17C-087 (3) OWNER AUTHORIZATION FORM',
1, ALA l r& ,
(Owner's Name)
owner of the property located at
(Property Address)
F1 e-y- . 4M± 6 G C)
(Property Address)
hereby authorize 1+w �AgrACA f�1 �nS
(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 Signature
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Date
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7aiw, tc Secure cav�-;]-age as under Sectini- pain 1--act e im- -?--rT r im"nLi -,W%
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ofup t S250-00 a day against v1,313Lor. Be;IT I. S St -M f= epi rnav be f3i-,,wardl e t
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In-vescigations of't-h8 DIA i0rin5uraixe coverage verhr.caii-.---aIP
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: .�� ��c�A
J License Number
�n O J O NO
Address Expiration Date
a°
� 3-
Signatut ' _ Telephone 1 a. 0.01 ie
9.Re istered Home 1 provernent Contractor: Not Applicable ❑
L
Comiianv Varne Registration Number
a MA o(6 D 1b�1y3
Address 1 J i J f Expiration D to
Telepht� W"3/3®
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 buildipg permit.
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) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[D]
Brief D_escpption Rf Propo#ed
Work: r � r 6
K1'el 1")
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 ro ms in each family unit: Number of Bathrooms
c. Is there a garage ched?
d. Proposed Square footage ew 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 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, &A V(.Q cL as Owner of the subject
property
hereby authorize
to act on my behalf, in all m s relative to work authorized by this building pert/ it pp nation.
Signature of Owner Date 1
I IUM as Owner/ horize3-
A ereby 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 pains and penalties of perjury.
Print Name
Signature of OiA6r/A#K Date
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 a er been issued for/on the site?
NO Q DON'T KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW er/ YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW k YES 0
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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, exc vation, 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
D ��1 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
Pi 413-587-1240 Fax 413-587-1272 Plot/Site
Plans
tri ,Q� � O1 OtheSpec fyOe h ' � n.
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
I (Do Gh.e.r)Lj( Map Lot Unit
C)co�C ' M v' o to.2- Zone Overlay District
1 , ' Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Addres$:
41 -� -- Z
Teleph ne
Signature
2.2 Authorized A ent:
an
pis
�f1v.0(A,WA ' ) a A h n 10 0
Name(Prin Current Mailin A dress:
LI I3- ( Q1 - 31 3 D
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 00 (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) 5 (( Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1091
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON01050(413)214-2414
PROPERTY LOCATION 100 CHESTNUT ST
MAP 17C PARCEL 087 001 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 o?
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
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
D n Delay /
aSignatureil ing 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.
100 CHESTNUT ST BP-2015-1091
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-087 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-2015-1091
Project# JS-2015-002068
Est. Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 11064.24 Owner: LEYDON ANDREA
Zoning: URB(100)1 Applicant. JAY BOLAND
AT. 100 CHESTNUT ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON.511212015 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 5/12/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner