17C-103 (7) OWNER AUTHORIZATION FORM
---i: 3
(Owner's ame) '
owner of the property located at
(Property Address)
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform worts on my property.
r' Own(ePs Signature r� -
Date! /
Property Address: � � V�
Contractor
Name:
Address:
City, State: ��� �� U�
Phone:
Property Owner
Name:
Address:
City, State: ���- 1�
(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 signature �,� -E�
Date
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines"Homeowner"as, "Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building:department for the City of Northampton wants person(s)who seek to use
the fionre owner exemptioa;to act as their own constivction-supervisor;to be aware that
by doing so you become responsible for compliance with state building codes.and
regulations. The inspection process requires that the-building department be called to
inspect work at various stages,which include foundation/footings (before backfil h
sonotube holes (before-your),a rough building inspection(before work is
concealed),insulation inspection(if required)and a final building inspection.The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occuoancv
until.the work can be inspected
If the homeowner hires other trades to perform work(electrical,plumbing&gas)the
homeowner will be responsible to make sure that the trades hired secure their proper
"ts in conjunction to the building permit issued,and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
.(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to-me'.
Date
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents .
Office oflnvestzgations
600 Washington Street
Boston,MA 02111
+ www.massg ovlflla __ -
-Workers' Compensation Insurance Affidavit:.Builders/Contractors/EI�clriciarnslPlumbers Jl
Applicant Information Please Print LieffffiN
Name{Business/0rgaaiion/Tndividuat):.
Address ._ r
City/StatelZip � �� Phone.#: �° -. -1i ---
Are you an employer?Check the appropriate'bo= -Type of i o ect(required): +
I am a employer with 4-. [] I am a general contractor and I 6. New arristiucti
employers(fall atxilor part time)
have hired the sub-contractors
2_Ej I am a sole proprietor or.part= listed on-the:attached sheet 7. [�.Remodeling
ship and have na=ployc= These sub-contrlcinrs have .8. 0 Dei3blition
working for me gay capacity. a tIo_yeesand_Izave wot3ceas'.
_. P.;nctrra„c 9 Ding on
P46 W6*ew Con* IPSM-AMIM n
5. [].We are a cagmaton and its 10 P1lectacal repairs or additions
am a homeowner doing all work of$cers Nava eel their I LE]Pki*ng-repairs or additions
rift afexe Mr Oii per MGL
myself[No WULS-mb comp. �e:152,§1(41 and�we have nd Q
13 �.
employees:[No workers'.
C
omp.insurance req�},
=any appficaat that clxeJa t=nm i a1w sn out the section belawA*wing their Wads'co-pcosatioa pohiey iafiorm daa:
t Ilc�eowaers a+bo s&=*this afd,,kt: fiy we deingal wade and th bim ouUi&caatacXa Est snh nodt a new-affidavit b icatmg AWL
tCoa�dnt awk this box mnst.attad=d an aMbanal shed 4 roving Ste mme of the snbeo oiradoes and-state wbetlier orso"bosraentitia have
eu>pioyees 'Irftsib canttac.t=bx*eampbyeMtb<5'mustprmdb*=wod=ecomp._pohicyaamber -
rant an employer drat isprom ing workers compematioa wsw=r_e for-my employee& Below is the policy gad job-site
iriifornEd ore
Insurance Company Name c 1 C1\
Policy#or Self-ins.L..#�+.� � ��'f� G �-� J (ration Datc.
y /
Job Site Address: �. � .�. J � - - C� P-t���'�` ��1
Attach a copy of the workers'cou�p+ensatioa policy deciazafien page(showing the pgricy number and ezu�tion date
Failae.to secure coverage:i] regimes ifi.$6cftan 25-ofMGL'c. 152 can 1ei&6 die unpos`rtian of t pesaftres-of a
fine up to$1,500.00=Nw obe-year.h46sonma4,as well as cif penalties in the form of STOP a •a Sne
ofup to$250.00 a against rise*ator %Be advised Ifiat a copv of this statement may be�fo�clad
raves ations 4E&_ )IA for m rand covera�►c --
I dso her rte_ fy:uxdrr they ;applal of--per�ury:tlsat tlu irifonsratranorided gittrrresraitmriea'
DaL-
Phone#-
_D tc'tQl use aaly. Do nat write in this area,tb be comp_ by city or(Dhoti official
City or Town: Pcxmit/License#
Issuing Authority(circle one):
.'1.Board of Health L Building-Department 3.Cityfrown Clerk .4.Electrical Inspector 5.Plumbing Inspector
s
6.Other
Contact Person: Phone#:
1
SECTION 8-CONSTRUCTION SERVICES
8.1 Ucensed Constriction Su rvisor. j Not Applicable ❑
Name of License Holder: `� �`��
License Number
Address E*rabon Date
Signature elephone
Not Applicable ❑
Company Name Registration Number t
Address Expiration Date
Telephone k �—
SECTION 10-WORKERS` 0111pENSATION INSUliAi�E FFFIDA\/II 0LMLXi152,..5m.W{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...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwelllines 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 10835.1.
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 strictures 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 liiable 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(checle all.aadilcAh .
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Does 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[RBI]
Brief Description of
Work:' \,Z) `�st e
l�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
a. Use of building.One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is then: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. Willi building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION Ta=OWNEEt AUTHORt�At'ION TQi E_COMPI+E ED WHEN
OWNERS AGENT-OR CONTRAGTORAPPLIES EOR=BUILDINCsP.�
1, as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the p!%sandpenatties of perjury.
nt Name
Signatu of Owner/Agent Date
Section 4. ZONING Alt Information Must Be Completed.Permit Can Be Denied Due To Incomplete information
Existing Proposed Required by Zoning
This columns to be filled in by
Building Department
Lot Size
Frontage ! €
Setbacks Front
Side L:= R:= L:= R=
Rear
Building Heigbt
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
-�
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book h Page �� and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES ® NO 0
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 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 Q NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
c t witaing Llepartment
12 Main Street
Room 100
Nbr ampton, MA 01060
�s
(;,,e 4 U 87-1240 Fax 413-587-1272
Electric.Pt � ,,;
ort
o � UCT,�°►t-TER.REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1=SITE INFORMATION
1.1 proms- This secfion to be compieted by ot#'ice
'.W k
�����"�' `= O�reriarjfDistrtct
SECTION 2-PROPERTY OV11N1=RSHIPfAUTHORIZED AGE[ T =
2.1 Owner of Record:
Name(Print) �i''I�Addres � > �`
Telephone 'C,
Signature
2.2 Authorized
e( ) Current Mailing Address:
Signature Telephone "
SEOTlON 3 'E�TIMAT�C�[�ISTItl3GTIOl+I COSTS '. -
Item Estimated Cost(Dollars)to be Olficiai tls Qniy
completed by fruit applicant
1. Building
(a)Building Permit
2. Electrical (b}Estimated T I Cost of
__-Construc#ion frorrr:
3. Plumbing BuildiagPerarltFee
4.4fti anical(WAC) -
5.Fire Protection
6. Total=(1 +2+3+4+5) Chedt Number
-` This:Section Foy OfflcialaTse On .
Building PermWNumber Date
Issued
Signature:
Building Commissionprllnspectar ttf Btdir�s .
File#BP-2015-0907
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD01104(413)732-3922
PROPERTY LOCATION 17 STILSON AVE
MAP 17C PARCEL 103 001 ZONE URB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERM_ IT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
kpeof Construction: INSTALL WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 101877
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF MATION PRESENTED:
VApproved 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
Y
Signature of uil mg 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.
17 STILSON AVE BP-2015-0907
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 103 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-2015-0907
Project# JS-2015-001744
Est. Cost: $2702.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq.ft.): 9888.12 Owner: YOST ROBYN
Zoning: URB(100)/ Applicant. URBAN & SONS INSULATION CO INC
AT. 17 STILSON AVE
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON:313012015 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WALL 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 3/30/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner