25C-214 (6) OWNER AUTHORIZATION FORM
Michael Gulden
1,
(Owner's Name)
owner of the property located at
I Linden Street Northampcon, MA 01.060
(Property Address)
I Linden Street Northampton, MA 01.060
(Property Address)
Bryan G.Hobbs Rernc,:
346 Conway St.
Greenfield,MA 01301
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.
Owner's Signature
1 Y
1r2
5-ate
C E 0 v F=
DEC 2 2 Z015
U.
City of Northampton
!� Massachusetts
�i DEPARTMENT OF BUILDING INSPECTIONS yJa
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address: -�Y� ca P_, S 4Y
Contractor
Name:
Bryan G.Hobbs Remodeling
Address: 346 ' St:
City, State:
Phone:
Property Ownerr V is ,d-f rt)
Name: V'►C yY-e-, Y) ,Sw,�� V� �� c�c� lvyd I`�lrcl�c . i �TV ( cr� ✓'
Address: I L i vide Y` S4
City, State: f- w'41" el-4 ' r + a'', " >!�" ! o U
I 5Y4 n,Y, 14 ° bh S (contractor) attest and affirm that the building I 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 signature 5
Date I j 3v j
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work:
The debris will be transported by: Fyt-i '' tJ t7 bi�S
The debris will be received by:
Building permit number:
Name of Permit Applicant Q vLi O�
Date Signature of Permit Applicant
The Commonwealth of Massachusetts
1
'" _ Department of Industrial Accidents
Office of Invesdgadons
' 600 Washington Street
Boston,MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BusiumsrOrpmization/Individual): Bryan G. Hobbs Remodelin
Conway St.
Address' Greenfield,MA 01301
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.4 I am a employer with 4. ❑ I am a general contractor and 1 6 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 7 1 am a sole proprietor or partner- listed on the attached sheet t Remodeling
ship and.have no employees Tlese sub-contractors have 8. []Demolition
working for me in any capacity. workers' comp.insurance.
9. E]Building addition
[No workers' comp.insurance 5. ❑ We are a corporation and its 10 Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.[] Roof repairs
insurance required.]t employees. [No workers' 13.W Other o s kz vi,- ,
comp.insurance required.] t
*Any applicant that cbedw box#d must also fill out the section below showing their workers'compensation policy inf nmation:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContre Mrs that check tbis box must attached an additional sheet slowing the nacre of the sub-contractors and t3eir workers'comp.policy information.
lam an employer that lsproviding workers'compensation htvurance for my employees. Below is the policy and job site
information. r
insurance Company Name: 1 (,3 )A e- 0 11`l r .. Oom 12 r c
�t �°
Policy#or Self-ins.Lic. #: �-1! 1 Expiration Date: 10 ' � I,
Job Site Address: ' Ll r7 d ej-i S4• .,�Q� f Jq
CitylStateJZip:�L�I''-��i
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 certify under the pains and pjenwalties of perjury that the information provided above is true and correct
Signature: )9 i��� r i 6,1v Date 1,2-I Syl,:a
irp-
Mne#: i4 I`<— r7 e7 S gS
Offlcial use only. Do not write in this area,to be completed by city or town offEcial.
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 11 Name of License Holder, Bryan G.I 0 8 S 9 Fl G,lobbs Remodeling
346 Conway St. License Number
Greenfield,MA 01301 15-12— /1 G
Address Expiration Date
5 r- OA6 �I1 ,3 - 1�15 � �tdc; C
SignatAr Telephone
9. Realstered Home Improvement Contractor: Not Applicable ❑
1 ? e3 5-(,'4
Company Name Registration Number
Bryan G.Hobbs Remodeling
346 C onway..St
Address Greenfield,MA 01301 Expiration Date
Telephone t Imo 'ej U
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...... ❑
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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[0] Other[ ]
Brief D�,c'.r.qtion of Proposed
Work:=((-. bloWkq 1✓1 Oa s l CCtI�+(� t (�ro���d��'!� i✓tr4a (! e"kk,�_ur4 Lt6yr'-411 ex(s F-t ►��
17
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
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.
J azlk cz&Le o)
a re of Owner Date
as Owner/Authorized
Agent here 6y 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.
Dnl �, t7
Print Nam
)'� (iy' 60 1a l 301 t 5
Signature of Own r/Agent 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 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 O DON'T KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
''
Department use only
r, !City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
P
��$ 212 Main Street Sewer/Septic Availability
Lr s Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 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
L S4 y f Map Lot Unit
Zone Overlay District
I�t Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
rrr� �SYI�t4 n zmir,�tc�.-c.t (��t �c j �t ,� ► �, �f. ►�l�a��►.��..�„��C ��:��
Name(Print) Current Mailing Address: a 2— 2 ?� 12— 3
Telephone co
Signature
Bryan G.Hobbs Remodeling
2.2 Authorized Agent: 346 Conway St.
n ya Greenfield,MA 01301
Name(Print) Current Mailing Address:
Rvt,�t b� y►3 X775
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 2 e:7/) t,0 (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 e7 q. (d Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File 4 BP-2016-0861
APPLICANT/CONTACT PERSON BRYAN HOBBS
ADDRESS/PHONE 346 CONWAY ST GREENFIELD01301 (413)775-9006
PROPERTY LOCATION 1 LINDEN ST
MAP 25C PARCEL 214 001 ZONE URCO01)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid vlowo
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessor3�Structure
Building Plans Included:
Owner/Statement or License 83982
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
1� Pproved FOR TION PRESENTED:
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
f /1'
' n lay
Signa ure of Building 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.
I LINDEN ST ' BP-2016-0861
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-214 CITY OF NORTHAMPTON
Lot:-00 L PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0861
Project# JS-2016-001452
Est. Cost: $2299.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BRYAN HOBBS 83982
Lot Size(sq. ft.): 9975.24 Owner: SMITH WARREN J
zoning: URC(101)/ Applicant: BRYAN HOBBS
AT. 1 LINDEN ST
Applicant Address: Phone: Insurance:
346 CONWAY ST (413) 775-9006 WC
GREENFIELDMA01301 ISSUED ON.11512016 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 1/5/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner