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36-161 (5) OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at (Property Address) (Property Address) hereby uthorize d �4� � t S•eS LLCM Y - , (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. fi"-SL�- Owner's Signature r 'I�� Date i The Commonwealth of Massachusetts Department of Industrial Accidents Offue of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriciags/Plumbers ADylicant Information Please F Nint 'b T.Name(Business/Organizadon/Individual): _ L Address: 0�b City/ tate/Zip: ` bj` Phone#: L11 -V-)-7- Are An 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. El New 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. 7. ❑Remodeling ship and have no employees 'These subcontractors have g. ❑Demolition working for me in any capacity. employees and have workers' t 9. F1 Building addition [No workers'comp.insurance comp.insurance. 10. Electrical or additions required.) S. ❑ We are a corporation and its ❑ repairs 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12 ❑R insurance required.]t c. 152,§1(4),and we have no Su�a4w ) employees.[No workers' 13. 7 comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then him: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. I am an employer that Is providing workers'compensation Insurance for my employees. Below is the polky and job site i,{formaLion. O .Insurance Company Name: C Policy#or Self-ins.Lic.#: —� 3747 xpiration Date:0v�%-PO'Ce- 1 Job Site Address: /o g y 8 u T{ %� '><` xa/ City/State/Zip: d 2 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). 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-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 c e pains en o :;jury that the information provided above is true and correct Si Date: Phone#: Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health Z.Building Department 3.City/fown Clerk 4.Electrical Inspector 5.Plgmbipg Inspector 6.Other Contact Person:- Phone#: , ` � � � / SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: C 5 E�iense Number Address Expiration Date Signatu,re--- Telephone 9. Registered Home Improvement Contractor: Not Applicable 0 Company Name Registration Number Address Expiration Date Telephone 12 76- 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...... El The current exemption forhomeomnerx^*mcxunded * iodude one(1) mtwo(2)families and m allow such homeowner mungvAevoindividuu| for hire who does not possess alicense, provided that the owner acts as supervisor.CMR780, Sixth Edition e Definition of lllomeowner� Person (s)who own a parcel of land on which he/she resicics or intends to reside,on which there is,miu intended mho, o one or two family d*cUin-,attached cx detached structures accnxmxymxuchmmuud or farm structures. A person who Eonstructs more titan one hoine in a two-year period shall not be considered a homeowner. Such^homonwne,^shall submit to the Building Official,ono 6,on urcop|ob!o to the Building Official, responsible for all such work performed under the buildina permit. As acting Construction Supervisoi yuurpresence ou the job site will bn required from time mtune,during and upon completion of the work for which this permit ixissued. Also hoadvised that with reference mChapter \5Z (V;orkors' Compensation) and Chapter 153 (Liability of Employers m Employees for bnurics not resulting in Death)nfthe Massachusetts Gcocm( Laws Annotated,you may he liable fovpcoon(x) you hire*perform`"xk6xyuuonJcr this permit. The uodomiancd^homcvwno/`cuti6usand assvnics uxponsikUity kncomplixncc vith the State Building Code,City of Northampton Ordinances- 3uueund [nualloningLuvaondS'menl'MmxuhLucuoOcoco|LuwxAnnotamd. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all ap)licable) New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks jC] Siding[01 Other Brief Description of Proposed ll �'�� e II U �, aver 41 2 /�fT/CJ Floor-r- ©pen d TQ. /O 9� Work: / >�� 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 . 1. 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, See- A U"E 41"I LQ T6T'm as Owner of the subject property hereby authorize n 2r10 C'1 SeS LL to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I f°— as Owner uthorize g ereby declare that t a eme s and ation on the foregoing application are true and accurate,to the best of Wedge a elief. Signed under the pains penalties erlury. !3tan rc�fs�l 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 Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO (�) DON'T KNOW Q YES 0 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 0 Obtained Q , 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 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 V NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 1 Lir Department use only fforthampton Status of Permit; pg' Department Curb Cut/Driveway Permit NAY /lain Street Sewer/Septic Availability om 100 Water/Wetl Availability Electric, PiurnuiNortham ton, MA 01060 Two Sets of Structurat Plans p 240 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 Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: DENNIS REARDON 1094 BURTS PIT ROAD F-10 ren ee-, 1!719 010&2 Name(Print) Current Mailing Address: 413 584 1767 Telephone Signature 2.2 Authorized Agent: euri 8 r`oA4uU Pd 60'x l 2 7 Cl.,ap'e a Name(Print) Current Mailing Address: 413 301 8010 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 1,400 (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=0 +2+3+4+5) 1,400 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-1142 APPLICANT/CONTACT PERSON JASM ENTERPRISES LLC ADDRESS/PHONE P O BOX 1276 CHICOPEE01201 (413)427-5481 PROPERTY LOCATION 1094 BURTS PIT RD MAP 36 PARCEL 161 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinp,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 108517 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOjMATION 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 S f uil mg 6fficial 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. 1094 BURTS PIT RD BP-2015-1142 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 161 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-2015-1142 Project# JS-2015-002151 Est.Cost: $1400.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JASM ENTERPRISES LLC 108517 Lot Size(sq. ft.): 11543.40 Owner: REARDON DENNIS F&JEAN M Zoning: Applicant: JASM ENTERPRISES LLC AT. 1094 BURTS PIT RD Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427-5481 WC CHICOPEEMA01201 ISSUED ON:5120120I5 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 5/20/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner