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24D-122 • . The Commonwealth of Massachusetts Department of Industrial Accidents oi g;3k=- Office of Investigations .t,„ E.'MILE; - 600 Washington Street =I•i"=• ° Boston,MA 02111 „„..“. wton:masegovidia , -Workers' Compensation Insurance Affidavit Buiders/Contnctors23ectricians/Flumbers • Applicant information Please Print Leebly Name : c'`C=” �, —t-YCi S 1�1"I�'T'v Address: ` icr"y �S� SPCn.P �i City/State zip:�yF'�) C.3 t ••\\') -phone#1 _ 7\0\° ...92 Are Iron anempleyeTCheek the appropriate boz; Type of fleet(required): /J 1.1gi,I am a employer with i 4.. 01 am a generaleonirertm and' a lave kixnd ds ssshcomraes 6. 0Newemishnrti� Iemployees am a sole(fop amYm ra partner- listed on @ie atnehed sheet 7. 0 R®odeling 201am aaolelkoprietm orpartoer These mbeommtraahavestipend leve aa employees - waiting frame in any capacity. �Y�to_3'ecs_aod5 woricea' y $m7diY ;a3dtG ego weans'comp.ksentoce —.....___. .:... -... rupmcdl 5.0 We aces and its 20.0 repairs orad&nom 3.0m 1aa bomeowoerdaingin worko have r 'n t 11.0 Nimbi*.repents a:additions uryselfxiettOfexemp_ Pa Ma tN regnant] t t• s:152,41(4x and we have no 12-D0 Boot S\ . t -1 t employees-[No waders'. . :.. -. comp.iosuraoee tetpmdd.) - .. . . • *Any atnchrJnhaAawash*Saawmeaaim Ldaeab,,.krra iiii::irweidoers'soccereettion isfantwice. - r Hamcovnacri see mama affidivitiar'•ting they are tag as work sod 9mh've ohmic cocersanis r lwitadnfna such. '.ontract=tat check alis•R2®Yamfhw Z1.srcamal Aga sboying,&m=oftaC»S(g9iatIaa and Valethefwnotaa- dt turn eatiployn 8&c aalit®P>o}'m.>hr_smtyav idtm�.nim'aa�aP^�9a�tica. _ I an,an employer tatsproailrag worhaa'conensatin iasw•mraeforayempioyeer. Betas is tree policy and job sire baformnosat C\ a 1\ _ inat¢m;n compaar rr� .�("~,c . ` \ Policy#mSeif--•iins.Lac,6: W\7.4%,CS.ADOS >Sb3 , VODrv.TemnunirmPatm +" i\},:.r• ` Q\VU.J Job Site Address :1 Y�c - , t sy/5lafr'Yap:`moi`) C.t N..i\` }• 17 t(:.4 v., Attach a copy ofne werker?conip notion Polley dadan*aa Portnoy?*the ppscy number andeapirotion date). Faime tasecure cordage,as regiiue t Sect x"7SABf7�3GI:'c 152lei&'ad tithe iitibIrm d1Z?jq¢tes ofa fine op to$1,500.00 aed/moa,-yearimpmc as well as civil palate=it the form ofd STDP WORCOP.DeRsada fm ofup taS23100 a diet agamsttheriolatt Be advitedtkat a 9093'adds nine= 5:rwailed ar9K i3!$'re.of ,m._ Y!o'hereby :.radar, Liiiiiiii. -77:-afpejmythat tireoQarararfanproridedrtbort traeaademnvet -dental ase only. Dona write in this area,to be compfalef by dry or town mel I .__ .. _ Qty or Town; Ptrmlt/Ucense# Issuing Authority(circle sue): 1.Board of Heakh Z.emitting Department 3.City/Town Clerk 4.Electrical jnspeetor 5.Plumbing Inspector 6.Other - Contact Person: Phone#: - HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 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 twofamily dwelling,attached or detached structures acrn ary 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 person(s)who seek to use the home owner exemption,to act as their owncoastrnction vinu.,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 Dour),a rough building inspection(before work is concealed),insulation inspection(iif required)and a final building inspection.The building department requires these inspections before the work is concealed, failure to secure these inspections can result hi 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 permits 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 nrressary for the building permit issued tome. Date Address of work location Property Address: Contractor \ Name: �\ips\l��i'-\ La S. J t‘-s, \—\9"Address: �YJ— G L \�f� City, State: SNK'syam--> (n�Q�' Phone: fl�� _ar c\ Property Owner r. \ ' Name: '�.��M�J N� Address: C\ c�- ' -t-.y �DVA Cay, State: V ' � �� M \w Th\VO M -\ \\ _ (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 c ,„„abe -- Date \‘. — RISE60 Shaw/mut Road,bolt 3I Cann,IM 02021 1339-5026336 ENGINEERING' wwR.mSEerghwerIng.com I n a ._ OWNER AUTHORIZATION FORM I, 51 MJ ss-)k A)) 1*-17 (Owner's Name) owner of the property boated ated at ( moony Address) (mayAdd' ) Mit (Property hereby authorize (Sub:cutback:1 an authorized submntractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. ivy-rider:.. a Signae f r is Date 7-9 HOOKER AVE BP-2017-0222 GIS#: COMMONWEALTH OF MASSACHUSETTS May-Block: 24D- 122 CITY OF NORTHAMPTON Lot:-001 Permit: Building Eate;:an: INSUL4TION BUILDING PERMIT Permit# BP-2017-0222 Project# JS-2017-000379 Est. Cost: $3649.07 Fee:565.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: URBAN & SONS INSULATION CO INC 106062 Lot Size(sq. ft.): 7753.68 Owner: GOLASH EDMUND Zoning: URC(100)1 Applicant: URBAN & SONS INSULATION CO INC AT: 7 - 9 HOOKER AVE Applicant Address: Phone: Insurance: 385 LIBERTY ST (413) 732-3922 WC SPRINGFI ELDMA01104 ISSUED O.N:849/2016 0:00:00 TO PERFORM THE FOLLOWING WORK: ADD CELLULOSE TO ATTIC SPACE 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: O= 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 8/19/2016 0:00:00 565.00 212 Main Street,Phone(413) 587-1240, Fax:(413)587-1272 Louis Hasbrouck-Building Commissioner File#BP-2017-0222 APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413)732-3922 PROPERTY LOCATION 7-9 HOOKER AVE MAP 24O PARCEL 122 001 ZONE URC(1001/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Bee Paid e4^..!/ 7/"�� �'7�(bC Building Permit Filled out (�„!� 41 �'" Fee Paid Typeof Construction: ADD CELLULOSE TO ATTIC SPACE New Construction _ Non Structural interior renovations AthIttion to EY1stina Accessory Structure Building Plans Included: Owner/Statement or License 106062 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION PRESENTED: pproved 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 PermitVariance* 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 CommissssiioonnrJ',/�J Permit DPW Storm Water Management itionDy,.414,010117# Tre 1/29.74c Si• :-. eo rfflelnig 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. mooing Ueper mem 5•.;. .u. i:: t - _ 212 Main Streetea ,a:,. • 6j:c6' Room 100 Northampton, MA 01060 phonet13-587-1240 Fax 413-587-1272 - ,ALTER REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1•SRE IifOIMfATlON f^.f�PmoervAdh#ess: ! This section to be completed by office. A . C,e'\C- t• wp Lot u�w o> C.RDflak '" SECTION 2-PROPERTY OWNER IIIP/ADTIOCAGENT et 2.1 Owrwr of Record: ... � oaSC>skkVA. Name(P* ) Coedit Address: Telephone Mumma /..2 Aut prized Aoers 3 \ � 1"Y S Telephone SECTXNR 3_asnewTEf£ONST#11eT1 tt'COsJS ` Item F_stinated Cost(Dollars)to be OfNial Use Only completed by Pert 1. Goading ta)Bu -PBimit Fee 2, Electrical (b)ESiiiiia ed Total of Co lsbuaton from(S). 3. Plumbing _ BuldingPennit Fee 4. Medwnirai(HVAC) 5.Fue Protection _ " S. Total=(1+2+3+4+5) 3 yLen V 7 Cheds Nunbee Ura".S This Section Fol Official Use Only SuiidFng PenniRNhmber: Issued. Signature: BoXdip GummissioodfnNe efBuntNs - Dab" Section 4. ZONING All InfanaHon Mat Be Completed.Rank Can Be Denied Due lb Incomplete Information Existing Proposed Required by Zoning This whom to be filled in by Building Dcpaanet Lot Size • Frontage Setbacks Front Side L: R: L: I R: I I I Rear Building Height Bldg.Square Footage 16 Open Footage lot area minuM bg&p ( paved I i ( I I Wkag) #of Parking Spaces Fill: (volume&loorim) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW AO YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES IF YES: enter Book r Page and/or Document#i B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: F C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property? YES O NO IF YES, describe size, type and location: 1 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 aae? YES © NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SEC41ENi e_CONS RUCtION SERVICES 8.1 Lkansetl CatteWe-tl- i SS�u.�rorvis_or: • t\ Not Applicable ❑ Name oLOSEI filer nJCI�A;w� — \� \9bp b/� License Number Epaabon Date —__ _.- Noi Applicable Th-Cy-S.,\ SLC Constlaine isaaa"fiumber c_ti‘ Address Expiration Date Telephone' . • - SECTION 10 WON s!ca ENSATION INSURANCE AFFIDAVIF_(M.6.LC.]52,§25C(f)) Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result in the denial oft the issuance of the building permit. Signed Affidavit Attached Yes S. No ❑ 4 The anent exemption for"homeowner"was extended to include Owner-mem/red DweIlia of one(I) or two(2)families and to allow such homeowoa to engage an individual for hire who does not possess a license,provided that the owner acts as saoervbor.CMR 780. Sixth Edition Section 10835.1. Definition of Homeowner Person(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,oris intended to be,a one ortwo family dwelling,attached or detached structures accessory to such use and/or farm sfnuaures A person who constricts 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 mieh work performed ender the buntline 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,von 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 Ga City of Northampton Ordinances,State and foal Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTIONS-DESCI JPTIONOFPROPOSEDWORK..tUsd€ataputkabW) New House 0 Addition . .. ❑ Replacement as Windows Altention(a) ❑ Rooting 0 Or Doors Accessory Bldg. p❑ 000n. d-�tian 0 New Signs (CI Decks [Ci Siding 1 Other Ng wo i S d E \,\\ S`Iz TAS Alteration of misting bedroom Yes Ps No Adding new bedroom Yes •a No Attached Narrative Renovating unfinished basement Yes `c No PlansAttachedAttached 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 Compbance. 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. WMbuilding conform to the Building and Zoning regulations? Yes Na. I. Septic Tank City Sewer Private well City water Supply SECTION Ta-OWUERAUTHCRZ *1I€tL TDBESSOMPLETED WHEN OWNERS AGENT-OR NTRACTORAfWlIES FORW DINGFERMR 1 `. Sit 4 SS �\ Czr,rj\b5\-\ as Owner of the subject property �.. hereby authorize � \ 'j' -�Ns � c iA to act on my behat,in all matters relative to wort authorized by this building permit application. t —iiiiimmiimummimic Sipnavae of Owner Date \\.1 as OvmedAuthorzed 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 penally' of perju ‘--70� Pant Name t��r„�_ Signature of• - Agent _ Date