23D-084 (2) 53 WARNER ST BP-2017-0678
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:23D-084 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:IM2,.WILBUILDING PERMIT
Permit rt BP-2017-0678
Protect# JS-2017-001110_
Est.Cost:$1789.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group'.,._ URBAN & SONS INSULATION CO INC 106062
Lot Size(sq. ft.): 25308.36 Owner: Nivegn Ismail
Zoning:URB(toO/ Applicant: URBAN & SONS INSULATION CO INC
AT: 53 WARNER ST
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGF I ELDMA01104 ISSUED ON:11/15/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:ATTIC INSULATION(CELLULOSE)
POST THIS CARL) 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: Oii: 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:
FeeTeDe: Date Paid: Amount:
Building 11/15/2016 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
•
F,
Cir/or No nharnpton
auildrig Department
212 Man S1reeIII �S v r5on A a pili.y-
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I
._ Doom 100 I J tr,°)v a A is l c ty = =..
E
Nc h nl or MA 01067 wo n'e'sc Srcrmr Pzcs
pIT------- �orie 413-5871 ?u Fax 4'1358( 1270 IOVS.='ol _
101nat So ct/ - -T-I
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OF TWO FAMILY DWELLING
1 SECTION 7 -SITE INFORMATION
1.7 Pro22oert Addr=_ss — Tnis sealer to-be completed by office
IBJ \\, - ,...RI,\“-<, 114ap Lo Lh I.
Zon Overlay Dlstact
Elm t Ca Dstric -
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT li
2.1 Owner of Record: �
\ V'a-rA ,Se,-1\}>\ -S\ a \' RI -r. \2 ST 1
Name(Print) Current Mailing Address: p- \ SQ� ._.s
Ci \ I
L
Telephone
I Signe:ure i
2.2 Authorized Acent:
---Totiv Y \-kV\H 5 LA(6- y SSt�Y,
Name(Pont) Current Mailing Ac Dress:
Signature - ashore 1
SECTION 3-ESTIMATED CONSTRUCTION COSTS 1
1 Item j Estimated Cost(Dollars)to be Official Use Only
completed by oermit apDllcnt
1. Su(dino ) (a ) Building Permit Fee F
2. Electrical 1 (5)Estimated Total Cost of
I Construction from(E,
3 Plumbing IBuilding Permit Fee
1
4- Mechanical(HVAC)
I 5. Fire Protection
15. Total=(1 +2-3.4,5) A -1g9 (,C,heckNumber / 739- � its 1
This Section For Official Use Only
iBuilding Permit Number 1 Date
��� sued_
I signature -..0 I 7/"ZS/,/ 1
I Building Commissioner/Icspec'or hi B uudin;s Date
0
Se; on 4. 7C,EMING fi Informarren Must Bemeted P Ian Be Denied Due Ts 'ncomplete Informanvo
Exostmg 1Proposed I Required by Zoning I
1 ?hs column o.411ed it by
3ui gDepanenl
Lot Sore ---T I
1 Frontage I I Setbacks Front __
Side L ,.. R _. r _ R _
Rea ___ _ 1 _, —
Euiidcg Height —
i I
Smig. Square Footage �_ 1 __ % I r
Open Space Footage i
--
(Lot arfianfifioos cc&pared 1 ___
Parking Spaces j[ -- --
I1 4 f. t :
Dion &7armor.;
A. Has a Specia'.Permit/Variance/Finding ever been issued far/on the site?
NO 0 DONT KNOW Q YE 0 ,
IF YES, date issued:
IF YES: Was the permit recorded ac the Registry of Deeds?
NO 0 DONT KNOW 44, YES 0 I
IF YES: enter Book l Page: and/or Document#:
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW g YES
IF YES, has a permit been or need to be obtained from the Conservation Comm'ssion
Needs to be obtained 0 Obtained 0 , Date Issued:—
C Do xis on the rap r ? YES Vii' NO
YES, descrabe size, type and tocation:
D. Are there anycopos_d changes to or additions of signs intended for the property? YES n NO
IF YES, describe er woe ands Jon
E. Wifihe constractiona Imy disc (cleaning, grading. excavator. or filing, over I acre or is It partof common Plan
that wi,l cistub over _e en vIrS 0 NO Q
S then a Nc ihamptoc Storm Water Management Pe;ali Morn the DPW is required.
I
I
li
SECTION 5-DESCRIPTION OF PROPOSED'NJORk fcheck ell acolicasie)
New House n I Addition ❑ I o ment Windows PJT_fation(s) I Roofing I
Doors
Accessory Eidg. ❑ Demolition U I Now Signs [Di Deck=_ f(] Siding IC] Othar ]
Brief Description of Propose
Work: '— + 1 )G1� '7 p0 a
Alteration of existing bedroom Yes No Add;ng new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
sat!`Nevi/house and or addition o existdria houshor. cornu ue the`oIot dndr
a. Use of buildingOne 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 Vtfoodstoves .Number of each
g. Energy Conservation Compliance- Masscheck Energy Compliance form attached?
h. Type of construction
Is construction within 10C R. of wetlands? Yes No. Is construchon within 100 yr fl000plain Yes No
j- Depth of basement or cellar floor below finished grade
k. Will building conform to the Budding and Zoning regulations? Yes No F
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 p.�
hereby authorize ‘ ���y +'���-'�5 ��S;S.\ \t \
to act or my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
- 1•••••—iai as OwneriAuthorized
Agent hereby declare that the statements and Ind;0.M•n on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and
enalties ofjury.
Qrl�n T �y
Print Nam
V V�
Signature of Owner/Arent C Date
.. 1iiST1ON 8-CDMSur.B.iiCFiSERVICES2.1 ,
N""ti �. � a:
Masora-0d n ru'
J onsv tion Smoeror. 5Ilcahl=
i Noma o _v = He � � ‘ �bUb2
L're'ise Ivnnber
sec
=ss
Ezprratcr.Dare
S5ndurq [telephone
B. Reai(ssffare(1}4 elmnrov=_meet Gon:r cror _ -`_ _. I Not
Applicable
;L"...kC\:::)t
Company Name
- Rec-station Nombe'
3� 1_�S3 :rtY s '� s�
Address Sanitation Date
elephoTs"\ 3z .
SECTION 10•WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152, §25C(6))
Workers Compensation Insurance afldavll must be co:apleted and submitted with this application,Failure to provide this affidavit result
in the denial of the issuance of the building permit.
Signed Affidavit Mashed Yes: E No . ti F
� .. — Home Owner txe.Dtidn
The current exernpdon for"homeowners" uas emended to(=lade Owns-oeuoied Dwellings of one(1) or ao ?families
and to allow such homeowner to engage au individual for hire who does coi possess a license provided that the owner a ots
as supervisor OMR 750. Sixth Edition Section 108.35.1.
Definition of Homeowner Person(a)who own a parcel of land on which ne/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 oeriod shall not he considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a dont acceptable to the Scalding Official.that he/she shall be
responsible for all such work performed under the building Der:nit
As acting Construction Snoervisor your presence on the job site will be required from thus to time,daring and upon
completion of the work for which this portrait is issued.
Also be advised that with reference to Chapter 152(Workers L pee anon) and Chapter 153 (Liability of Employers to
Employees for injuries.otrsulting in Death)of th_Massachusetts General Laws Annotated,You may be liable for p rson(s)
you hire to perform work for you under this poet.
The undersigned"domeowr-er"certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zo0ing Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
• as6Y7 he rh S 'Q;' de 0Fy'SSwc _,-,,
t. — 'tY ��1� t r fin] tions
16 -
0,a..6100 Evan,:�✓ r 0212 d
-6`,00.600_0.-"/M
www.rrtaas ^vii a
i in kers' Corapensa t InEdozszee Affidzyft _`ilkers/Cu,it z_:orE ct>•tc.iztms nt e:—Q
4.T60liicai t lmfaentatioD ,.,.y. ?ReneLFr nit Levddiv
Name(Sus.nessiOrgatlzano.✓nddi=viduaP): '� � -� >< t NiS_____ \\*. t V M. _
Address: r-D-')\eS' 1 \ r—� J c----c
.......
City/State/nip: SiesY/ :a, cAltPhone =:-1 ?-,,c") ..,..... n `73....,"Z
Are you zh employer? Check the app raprnzte box:
Ty-pe y^o, e of o e t (required),
S.� Iari ue_nloy rwt,h ( 4. (� Samag eza7 of c,rn sndI _
employees (full audio;part-time) * have hired the sub-contractors 6. ❑New v st,cion
2.11 I am a sole propuetor or partner- listed on the attached sheet, 7. L Remodeling
ship and have no employees These sub-contactors have 8, _ Demolition
working for me init . employees and have workers'
fly capacy. of 9. J Bvildi,.'g addtion
I required
oc' workers' comp. insurance comp in Gomm-nisi'
ornee
l r ny ed] 5. _ Weare a to.*pc+ -£ nand its 10.D rt e7 al repairs or additions
3.,_ I am a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or addihons I
myself [No worker..' comp. i.:,&ht of exempt o n per MOL 12.[ Roof jspairs
insurance required] t c 152, §1(4), aud we have no
employees. [No workers' Ie Other '- ``
e
comp. insurance require�d.l
ti tett...._
*Any applicant that checks box 01 must also Eli De the section hefow showing their workers'compestsaanon policy tri ma:ion.
':5o:mouton who submit this affidavit indicating they are doing of work and thenbire outside cum:actors must submit a new af5dr%t Indicating such.
tContractors that check this box must attached an additlona:sheet showing the manic of the sub-contractors and state whether or no:Arose entxss have
eahpio lees If the sub-cent-amiss have employees,they must provide their wotwrs'Comp policy number_
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 1 )N� C\ t,(�\
Policy;#or Seth-ins. Lie. #N r�g_g Ut��` �jb 0c3S Expiration Date: ‘ — A \� �(��,i.0
Job Site Address:S� \J {sC(,N- t---I A 1 CityiState/Zip]1A�1 k ��-r�'1� s I vICl '1 4r'4
Attach a copy of the workers' compensation policy declaration page(showing the policy number and e irat-on date).
Failure to secure coverage ay required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 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 Oce of
Investigations of t;e DLk for insurance coverage verification.
I do hereby cerpfy under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date: \\^---1 " \
Phone#. 4 -- >'L r3C) `)—QM '`�
Official use only. Do not write in this area, to be completed by city or town official I
I
City or Town: ....._ Permit/Licesse
Issuing Authority(circle one): II
I. Board of Health 2. Building Department 3. City/Town, Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
I Contact Person: Phone#: �I
... .� —J
Ci faStallebcflafttrs Gan
wriesuelts
"._ ,p 212 z e a Municipal sfsbfr,— Cobs-"h� off
r scan 1a. 110E0
'_N2FECT0a
Lnuis Hasbrouck Chuck Miller
Cuihd.nc cQmmissloner Assistant Ccmrniss%ones
H(,rlffPOWNER E)MPTJONACKNOft'LEDG'EMe,NT
The State of Massachusetts odlows the homeowner the right under 780CAMR 108.3.4 to act as his/Fier
' construction supervisor. The state defines "Homeowner" as, "Ferson(s) who owns a parcel on which
he/she resides or intends 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 home owner."
The building department for the City of Northampton wants any 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 buildo- a codes and re. r.slations. The inspection
process requires that the building department be called to inspect work at venous mages, which include
foundation/footings (before backfill). sonotube holes (before recur). a rough building inspection
(before work is concealed), insulation insaection (if reauiredl and a final building. 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 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
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 ,... �.......... _....
City of Northampton 212 Man Street, No:tha'mu'on, i✓I.9, 02060
Solid Waste Disposal Affidavit
In accordance of the provisions of MOL 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: S
The debris will be transported by: 'DC< ei)N\
The debris will be received by: � ic)��5L1 C
Building permit number:
Name of Permit Applicantcrti}�\
Date Signature of Permit Applicant
rTh
Property Address: .-912-) \CT
Nae: %, \ "t'5JS r SU\t ( OriA
Address: c s3S C3F(‹-C`/ �5
city, State: 'L-C Q-'4÷
Phone: r-- --;1\ 2
Property Owner
Name: , r.- \\
Cil,, State: \\,%?r 11/.. . c \ j
I, t G 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 at this affidavit
Contractor signature.--
4,111111‘.
ignature
Date \\` �` \�
r
`4•
RISE - aas,maRoad,Una 2lCaton,wrr2021,3311-5024335
ENGINEERING' untlallEagioaerboomat
OWNER AUTHORIZATION FORM
t. ►,iJe I5, t1
(Owner's Name)
owner of the nasty located at
034.4ta•P'' 47t
(AaPerty )
�.�.., ihr._ UMC
hereby authorize \-AK .-1--AS �I r1.3k i AUG - 2016
(Subcontractor) I I
an authorized s bmnbacbr for RISE Engineedng,to act an my behalf to a building
perm[and to perform work on my property.Itis form is caly valid with a scrod contract
�OwnVsSignature
�
b� Uro
Dela