Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
17A-248 (6)
L OWNER AUTHORIZATION FORM M 4 P-e-11*) - Z (Owner's Name) owner of the property located at (Property Address) IF6 jr=evJ c,&,, m� l (Property Address) f(1 hereby authorize S� �, L L (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 Sign .-- o Date „� i The Commonwealth of Massachusetts Department of IndustridAccidents Office of Investigations 600 Washington Street IF Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers ARylicant Information Please trint Legibly Nagle(Business/Organint ion/Individual): L Address: 4�;b tci )c I City/ tate/Zip: ~ ( Phone#: Are an employer?Check the a propriate box: Type of project(required): 1. I am a employer with�� 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors i 2.El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling and have no employees These sub-contractors have g. Demolition workin for me in an capacity. employees and have workers' S Y P tY• t 9. E]Building addition [No workers'comp.insurance comp.insurance. required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12.F]R iss insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.[ya'other comp.insurance required.] *Any applicant that checks box#1 roust also fill out the section below showing their workers'compensation policy information. t Honteowaas who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for nV employees. Below is the policy and Job site Wormadon. Insurance Company Name: Policy#or Self-ins.Lic.#: 3145-3727 xP iration Date:t/J Job Site Address: / .Ca S free, City/State/Zip: © 1 ()(0 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to segue 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-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 nce pains an diken ' o erJury that the information pro vided above is true and correct S Date: Phone Official use only. Do not write in this area,to be completed by city or town of ciaL City or Town: Permit/License# Issuing Authority(circle one). 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: ^ ' / Exemption SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder License Number Address Expiration Date 9. Registered Home Improvement Contractor: Not Applicable t] A�l Company Name Registration Number Address Expiration Date >� 12 7-6 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...... 0 11. - Home Owner The current exemption for^'hom000nco~was extended minclude one(1) or uvo(2)famUies and m allow such homeowner m engage on individual for hire who does not possess u|uouse. provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Derinition of Homeowner- Person(s)who ovvii u parcel nf land ou which he/she resides oo intends W reside,ou which there ix`or is intended to be- a one o,/vm I'amik, dxdhu@,attached ordctached oon,tuos accessory to ouub use and/or farm structures. Such^homunvno,^shall submit to the Building Official,vna /nnn acceptable to the Building Official, responsible for all sucli work As acting � yno,presence onUxjohxbowU| boregubzJbnmc`momdrrie.duuuguudupvu completion nfthe work for which this permit isissued Also bo advised that with reference roChapter |52 (\Yorkco' Compensation) and Chapter |53 (Liability of Employers to Employees for in'luries not resulting in Death)of the Massachusetts General Laws Annotated,vou may be liable fovpcmouo} YOU hire mperk`rm work for You under this permit, The undersi2ned—horricowncr"ceitifics and assumes responsibtll� I'()'-compliance xith the State Building Code,City of Northampton Ordinances, State and Local Zonino Laws Lind State of Massachusetts Cieneral 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 Siding[1--3] Other[❑] Brief Description of Proposed —r ,� / Work: �h�UTA �2 /5��►► o✓a/ST" L�,�f b�Gjla h°/7 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.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 1 Se-p— 11 r�or 2 Qrrn 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 as Owner/Authorized A ei hereby declare that the ateme rmation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. �P<-� aracls�a� Print Name 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 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO (�) DON'T KNOW 0 YES Q IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , 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 0 NO e 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 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. _ C ( , - I MAY 20 � s k Northampton, MA 01 060 Department use only City of Northampton status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify i 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 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: MAREN BROWN 98 LAKE STREET Name(Print) Current Mailing Address: 413 586-0901 or/Ze_ �rr� Telephone Signature 2.2 Authorized Aclen PO BOX 1276 CHICOPEE MAO 1021 Name(Print) Current Mailing Address: V/3 z/ 90/0 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 756) (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) 2 J�'O Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-1144 APPLICANT/CONTACT PERSON JASM ENTERPRISES LLC ADDRESS/PHONE P O BOX 1276 CHICOPEE01201 (413)427-5481 PROPERTY LOCATION 98 LAKE ST MAP 17A PARCEL 248 001 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 RIM JOIST INSULATION New Construction Non Structural interior renovations Addition to Existing Accessoly Structure Building Plans Included: Owner/Statement or License 108517 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: _L,,!4pproved 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 Signa ure o uilding 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. 98 LAKE ST BP-2015-1144 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-248 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-2015-1144 Project# JS-2015-002153 Est.Cost: $250.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JASM ENTERPRISES LLC 108517 Lot Size(sa. ft.): 16552.80 Owner: BROWN MAREN T&PATRICIA ANN MORRISON Zoning URB(100)/ Applicant. JASM ENTERPRISES LLC AT: 98 LAKE ST Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427-5481 WC CHICOPEEMA01201 ISSUED ON.512012015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL RIM JOIST 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 SiEnature: FeeType• Date Paid: Amount: Building 5/20/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner