25C-052 (5) OWNER AUTHORIZATION FORM
(owners Name)
owner of the properly tooted at
(Property Add ram)
(Properly Address)
hereby authorize
(Suboontractor)
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
9�
Date
J
Property Address: '�� �► �
Contractor C r
Name: ` �-� '� 3e�v, ,,so �n\ AA
Address: ---�� .� �
City, State: Pj-=�
Phone: ► ---
Property Owner ---�
Name:
Address: �� C,'��
City, State:
I, (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 signat re
Date \ `0
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 finny
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 Ndrthampton wants persons)who seek to use
the homre ownei exempfion,-ta act as their bwn-co oa su
. _ pervrs+or;to be avpare 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/footinas(before backrdl),
sonotube holes(before-pour),a rough building inspection(before work is
concealed'h insulation inspection(if required)and a final building inspection.The
building department requires these.inspections before the work is concealed,failure to
secure these inspections can result in fa Are 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 building inspections necessary for the building permit
issued to-me.
Date
Address of work
location
The Commonwealth ofl4fassachusetts
Department oflndustrid A4c ents -
Office oflnvesti.-ations
} 600 Washington Street
Boston,MA 02111
{ wwrvmass gov/dia
-Workers' Compensation Insurance Affidavit:Bngaers/Contractors/Electricians/PInmb-ers -
Applicant Information Please Print Le2bly-
Name(Bitsiness/Orgam�a ion&&vidna0:. --
Address:
City/Sta&Zip� y,��� Phone.#: --`�=--
Are you an employer?.Check the appropriate-box: T of o'tet
4.. I am a eral contractor and I � Pr ! (re4 ��-
1 Qy I am a employer with _ ❑ I 6 ❑New oonstraction
employees(full andlor part-tinoe).: have hired the sub-contxactois
2_❑ I am a sole proprietor or partner listed on-$�e:attached sheet 7 ❑g
ship;md have na=vloyees Thesesib-cantradozs 1aave 8. 0 Dei361ition
for me m qM?Ia__yees-and_-have woticeas'.
working' �y Y- �_ - �;�I �ga�fi' on
S. ❑ We am a, on and its IO.Q$Iectriari repairs additions
'3-❑ I am a homeowner doing all work o �De-r. - their 11.Q Piet ring repairs or additions
o worlorss' rift of exenion per
Mysex MCL
- 12 C .Roofn
152,§1(41 and we have no
m t c:
employees:[No worlraas'.
comap.msumnee }•
'Any appficaaElhatclxcles-box gl=mistAw SII onrthe section below-showing doir d�s'aanpauarim po5cymfo®atica
#=c ans who suhtmt t}tis aS3 davit: mg they are deingall-wk and thes.Tms outside conoaeooas most snbmii a new.affidavit ina acting zxiL-
IConttacLors that dwk this box mstanadicd in adfitionat sbed:slowing Ste name of the snb-con� have
employee&7f the sub =vacioa hive empbYec5 CZ3'MUstVMvU &*mss.'cow-polic5'$ -
I am an employer that isp v dinaa workers'comps nsalioa insurance far my employees Below is the pobicy god job-site
information. `l
Insurance Company Name
Policy#oiseff ms.Lic: VII 1�" � 0�' i�p f�►. Eapirafion Date.-A
Job Site Ada>ess � L--� — ""fir City _
Attach a copy of the wort tre compensation poricy.declaradon gage(thawing the pglic number-and P.131 Lion date).
Failme.to secure eoveragt;as egiiii .Sechno f 11�G'L e 1'52 c'an lead in a of pea ies of a
fine up to 51,500.00 mWw one-year.h*ison�'as well as civil penalties in the fmm ofa STDP'F . (1RD�and a free
of up to$250:00 a_dog against�e laRm:Be advised t i a copy of thrs siate�ant maybe forwa ed tome Office of..
.._ _
�oIIS Q#"tI�C�IA fOitlIIStn�C txlyCra'lre'VC� OII: -- _ - _ _
C! !W �2 L7 Ofy t f�le ptfOlAl/itlOn7lO1S1iECallCtl`
S: - �- --- - _ g- V
Phone —i � - -
CWkW use only. Do not write at this meff,to be comp by.�V or iowh o
at or Towgn: Permit/Idcense#
Issuing Authority(circle one):
J.Board of Health 2-Building Department 3.City/Town Cleric .4.Detdrital Impector 5.Plumbing Inspector
6.Other F
Contact Person: Phone#:
i
SECTION 8---CONSTRUCTION SERVICES
8.1 Licensed Construction Syupervisor.ld Nott�Applicable ❑
Name of License Hoer � v 66,C) l r -t
6"`� \,
License Number
Address Expiration Date
Signature Telephone
1: r :t^ Not Applicable ❑
-Company Name Registration Number
Address -� Expiration Date
Telephone, 1� •
SECTION 1Q=liflORiCERS'ChAPENSATiSIN[NStICEF1DA1lli -
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.......Z9, No...... ❑
' w 0edmigia
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 1083511=
Definition of Homeowner:Person(s)who own a parcel of lalnd 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: 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 bnildigg 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 -DESCRIPTIOICOF P ED W RK Icheckali aptllica t
New House ❑ Addition ❑ Replacement Windows Althration(s) ❑ Roofing ❑
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [Oi Decks [p Siding[p] Other[i�Q
Brief De � i
Work �`�t'
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. 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. Wi1F.building conform to the Building and Zoning regulations? Yes NO.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7�=OWNERAUZM:iORikT.ION TOSE_COMPLEI ED WHEN .
OWNERS AGENT.OR CONT#tACTOR APPLIES FOR BUIIMIIY PERMIT
as Owner of the subject
property /
y
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
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 pajp and Wnaltie s of perjury.
Print Name
Signature d—owner/Agent \ Date
Section 4. ZONING All Infomatiot Must Be Completed.Permit Can Be Denied Due To Incomplete Information a
Existing Proposed Required by Zoning
This column to be filled in by
Building Department a
i
Lot Size ----~ i
Frontage I —
Setbacks Front
Side L:= R:= L:r---�� R:=
Rear t
Building Heigbt �
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces t
Fill: 9
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:]
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES 0
IF YES: enter Book 1 ? Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW 0 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 ® NO tM
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
IF YES, describe size, type and location:
r
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.
tiuitaing uepartment
212 Main Street
G� Room 100
Northampton, MA 01060
°
�ph ne 413-587-1240 Fax 413-587-1272
TO STRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
pmOSi,M
SECTIQk-1 W-17E. IFORIIIIATION1
1.1 Property Address: This section to be compreted"byoffice
N �
SECTION 2-PROPERTY<OWNERSHIPIAUTHOWMDAGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Anent:
Name(Prim) - - Current Mailing Address: [�
Signature Telephone cam`
yi
SEGT1�13 ES'I't111IA"fED=t:EUC=TtON£O�7"S -
Item Estimated Cost(Dollars)to be fNciat(Is .an1Y
completed by unit applicant
1. Building (a)BURding Permit Fee
2. Electrical EstirriAted Total Cost.oi
Construction from 6
3. Plumbing BuNdrng Permit Fee
4. Mechanical(WAC) -
5. Fire Protection
6. Total=0+2+3+4+5) Check Number
This Section-For Official tfse G1n
Date
Building Permit'Number Issued:
Signature:
' suilding£ainmissionerinspec�arotHt�ldt►9s . :` - ' - Date
" 1
File# BP-2016-0928
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD01104(413)732-3922
PROPERTY LOCATION 55 LINCOLN AVE
MAP 25C PARCEL 052 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT d 19 0 Q 1 1 1 /
Fee Paid �21 21W
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL EXTERIOR WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existiu
Accessory Structure
Buildin,,Plans Included:
Owner/Statement or License 101877
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQIrI\IATION 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
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.
55 LINCOLN AVE BP-2016-0928
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-052 CITY OF NORTHAMPTON
Lot: -00 1 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0928
Project# JS-2016-001570
Est. Cost: $5456.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. ft.): 10497.96 Owner: GRINDEL JACOB
Zoning: URB(100)/ Applicant: URBAN & SONS INSULATION CO INC
AT. 55 LINCOLN AVE
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON.112112016 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL EXTERIOR WALL 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 1/21/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner