25C-143 (6) OWNER AUTHORIZATION FORM
(Owner's fine)
amm of the Property located at
(Property Address)
(Prop"Address)
hereby authorize
(Subcontractor)
an authorized subcontiractorfor RISE Engineering,to act on my behalf to obta
permft and to perlbim work on my Property.
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Owner's Signature
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The Conn zofnvealth of Massachusetts
Depin-tnzent of Industrial Accidents
Office of Investigations
600 Washington Street
. Boston.MA 02II Z
rvn n,.nzass goi/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le>:ibIv
Name(Business!OrganizationIndividual): F '. U11D, RN �� +7 ! .1ou
Address:
City/State/Zip: 1 ' } 'j ) ' t, Phone its�`q'
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a em loser with 4. ❑ I am a general contractor and I
P G. ❑Nest=construction
employees(full and/or part-time). have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. i. ❑Remodeling
ship and have no employ=ees These sub-contractors have 8_ ❑Demolition
worldna for me ill aim ca acir<. employees and have workers'
p ). ❑Building addition
(No lvorkets' comp_insurance comp.insurance_-
required.] 5. ❑ We are a corporation and its 101-1 Electrical repairs or additions
3.❑ I am a homeowner doing all iwork officers have exercised their I l_❑Plumbing repairs or additions
myself. o zcorkers'coin . right of exemption per MGL
3 (N p I_❑Roof repairs
insurance required_] ( c. 152_S 1(4)_and ive lva-=e no
employees. [No workers` 13.❑Other
comp.insurance required.]
Any applicant that checks box#1 must also fill out Ate section below showing their workers'compensation police=information.
fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aflidax it indicating such.
;Contractors that check this box must attached an additional sheet showing ilia name of ilia sub-contractors and state whether or not those entities have
amploy ees. If ilia sub-contractors have employees_they must provide their workers'comp.polices number_
I am an emplot1er that is providing workers'compensation insurance for ant,ernp1gyees Below is ibe policy and job site
information. l _
Insurance Compam=Name: (- (' tii 1 i i,Z- _ L
Police#or Self-ins.Lic.#: t Cl t-.`}° 31 S ' 3'7 ='_2,17 11' 1 Eipiration Date:
Job Site Address: T Urti l" smut i— 1 City-/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the polio°number and expiration date). Cl 1 C�lf�
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1.500.00 and/or one-rear imprisonment.as trell as civil penalties in the form of a STOP WORD ORDER and a fine
of up to$250.00 a day, against the violator. Be advised that a cop y of this statement may be forwarded to the Office of
Investigations of the DIA forinsuiance coverage verification.
I do hereby certify under the pains and penalties of perjurty that the information provided above is true and correct
Si enature: rY Date: S
Phone#:
Official use only. Do not write in this area,to be completed bt'city or totvft official.
City or Town: Permit/License r
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Tow n Clerk 4.Electrical Inspector i.Plumbing Inspector
6.Other
Contact Person: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supmiso.. p Not Applicable ❑
Name of License Holder: ) D I S D 0
License Number
Address Expiration Date
Signaturh, Telephone
9.Renistered Home Improvement Contractor: Not Applicable ❑ _
Company-Name Registration umber
Address f + Expiration Date
Telephoq�2_� I-313D
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c.152,§25C(6))
Workers Compensation Insurance affidavit mu t be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building 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(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) E� Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[[3] Other[❑]
Brief Description of Proposed I
Work: t;�/� I Dy— V I r'1 t�j r�I ��P 1J)�� 1► L -�;,E-►'hr?T R'tm\£;I S
Alteration of existing bedroom Yes No Adding new bedroom Yes '�,—Noo=� �� J
Attached Narrative Renovating unfinished basement Yes —�.�'�c
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
as Owner of the subject
property
hereby authorize
to act on my behalf,in all matteN re ative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare ttVt the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signe7�A
er the pains and penalties of perjury.
Prin t Name
Date
Signature of r
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 pver been issued for/on the site?
NO ® DONT KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW � YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW C� YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO Q,
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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
1
Department use only
fit' �� i` pity of Northampton Status of Permit:
--`` 3uilding Department Curb Cut/Driveway Permit
we ' �, 706 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability,
R hampton, MA 01060 Two Sets of Structural Plans
Electric,Plumbing
& ins o41 - 87-1240 Fax 413-587-1272 Plot/Site Plans
t3orthampton,
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 q o t-ch vz1 i Map Lot Unit
N ' 1Q , (� 1 (l Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
1 I alp KL . Ku�d
Name(Print)zkh'ed Current Mailing Address:
Telephone . L / .
Signature
2.2 Authorized Anent: a (�
L C� 1,z�-
Name(Print) Current Mailing ddress:
Signature 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=(1 +2+3+4+5) j r 6-0 Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2015-0863
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON01050(413)214-2414
PROPERTY LOCATION 39 ORCHARD ST
MAP 25C PARCEL 143 001 ZONE URB000)
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 WALL INSULATION&BASEMENT RIM JOIST
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:
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
Demolition Delay
3 /J
Signature of Building 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.
39 ORCHARD ST BP-2015-0863
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 143 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-2015-0863
Project# JS-2015-001680
Est.Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 7666.56 Owner: MIGLIORE WILLIAM
Zoning. URB(100) Applicant: JAY BOLAND
AT. 39 ORCHARD ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON.311712015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WALL INSULATION & BASEMENT RIM
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 3/17/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner