29-396 (3) AM W-
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ass
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PERMIT AUTHORIZATION FORM
I, Pema T Rangdol ,owner of the property located at:
(owner's Name,printed)
106 Sandy Hill Rd Florence
(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 buildin it to perform insulation and/or weatherization
work on my property.
X -
Owner's Signatu
!l
Date
TOR 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
rortl�+tb U�Ureh
Rev.12132011
r
The Commonwealth of Massachusetts
Department of Industrial Accidents
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 lipcY �'
Name(Business/Organization/Individual):
Address: S ii --
City/State/Zip: 1.(.. r-N �l ,`-) Phone#: '°6- l- 3 1 3C-
Are you an employer?Check the ppropriate box: Type of project(required):
1.01 am an employer with 4.01 am a general contractor and I 6.0 New construction
m loyees(full and/or part time).* have hired the sub-contractors 7.n Remodeling
�
2. I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8.0 Demolition
working for me in any capacity. employees and have workers' 9.0 Building addition
[No workers comp.insurance comp.insurance.
required] 5.OWe are a corporation and its 10.0 Electrical repairs or additions
3.01 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers'comp. right of exemption perm MGL
insurance required]t c. 152, § 1(4),and we have no 12.0 Roof repairs
employees.[no workers' 13.0Other
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 roust 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 most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.Below is the policy and job site
information.
Insurance Company Name: f a G 'C'
Policy#or Self-ins.Lic.#: 1 Expiration Date:
Job Site Address: City/State/Zip: Q[MU- ,f)A Q\Q(&'2,
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 certi Eder t l ald ofperjury that the information provided above is true and correct.
Signature: Date: [ f 1] I 1
Print Name: f c� Phone#.
Official use only o not write in this area to be completed by city or town official
City or Town: Permit/license M
r
Issuing Authority(circle one):
1.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 Supervisor: Not Applicable ❑
��. c
Name of License Holder: � f lot 8 2 0
License Number
► a(�7 ( 14
Address- Expiration Date
Sign Telephone
9.R i ter d Home Improvement Contractor: Not Applicable ❑
L/ &Q�
Co n Name J Registrati`�' Number
Address . Expiration Date
' Telephone t
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 buildJpg permit.
Signed Affidavit Attached Yes....... Id 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) 7
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[_] Siding[p] Other[C]
Brief Des yWdo Pr posed 1
Work: l�I` [D CAP 12)1( 241(1� S
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 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
I, as Owner of the subject
property
hereby authorize
to act on my behalf, in all mqlers relative to work authorized by this building permit application.
I �y
Sign re o er Date
I, , N as Owner/Authorized
Agent hereby decibre 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
Lat I Ir
1
Signat of COR/Agerif Date
_ Department use only
-}t City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
6 2��4 212 Main Street Sewer/Septic Availability
V °` Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
Electr,c. F ,nit rc s � ��
'p�lq{1e 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 Properly Address:
This section to be completed by office
i �lx Map Lot Unit
0(' n C_� ' ` � Zone Overlay District
f' Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 gA=r of Record:
Name(Print) Current Mailing Ad re
AWVA Telephone '
Signature
2.2 Authorized Aaent: 4-21r) MT me.
Name(Print turrent Maili ddress:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building s-fib (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)
b� Check Number Q ,5
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0671
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESSIPHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 106 SANDY HILL RD
MAP 29 PARCEL 396 001 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
Typeof Construction: INSTALL ATTIC INSULATION&AIR SEAL
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
INFORMATION PRESENTED:
proved 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
elay
Signa of Iruil mg fficial 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.
106 SANDY HILL RD BP-2015-0671
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-396 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa: INSULATION BUILDING PERMIT
Permit# BP-2015-0671
Project# JS-2015-001283
Est. Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sg.ft.): 11020.68 Owner: TSEYANG PEMA&CHOYING RANGDOL
zoniniz: Applicant: JAY BOLAND
AT. 106 SANDY HILL RD
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON:1211812014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION &AIR SEAL
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 12/18/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner