Loading...
31B-138 (5) f , OWNER AUTHORIZATION FORM I I, (Owner's Name) ' owner of the property located at /R, (x siz,?C>,, 0, (Property A L (Property Address) ik hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. ere, Signat Date • Property Address: � I � Contractor Name: `Address: U City, State: Phone: - Property Owner r , Name: Address: City, State: (contractor)attest and affirm that the building 1 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 signatur 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 dweAing, 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.Northampion wants person(s)who seek to use the home owner-exemption,-to act as their own construction supervisor;to be aware that by doing so you become responsible for compliance with state budding codess and regulations. The inspection process requires that the.building department be called to inspect work at various stages,which include foundation/footings(before backfill), sonotube holes (before pour),a rough building inspection(before work is concealed'h insulation insvection(if required)and'a final buildine 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 occupancy 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 buildmg inspections necessary for the building permit issued twine. Date Address of work location The Commonwealth ofA assachusetts Department of Industrid Accidents Office ofInvestigm ons 600 Washington Street Boston,MA 02111 www.massgov/dia -Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers APPUcant Information Please Print �'b Name(Business lorsaniaalionlin&vidual):. Address: City/State(Zip:�WJA�) 14-4��, '�I k tj-Y PhoneR. Are you an employer?.Check the appropriate'box: T of. ect 4.. I am a eral contractor and I 'Type Il I�j am a employer with_ ❑ 1 6. ❑New t:onstraction employees(full and/or part time).: have hired the 2_❑ lam a sole proprietor or partner listed on-the attached sheet 7. (]Remodeling ship, atd.have na=Vloym These have S. ❑Dci iolMon workiig for we m any caliacity eloyees and_have woticess' Btn1 a� n 'Comp-Msm-dwe ) 5. 0-We area a coigozattion and its 10 Elxtrscai reQans or additions 3.❑ I am a homeowner tioit:g all work o have wised their 1 LQ Pitubing repairs or additions el£ o workers' right of exert iori per MGL [N e�P- 12. Roof repairs insurance re��1 t - c. 152,§1(4 and we have no loyees: o workers' 13` Other v comp.insurance requed-}. . '°Any appiiont bat cbeda box a l-mos P Aw fM out&e section bck*showiag dmir do rs'- tim paluy i tim t liomeomners cvho submit @di bdiO�g they are dokgatt morn and rhea hire ouUkT-_vowxa=a tsal5t submit aaaw.zff davitb&cafins such 1ComYacmrs that acck this boz motamwhed an additimat shed shoa+im the n=c of the sab cones sandsfate wbetkr eraot ihoso-ernities have empl*v='W the mb-cna=x=bare evvbyas.they mustPavide ihes war dazs.'comp-Poky 8wnbcr J=an eoployer tls isymWding workers'evmpmsadon insnraacefor ivy employees Brlow is the pokcy and job-s&e -uaforraaiion i-., .- _ - as==Cow Nature Policy#or Self ins.Luc: :� � C7C1�1. �'V c>• Expiration Date: '-''� \V Job Site Address: Attach a copy of the workers''compensation policy dedarathen pa4ae(showing the pgbey nnmlier and-expiation date). Failme.to secure c6verage-.as rtagiiu r.Seattrni251 of11�GL`c T52 ran Iea&6 ilhovatiin of`ct> —peealttes of a fine up to S1,500.00 and/or ore-year i riso 'as well as civsZ penalties is t}te fad of a STOP W©RK-QRD I a e of up to$250.00 a day against the vie1athr.-Be advised 1W a copy of this statenient maybe forvvaFded wo the O of Tnveshaaf3.ons ofths CIA for"msiaancc co`ve`raine-ven`tica�on: �- _ �-� I do her _ under d e o f :thaf the ircfor tiun rovrdra� qt�s tr a udrar PCt Si nab 0,07dd use only. Do not write in this area to be cenVleW comp - by city or town bpofciat .City or Town:_ PermitlUcense# Issuing Authority(circle one): .-1.Board of Health 2_Buflding Department 3.City/Town Clerk .4.Electrical Inspector 5.Plumbing Inspector 6.Other E Contact Person: Phone#: 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 buildirm oermit. Signed Affidavit Attached Yes.......' , No...... ❑ 1 l �� -lip -1111 The current exemption for"homeowners"was extended to include Owner-occnuied 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.CAM 780, Sixth Edition Section 1093.5.1. 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 shalt 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 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 §ECTION5-OESCRIPTIOft-OFPROPOSEDW K(checkaltapalica New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ &Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding Qom] r Brief Work:Desorption of Proposed ,�, , A4 5; Alteration of existing bedroom Yes No Adding new bedroom W Yes \Jt' Nov 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 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. WAI.building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a OWNEt�Ati ®R-9""CO + �N OWNERS AGENT M:C€ ff2ACTE3!R APPEfES FAIlDING PRMI T I 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. Signah"of Owner Date 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 pains and pens ' qury. Print -i-�� Signattre of Ownei Agent Date Section 4. ZONING All Information Must Be Cornpteted.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size J� 3 Frontage i Setbacks Front Side L:= R:= L:= R:= Rear C� 0 Building Height �� 3 Bldg.Square Footage % �� Q Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces Fill: F VO1tHme&(ACat1p11 A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON-T•KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: j C. Do any signs exist on the property? YES 0 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 Q NO 0 IF YES, describe size, type and location: I 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 Storrs Water Management Permit from the DPW is required. tiunaing uepartment � = 212 Main Street Room 100 pion, MA 01060 l � Ap41 -1240 Fax 413-587-1272 E�. u LU , Ele U T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING r,. SECTION._# SII'EIfIFORMA'fIE)N=- 1.1 Property Address: ;.This section to be compteted`by. office_, Map Lot tlmt �or�e 4�er�jf Distnct EIm 3>'iilsttrkt: � .�� CB_District ,� .. - SECTION.2-PROPERTY dWNERSHiP/ALIT HORIZEDAGENT 2.1 Owner of Record. Name(Print) Current Mailing Address: Telephone elephone 2.2 Authorized Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMAT�DI;ONSkOtNCTtON=COSTS' Item Estimated Cost(Dollars)to be Official Useco completed by it applicant = 1. Building (arBuifding Permit Fee 2. Electrical (b)Estunatecl Total Cost"of .:Construction from 6. :. . - 3. Plumbing Burng:PermttFee . . 4. Mechanical(WAC) 5. Fire Protection 6. Total=(1+2+3+4+5) umber This Section For:OfflcialaJse On Building Permit Numbe Date r. Issued: Signature: Building-CommissionerAns*—of Buildings Date File#BP-2015-1293 APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELDOI 104(413)732-3922 PROPERTY LOCATION 28 BRIGHT ST MAP 31B PARCEL 138 001 ZONE URC(99)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin 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 101877 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 i el ss� Sign of Buil ingofficial 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. 28 BRIGHT ST-2ND FLR BP-2015-1293 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B- 138 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-2015-1293 Project# JS-2015-002380 Est.Cost: $3507.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: URBAN & SONS INSULATION CO INC 101877 Lot Size(sq.ft.): 10759.32 Owner: MACKAY SYDNEY Zoning:URC(99)/ Applicant: URBAN & SONS INSULATION CO INC AT. 28 BRIGHT ST - 2ND FLR Applicant Address: Phone: Insurance: 385 LIBERTY ST (413) 732-3922 WC SPRINGFIELDMA01104 ISSUED ON:611612015 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 6/16/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner