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36-313 (4) OWNER AUTHORIZATION FORM (Owner's Name) APR 2 2 2015 owner of the property located at 9, c (Property Addrm) (Property Address) i hereby authorize ; 6f'6 b b trL Subcontrtor) an authorized suboonhWor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Signature Date { F T C'Oni�ve 7 --e 'i'he FlY, .tl6ri -7 —SO 7S: -PI SO 9\0a lt'o ki4 q q)3 �LL=ql 3�_ -It1!L4�17'?'.MT421K-fer?"C"neck ih�- ;­E­ 71 1 am a em.0oyer with alto co- rs m0c)-ces"foll ancycr par-millie).", nl'�,aclo_ 7 2. i am a sot:;proprietor or par crier- and have no enluloyees, Demnofid 9. _:'f. f r Z'or me n any co A-v 'Q.;rip.ihnsurwncc -.aracoi'. d ,z Fim a,bcmneovmv.r Qloin'c,all W*ork n.:a t i o rm'sti-C. fNo comp. r i �nd-'vc ha- nsuranc -f er rN, "q ed.1 ~ -,y aeuiicalrt?nat cliticl:s���*i :rast also tilt nut tfie>�cti�n�zi.c:+.s`��=ir�x_tire:;^wo?�:er��c���,eas2:son po'siz�•inon�2.ion. a ffidavit i -nors NvN0 subn'' this wffid vil indicathin the"m-e doilt.sli ',r! aw� air-�outside cortmciDis must suiomi, -new a." f naric e�'!hesub-conzrmlctors mid smewhetheroymi thusev-101t; 11L, Iliat check this box must attached au oddidoml s�,ce,' ?e cs. if the sub-Cunvnctors have eivpioyees.ihey must rru­idt: mnlrx-ool;cv nu'ma-_ "il? .n,?Dlqver fiz at J'g providing 'r)PII'cnc2j!y' cm-m-lovee& 5. Tv ilte i"-,Ucy -o L _S W -1(-,& 4 ,L"I c--9: E'Luimtioll NN V i �f 0 Job Size Add-ress: I' c I 1)� ci, C"Istz'Lez- c a zopy 021 e V"Ov a Ke7s' CGIM�IIIZDIM U a-ed, unrdlerSect' n -z�r .7. la !2, a-ilvive-to secure cow rage as requi, .5- -P.-ri lead�0-me r.-A. fine iri) Psnal"Ues STC`_ 0v-,L tjzlt -up to"')2950.00 0.day against the Violator. Be advic�cic�rhac c-:)f nits st eme mav be rvvFrdled-- -he C­`- in-vescigations of the DIA for RISLIMMIce do llei wby cciI45'und -.m�po-n r'z�'vve"g e'77!4:VUM-'�!07!7 t :1 Lo I 13#F(jfr_� - -3 I 'S C) 3 a) Ll - Qffi eld use ota�v. Do nof ivelfe in ChIs area,10 be p OF sGPPII o-, 11, 4 li ime). S.Ron rd_­7 T-4 ea I L.11 2. Bumirlinci D-aDarimuerit :M 1: A 7:' L. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:. C b r% License Number �� �► s n �� a�o t-4a--� II (, Address Expiration Date Signahp Telephone 9.RIDgistered Homr,Improvement Contr tor• Not Applicable ❑ m�z I �ic(� 03 Company Name Registratio Number � a ► � ulo �� Address Expires ate Telepho e - �36 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....... V 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 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[01 Other[E] Brief Description f qFop9sed a�� /1 1 ,1 Work: c�Ce _ !J 1 J C e-I (t �'G` 2�1 v�b�`d o-Sr�i for Yes No Alteration of existing bedroom es No Adding r 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 ooms in each family unit: Number of Bathrooms c. Is there a garage a ed? d. Proposed Square footage of ne struction. Dimensions e. Number of stories? f. Method of heating? Fir s or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Ener pliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplai 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 -7- PL X17 l> S as Owner of the subject property 1 hereby authorize 1��� SQ � �n to act on rny behalf, in all matterA relative to work authorized by this building permit 4plication. Signature of Owner Date I ( � 2�- d as owner/ ge ereby decla a that the statements and information on the foregoing application are true and accurate,to the best of mge and be lief. Signed under the pains and penalties of perjury. Print Name _ Signature, con ent Date uMAI i 41 Main Street Sewer/Septic Availability 00M 100 Water/Well Availability Electric,PVurnb`�g&Mq J1C'� a pton, MA 01060 Two Sets of Structural Plans Northamp _ 87-1240 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 Property Address: This section to be completed by office I & q (ar��/��1 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Dwner of Record: M a G dI ct 1 yr Name(Print) Current Mailing Address: a ched Telephone f Signature )� ~ �( � o 2.2 Authorized A en Lv�L C 14 Arscvt-k M(I Name(Print) Current Mailing d ess: Signature .x Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building , ()o (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) 7c ' o(} Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-1090 APPLICANT/CONTACT PERSON JAY BOLAND ADDRESS/PHONE 12 PISGAH RD HUNTINGTON01050(413)214-2414 PROPERTY LOCATION 169 CARDINAL WAY MAP 36 PARCEL 313 001 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 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 o Delay -� Signa ure of B ilding Offic al D 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. 169 CARDINAL WAY BP-2015-1090 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36-313 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-2015-1090 Project# JS-2015-002067 Est. Cost: $1400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sq. ft.): 18905.04 Owner: PENZIAS DEBORAH J&CYNTHIA A ROBERTS Zonin : Applicant: JAY BOLAND AT: 169 CARDINAL WAY 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 Sisnature: 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