32C-300 OWNER AUTHORIZATION FORM
V)to
b1
(owners Nome)
owner of the property kxated at
eopefty Address)
tsk
(Propel,►Address)
hereby authorize 6-yual
( )
an authorized suboonbador for RISE Enggtnes",to ad on my behaff to obtain a building
permit and to perform work on my property
sig re
Date
The Commonwealth of Massachusetts
f
Department of Industrial Accidents
Office of Investigations
600 Washington Street
IV Boston,MA 02111
www.massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Leeltbly
Name(Business orgimzationandividuaD: Bryan G.Hobbs Remodeling
346 Conway St.
Address' Greenfield,MA 01301
City/State/Zip: Phone#:_ l .5L- /77 `) -�( G u t1
Are you an employer?Check the appropriate box: Type of project(required):
1.E( I am a employer with-(, — 4. ❑ I am a general contractor and I 6. ❑New constirnction
employees(full and/or part-time).* have hired the sub-contractors
2.F-1 I am a sole proprietor or partner- listed on the attached sheet t Remodeling
ship and have no employees These sub-contractors have 8. (] Demolition
working for me in any capacity. workers'comp.insurance. 9• (1 Big addition
(No workers' comp.insurance 5. ❑ We are a corporation and its 10.F-1 Electrical repairs or additions
requited,] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL k l.❑Plumbing repairs or additions
myself.(No workers' comp, c. 152,§1(4),and we have no 12.❑ goof repairs
insurance required.]t employees. (No workers'
13.(�Other If l S� c���''1
comp.insurance required.] V L it n
'Any applicant that checks box#I must also fill out the section below showing their workers'ct mpen"on policy informstion:
t Homeowners who subnit this affidavit indicating they are doing all work and then hire outside contractors must subtnit a new affidavit indicating such.
tconvacwn that check fts box must attached an additions)sheet showing the name of the sub-cont actors and their workers'amp.policy infan»at i m
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and,fob site
Information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: 2 Z Ck.,1. •� C� I Expiration Date:
Job Site Address: L 7 V W P / l � eity�state�zip: E��t f p�k � ,,`)9') ' �
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Fa&=to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimhW penalties of a
fine up to$1,500.00 mWor 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 coverage verification.
I do hereby edify under the pains andpe��n��akiies ofperAry that the information provided above k true and correct
Si � Date: I ► -7
n • - C
Offleid use only. Do not write In this area,to be completed by city or town eAkIal
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Chy/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder: 0� 06 q8 2—
346 Conway St. License Number
Greenfield,MA 01301 `J
Address Expiration Date
'Lit 4 d ,
Signature I Telephone
9 Realstered Home Improvement Contractor Not Applicable ❑
Bryan G. Hebbs Remodeling 13 qS-(0 q
Company Name 346 Conway St. Registration Number,
..
Greenfield,MA 01301
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(l) 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 [0] Decks Siding[D] Other[ @
Brief Description of Proposed �,
Work. f�i r• t �� O�X p Q k
Alteration of existing bedroom Yes--No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No r-(7, C e,v b(A,t
Plans Attached Roll -Sheet
6a. If New house and or addition to exis#inc 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
'e as Owner of the subject
8 ;d
property
hereby authorize '
to act on my behalf, in all matters relative to work authorized by this budding permit application.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare t at 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
Date
Signature of Owner/Agent
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?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW "x YES
IF YES: enter Book Page and/or Document#
4
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q 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.
City of Northampton r �' ! 'c '
NIP
g Department �1h1( ay !°� r� law
EC�=� EE 21 Main Street !! °
oom 100
A {� -1272-n4 3 o a ton, MA 01060
�� � 7- 240 Fax 413 587
7° '�
F1
PP Dcsaa ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
P V e ! " ywp y Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�L tr t P Q. z b� + C;4�r,k - r7
Name(Print) Current Mailing Address—{
.. ... & 2..t a Telephone
Signature
2.2 Aut ors
zed Aaent:
LjL- o ai) 6,4
� ..
Name(Print) Current Mailing Address: „✓
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building p (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) q� Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0886
APPLICANT/CONTACT PERSON BRYAN HOBBS
ADDRESS/PHONE 346 CONWAY ST GREENFIELD01301 (413)775-9006
PROPERTY LOCATION 27 VALLEY ST
MAP 32C PARCEL 300 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,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 83982
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
V 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
D ay
Sign of WildIng diftcial 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.
27 VALLEY ST BP-2015-0886
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-300 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-2015-0886
Project# JS-2015-001723
Est. Cost: $2469.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BRYAN HOBBS 83982
Lot Size(sq. ft.): 6011.28 Owner: DEBLASE JOSEPH A&PATRICIA I
Zoning: URC(100)/ Applicant: BRYAN HOBBS
AT. 27 VALLEY ST
Applicant Address: Phone: Insurance:
346 CONWAY ST (413) 775-9006 WC
GREENFIELDMA01301 ISSUED ON:312512015 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 Siznature:
FeeType• Date Paid: Amount:
Building 3/25/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner