31A-024 (8) Property Address:--v C� '
Contractor nA
Name: �- ���SJ �To
Address: -V/
City, State:
Phone:
Property Owner
Name:
Address:
City, State: �`�`� ���� �
(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
Date
l
OWNER AUTHORIZATION FORM
(omees Flame)
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an atdwdmd obcm&ador lbr RISE Engkiewbig,tD act on my behalf to cttatn a bt0ft
permit and to pawm work an my pmpedy.
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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 fancily
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
home owner."
The building department for the City of Northampton wants persons)who seek to use
the home owner exemption-to act as their own consb uddon supervisor;to be aware that
by doing so you become responsible for compliance with state building codes 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),insulation inspection(if reau ed)and a final building inspection.The
building department requires these inspections before the work is concealed,failure to
secure these inspections can result in failgre 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 reouesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to`me.
Date
Address of work
location
t
The Commonwealth of Massachusetts
-IJPDepartment of Industrial Accidents .
Offiee oflnvestigations
600 Washington Street
Boston,MA 02111
{ www.massgov/dza
-Workers' Compensation Insurance Affidavit: Bufiders/Contractors/Electricians/Plumb-ers
Applicant Information Please Print LegR&g
Name(Business/org onau&viduao):. --'�' S V
City/State,/Zip: 'LS.�_ Phone.#:
Are you an employer?.Check the appropriate•box: L_7
ro'ect
4. I ani a eral contractor and I P I (required=.
IV I am a employer with � ❑ �
employees(full and/or part-6me}.s have hitrd the soli-conttactars ew constnu�on
2_❑ I am a sole proprietor or partner-
listed on thi-attached sheet. modelmg
ship and have no loye w These sub-contractors have eiaolidon
working for-me in any capacity_ a Ioyeesand_bave workers'.
a�difion
N&wexkep- romp- _ ..
5. ❑.We are a ccnpgiation and its ectacal repass or additions
requir�j officers hxietx rased them mbing repass or additions
3.[] I am a homeowner doing aIl work r right of exemption per MGL��[No '�- of
insurance requ rc&]t �c. 152,§1(41 and we have no 103' -[No wormers hex 5U Q
con*•insurance requite-} .
'Any appfioat ihat drrJcs boz gl-mat ISO fill out the section bdowshav&g theirs'compaosatim policy Vie:
t f3a�V=C2n�vbosubmitthisaffdzvit:n&t dry are doingallwork and then.hueao2side wnnacmis t>zastsubmitasewaffidavitin&cmingsuch:
1Co s that check this boz m st-attaehed an a bun d sheet showing the name of the subcam�and bave
-vbYees.•Kthesub-cmw..ct=brieemployers they wod=?cam-porWymanba. -
.I ant an employer that ispiovWw.-workers'coatpemsatfoa brsura we for nap e*plgyam Bdpw is&e policy and job:site
informauion.
Insina=Company Name.-
Policy#or Self ins.Lic.#V4I\2_?��i 3 U�- .��p�-\�!`5 V_-4.- Expiration Dat .-N .
Job Site Address:�'�'c`�
city/stat� ��►�� �1.. �,� �?\��T1
Attach a copy of the workers''compensation-policy deduafen page(showing the pyTicy nambeF and ezgi�tation date
Failure.to,secure c6 -as- ander.Seafion 23 fI�GL`c`152_ran Iead-ba fire imposiliori of ca r peio ties of a
fine up to$1,500.00 and W ohe-year imprisommeu4'as well-as civil penalties is the form of a STOP WORK-C1RD1 Z and-afire
of tip to$250.00 a-deg against the violator. Be advisees that a copy of this stabem�may be forwarded toy the q@i of
r .,
�streat>.bas`ofthc�)IA=,.
for mstaance cavorarae vesr�canon: _ _
_under
---- t rarrfy p pp#alt�s:ofperpuy tl rat"t)u infor�oR provtded:ahave�irr�.��rierl ---
Si �: _- �:bafe-1 _0I
Of j`rct'dl ase only. Do not wrke in this 6r to be comp by city or town officraL
City or Town: PexnritlLicense#
Issuing
Ant] (circle one):
1.Board of Health 2.Building Department 3.CityfTown Clerk .4.Electrical Igo,pector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Workers Compensation Insurance affidavit must be completed and subrhitted with this application.Failure to provide this affidavit will result
in the denial of the Wince of the building permit.
Signed Affidavit Attached Yes.......09 No...... ❑
The current exemption for"homeowners"was extended to include Owner-occauied 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
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 t a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,one form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildige permit.
As acting Construction Supervisor your presence on the jolt site will be required from time to time,during and upon
completion ofthe 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
SECTIONS-DESCRIPTiON"OF-PROPOSED WORK(check all Aoaiicabtei
New House ❑ Addition ❑ R mentQ ndom Alterations) ❑ Roofing ❑
Accessory Bldg. ❑ Demolition ❑ New Signs (o] Decks (0 Siding[p] Other
Brief Description gLRroposed
Work: �`, (c— V
Alteration of existing bedroom Yes No Adding new bedroom Yes No
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.tion. 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. WM-,building conform to the Building and Zoning regulations? Z>4` Yes NO.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a E#�
OIAiIVAEIHE}RtZJl77Ol� T13QM 'CEtt3�BEN .
OWNERS AGENT 0R CONT12AC7R APd'.ElES FOii 13E)IDING#ERMIT
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
1 as Owner/Authorized
Agent hereby declare that the sta ements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under pains a aloes of perjury.
Print Nwe
Signature of Owner/Agent Date
r
Section 4. ZONING Alt 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 Del-tinent
Lot Size -�'
Frontage P i
Setbacks Front
Side L:= R= L: R:C
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area mimes bldg&paved E ri
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW (D YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 19 YES
IF YES: enter Book 1 4 Page Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 1U YES iQ
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained Q , Date Issued:
C. Do any signs exist on the property? YES NO ievk
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 �C
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.
i
�u»aing Department
212 Main Street
Room 100
i thampton, MA 01060
,SAN � 4
587-12 40 Fax 413-587-1272
I SRI
Nil
ol
r`
UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE:INFOf2MATION
1.1 Property Address: This section to be completed by office:.
\ Ma tot �rilf
`�on� - O1_rerlax Dastrict
_ istdct
.SECTION2-'PROPERTY OWNERSHIP/AUTHORFZED AGEI E
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
elephone
2.2 Authoriz ent:
ame(Print) Current Mailing Address:
Signature Telephone
SEGTIhAwl ESTINfATEE)trDNSMCTIOW STS
Item Estimated Cost(Dollars)to be Ilseiy
completed by rmit applicant
1. Building _
(a)=�ui(tiirig:Permiti Fee
2. Electrical
(by,E6 host of
_:Constriction from:
3. Plumbing Bullding Pennif
4. Mechanical(WAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Cfiecic Number
7. This S ection For Official`Use On -
Building Permit Number. Date
Issued:.
Signature:
Building_Commfss onerAnspector ofBindings;
Date
File#BP-2016-0849
APPLICANT/CONTACT PERSON URBAN& SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD01104(413)732-3922
PROPERTY LOCATION 42 FRANKLIN ST
MAP 3 1 A PARCEL 024 001 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 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 TION 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
e n
Signature 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.
42 FRANKLIN ST BP-2016-0849
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 I-024 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-2016-0849
Project# JS-2016-001438
Est. Cost: $2915.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. ft.): 17903.16 Owner: BRENNEIS SARA
zoning. URB(100)/ Applicant: URBAN & SONS INSULATION CO INC
AT. 42 FRANKLIN ST
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON.11612016 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:
FeeTvpe: Date Paid: Amount:
Building 1/6/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner