.2 Authorized Aaent:
n r u vn 5 i h1?,4 I
Name-fPrini)j Current Mailing Address:
�R
Signature - Telephone
SECTION 3 f-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building oo (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) 7t--f Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0681
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 94 VERNON ST
MAP 31A PARCEL 297 001 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
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101880
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO,,RMATION 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
lit' Delay
ignature ui g is 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.
94 VERNON ST BP-2015-0681
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 A-297 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-2015-0681
Project# JS-2015-001305
Est. Cost: $1200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft]: 11979.00 Owner: BUTLER STEPHEN&CHERYL A
Zoning. URB(100)/ Applicant: JAY BOLAND
AT. 94 VERNON ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON.1212212014 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 12/22/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner