24A-119 (8) 26 CALVIN TER BP-2017-0870
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 119 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.1144/2�A))
D( 8111_
Category: INSULATION BUILDING PERMIT
T
Permit BP-2017-0870
Project# JS-2017-001469
Est.Cost: $1780.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BRYAN HOBBS 83982
Lot Size(sq.ft.): 8450.64 Owner: EI,KINS NIRA HARPER
Zoning: URA(100)/ Applicant: BRYAN HOBBS
AT: 26 CALVIN TER
Applicant Address: Phone: Insurance:
346 CONWAY ST (413)775-9006 WC
GREEN FI ELDMA01301 ISSUED ON:l/18/2017 0:00:00
TO PERFORM THE FOLLOWING WORK:WEATHER STRIPPING, AIR SEALING,
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/4 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 1/18/2017 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0870
APPLICANT/CONTACT PERSON BRYAN HOBBS
ADDRESS/PHONE 346 CONWAY ST GREENFIELD (413)775-9006
PROPERTY LOCATION 26 CALVIN TER
MAP 24A PARCEL 119 001 ZONE URA(l00)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid p
Building Permit Filled out 99V
Fee Paid
Typeof Construction: WEATHER STRIP NG.Al LING, INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory 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
INFO ATION PRESENTED:
/ Atpproved 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
o ti lay
�
Si e B mg rcial 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.
Department use only
..A\ City of Northampton Status of Permit
A Building Department Curb Cut/Driveway Permit
l 0 212 Main Street Sewer/Septic Availability
\ Room 100 Water/Well Availability
\� Northampton. MA 01060 Two Seta 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
alv Cowtn Ie -race Map Lot Unit
Zone Overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,1 Owner of Record:
\w-c £-LKvr S ala- Cullum-Myr./ 1.164ra r phnn, MP
Name(Pnnt) Current Mailing Address:
213_ 1 l 1\10` 1 C_3410iTh
Signature l TelePhone( y 13) 3zo -3‘58
2.2 Authorized Aaent:
Name(Pont) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 11 80 (a) Building Permit Fee
2. Electrical V (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) 1180 — Check Number 40 QC! 66
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings 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 hued in by
Building Deponment
Lot Size / ✓�
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage 4e
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Findingr��tever been issued for/on the site?
lel
NO O DON'T KNOW YES o
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW g YES O
IF YES: enter Book Page and/or Document ft
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW jj) YES C
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained C Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES O NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO fl
IF YES, describe size, type and location:
E. WN the construction activity disturb(clearing,grading,�exc/avation,or filling)over I acre or is it part of a common plan
that will disturb over 1 acre? YES O NO EV
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
SECTION S-DESCRIPTION OF PROPOSED WORK(check allapplicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [Ca Decks (q Siding(0) Other(o7
Brief Description of ProposProposedW
Work: 2e,ki'tt'X' 5,'r>,fQit`CZ - o r sc'ax��\ 1flSutOhrse\
JJ.
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ' No
Attached Narrative Renovating unfinished basement Yes Ler No
Plans Attached Roll -Sheet
es. if New house and or addition to existing housing, complete the following'
a, Use ofbuilding '. One Family /d 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?
I 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 W0 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 73-OWNER AUTHORIZATION•TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
N1y Q CkOnS as Owner of the subject
property \ - ,�
hereby authorize tY'SGIY\ Ac) ns 7Netihr
to act on my behalf,in all matters relative to work authorized by this building p It application.
jee 11vUA-rvx'.Lat: turf 1- 10-
Signature of Owner Date
I, ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing appiitatOn are true and accurate,to the best of my knowledge
and belief
Signed under the pains and penalties of perjury-
Print Name
Signature of Owner/Agent Oats
r SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction} iSupervisor(CSL) /YP 3 q t „51-y G+
_toEt`t kb }Z�• License Number X Expiration ate0
' pie if C' - Holder s /_ eencl�l�j List CSL Typo(see below
OM • .�i, yat v t y-ST" CX It.1 YP ) escr
Addrey� � //�-^� TYPe DESerCu F
gay do In 1'+ U Unrestricted(up to 35.000 Cu.FT)_,..
N.� tilt �:[ R Restricted iS2 Family Dwelling
Si(yneturc M Masonry Only
s�'�- /• ����" RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
B Residential Demolition
5,2 Registered
1 Reg eredlomeImprovement a r � ) /3Q C /
iSOC2 - ir `H1C>ompeny�arne or IC Re ant N.
Registration Number
<Ala LTrILAIO..y - ,zn--� ►_ .A 7'23"7
Address rrLL tt � t �t p
j figuLt., y`�" `� y�r}(js Expiration Datc
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 ..,,,...., r. No ❑
SECTION 7a:OWNER AUTHORIZATION TORE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, _ , as Owner of the subject property hereby
authorize ti)(\O,K1 tv)\--ms 1h3 to act on my behalf,in all matters
relative to work authorized by this building permit application.
• S€3,2. Q,Ik;kho-1ZQ\-Cor-.
Si:nature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si,ned under the pains and penalties of perjury)_
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program),willtrot have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I 19135:respectively.
2. When substantial work is planned,provide the information below:
' Total floors area(Sq. R.) (including garage.finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
The Commonwealth ofMoeaarhusetts
Department of Industrial Accidents
�:M Office of Investigations
r,
;f 600 Washington Sheet
— ' Boston,MA 01111
n" 'n www.mass.gav/dia
Workers'Compensation Insurance Affidavit: Bufders/Contractors/Electrldaus/Plumbers
AnPBcant Information Please Print Legibly
A]enit u ns rpntn on/lmlividuai): Bryan G.Hobbs Remodeling
346 Conway$I.
Address: Greenfield, MA 01301
city/Stat&Zip: Phone#: 3-'fie? -q Dotg
Arerrreyou an employer? Chec/kk the appropriate box: Type of project(required):
1. ya I am a cu*yer with fr." 4. 0 I am a general contractor and I 6. ❑New emoreNon
employees(fill and/or pan-lime).• ban hired the orb-contactors
2.❑ I am a role proprietor or parmer- listed on the attached sheet 4 7. Remodeling
ship rad have no employees These sub-contractors have B. 0 Demolitiw
working forme in any capacity. workers' comp. insarmce. 9. 0 Building addition
[No workers' comp, insurance 5. ❑ We area corporation and its •
required] officers have exercised ibex 10.0 Electrical tepaiia or addition
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself,(No workers' comp. c. 152,41(4),and we have no 12.0 Roof repave 11
!romance required.]t employees. [No worker' 13.51 Other i/1 sLiorfw e v
comp. insurance required.] 44.1 ey
*Any appliae Thai ctt'lwbot e l mut also fill . las maim below tewitr txir wain'cmmpoznlioo policy inforeadoa
t Homoowma lobo rhes rid affidavit Edct1q May an doing all wick sod dim hire outside cotmuion must auto*a ono affidavit Waring much
'Cunnmttu dart clock ddbox on tubed m uddiana.l abut.bowby tact Enna of @a ab-menton and to wooer`conp policy btfoi msncn
(am an employer that is providing workers'comtpe'umion insurance for my employees Below it the polity and Job eta
fafowatation
insurance CarpmyName: N i?'I GLIA st Atari at (1-1)171(41/ii_I
'olicy#or Self-ins.tic.#: i2-2 LAIC.5 17 CI d _ Expiration Date: i e/i_Gj/q-
ob Site Address: City/State/Zip:
amen a copy tithe workers' competaanoo Panel declaration page(showingthe policy number and expiration date).
allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ae up to$1,500.00 ani/or one-year iceprisamocnt,as well as civil penalties m the form of a STOP WORK ORDER and a fine
`up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
vestigations of the DIA fm insurance coverage verification.
lo hereby cent& the pains an/dpshies of perjury that the information provided above is rue and correct
mature i Dare: /01.21-a.
este#: - 17 S— cj a 01 i
Official use only. Do not writ d Mit area,to be completed by city or town official
City or Town: Permtt/ldeeme#
teethe Authority(drcle one):
t.Board�erof Health 2.Saucing Desartmeat 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector
F Other
:outset.Penna: Phone*:
ACORO
O°
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER{S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy{ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NACOMSRTACT Tracey Kul[lewicz
A.H. Rist insurance Agency, Inc. tb Far (413}853-4373 1 FAX w:(419/863-9655 _
159 Avenue A AD ADDRESS:
P.G. Box 391 PRODUCER 00009060
CUSTOMER IDP
Turners Falls MT 01376 INSURER(S)AFFORDING COVERAGE RAMP
INSURED INSURER A:Liberty Group
Bryan Hobbs dba INSURER e: _.
Bryan G. Hobbs Remodeling INSURER C:
346 Conway Street INSURERD:
INSURER E
Greenfield MA 01301 EISVRERP:
COVERAGES CERTIFICATE NUMBER:2017 CERT REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
:NSR TYPE6 INSURANCE .120L USR ROUCl/EPP Part UP
LTRatu POLICY NUMBER -IMMASONYYYLXIMADDAPNYL LAMAS
GENERAL LAMM EACH OCCURRENCE I$ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISETO RfNTE6 300,000
PREMISES(EA ENTED $
A I L--�CLAIMS/MADE X OCCUR LLL RS56084898 8/04/201600/04/2017 MED EXP{Any 0110 ! s 15,000
PERSGNALa AM INJURY
$ 1,000,000
GENERAL AGGREGATE :s 2,000,000
GENL AGGREGATE LIMIT APP LIES PER'. PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY JFc- ........... S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
,! 1,Doo,oa0
INF AEA/
ANY AUTO
A ALL CVrNEDAUTOS 881030738 01/02/2017 1/02/2018 90DILY INIURY As/pesos
BODILY INJURY AG accident) E
X SHIRED ULED AUTO$ PROPERTY DAMAGE
X HIRED AUTOS IPHREMYSILD
X NON-OWNED AUTOS $
X M955 PANE Funs S
A X I UMBRELLA LAB _X_ OCCUR DACE OCCURRENCE s 1,000,000
EXCESS WAD CLAIMS-MADE U2056094898 8/04/2016 8/04/2019 AGGREGATE S 1,000,000
DEDUCTIBLE 5 _
X REtENTION S 10 000 IS
.WORKERS COMPENSATION I I ' WC STAN ' .LOTH
AND EMPLOYERSUADMETY YIN
ANY
FlCER MEMBEFPARTEE%ECUTIVE NiA EL.EACH ACCIDENTOF
IMyaodeurr In NH) E L DISEASE-EA EMPLOYEFj$
DESCF ialnONo OPERATIONS Wow EL DISEASE-POLICY LIMIT Is
c $CRWfION OF OPERATWNSt LOCATIONS./VEthCLE$4Attnth AGGRO t01,ACdIioaal Renu,ki Shcedle,if mon..S.?ew/1m m
Classification: Carpentry 6 Insulation
CERTIFICATE HOLDER CANCFT I ATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Bryan Hobbs ACCORDANCE WITH THE POLICY PROVISIONS.
346 Conway Street
Greenfield, MA 01301 EUPHEMIZEDREINt65EMTAi14E
Tracey Kuklawicz/DNP / j 9.
ACORD 25(2009/09) 6)1988-2009 ACORD CORPORATION. All rights reserved.
INS025rcaser The ACORD name and logo are registered marks of ACORD
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 sold waste disposal facility, as definedbyMGL c 111, S 150A.
Address of the work: a o Ca\V(c le-T r Luce
The debris will be transported by: ---kyVp Nc�\ S Cd 61r
The debris will be received by: S Abs • ' S
Building permit number: 1
•
Name of Permit Applicant N \ra ELKY�S
A -10-1-1 ut 4-Lb—
Date Signature of Permit Applicant
4.
City of Northampton
I4 * Massachusetts F='
ddd s
l It r 1 t�/ DEPARTMENT OF BUILDING INSPECTIONS T- fa
f j; 212 Main Street • Municipal Building Ara. a
Northampton, MA 01060 itOln
Property Address: _ 4 ' 1 C(�\vm IfJf
\e-
Contractor
Name: �V\U11 1--,b\OS ROPIn A6A13 •
•
Address: TV CC,SnAI)( St .
City, State: Qc eSlc€A di , 1✓V(c
Phone: .4\--.& -- ---1-1S - 9(t;
Property Owner ` �
Name: 1VkY° Elk-Ar\S
Address: 2 k Cii\u-on Text
City, State: N ON( c.-r6 S
d`,)-tm MN
A�o ,�b4
I, 'iSr y cin„ (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
Federal IOM
RISE Engineering RI Contractor RmglRrauon No
MA Contractor Registration No
CT Contractor Registration Na
RISE60ShawmatRoad,Canton,NIA 02021 CONTRACT
ENGINEERING
339-502-6335 FAX 339.502-6145
Page 2
PROGRAM
CMA-HES EMOOEERINCI AROTHECIerWFORWORxus
mamma num
T -- __-- "14 DATE <utav Won ORM
Nira Elkins (413)320-3158 12/30/2016 444032 26102
•
oemCE'mar
26 Calvin Terrace 26 Calvin Terrace
BERIncs env.wrAn.Ma 0111110 CM.STATE,ZIP
Northampton,MA 01060 Northampton,MA 01060
JOB DESCRIPTION
BASEMENT DOOR:Provide labor and materials to insulate the back of the baseman door leading to the bulkhead with rigid board
as I2-10 or g.aer with thc required fire ming that moss ihe sections R-11654 and 316.6 requiremcmts of building code. Seal all
edges and seams with FSK tape.
SI 10.00
•
•
Total: $1,779.46
Program Incentive: $1,524.60
Customer Total: $254.87
WE HEREBY TO FURNISH 6ERVICEB-COMP LETE IN ACCORDANCE WITH ABOVE BPECIFICATON5.FOR THE BUM OF
"'Two Hundred Fifty-Four&87/100 Dollars $254.87
:moth FINAL ouPE<raN AND APPROVAL BY Rise£.CwtcRINO.Eta TORE.AGREES TO REMIT AMOUNT DUE IN TR,..OnERE.T OF I.m,.of<HmOED MONThlY ON Any
mOM.SEEREVERSEFOR IMPORT rIHFOMATUN on ou.R,U,TSEE,MICIMI OF ME.»IOM.ScuEOuUMo.ANDCOVTM,mTOR Rene .
-OiGEC.IGiuTURE m.a � onnomER AccEpiAN<F�r
Non:THO=mum MAY SE MINIM DATE Of ACCEPTANCE
ACCEPTANCE OP CONTAACt-1511AnavE PACES.
GAYS. AS SPECIFIED.PAYMENT WLLME NABS As MARINO MOVE MVEETmiImROEa TO 00 MS WORN
r
RISE60 Shawmut Road, Unit 21 Canton,MA 02021 1 339-502-6335
ENGINEERING www.RlSEengineering.com
OWNER AUTHORIZATION FORM
I, tire-r4- Liam.)
(Owner's Name)
owner of the property located at:
2c ' 2 &1A )tt
(Property Address)
(Pritreerty Address)
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.This form is only valid with a signed contract.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's
responsibility to close out this permit by contacting their municipality at the completion of this work.
r ` �
Owner's Sunature
i4 f b
Date •
6.2018