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29-442 (2) BP-2021-2283 66 ELLINGTON RD COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 29-442-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) • BUILDING PERMIT Permit# BP-202I-2283 PERMISSIONIS HEREBY GRANTED TO: Project# INSULATION Contractor: License: URBAN & SONS INSULATION CO Est. Cost: 3845 INC 106062 Const.Class: Exp.Date:06/12/2023 Use Group: Owner: SODERBERG SANDRA L Lot Size (sq.ft.) Zoning: FFR/WSP Applicant: URBAN & SONS INSULATION CO INC Applicant Address Phone: Insurance: 165 STAFFORD ST (413)732-3922 A0159437003 SPRINGFIELD, MA 01 104 ISSUED ON:12/10/2021 TO PERFORM THE FOLLOWING WORK: INSULATION/WEATHERIZATION 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. Signature: ' , 512.nda, Fees Paid: $66.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner Department use only - City of Northampton Status of Permit: Building Department a Curb Cut/Driveway Permit 212 Main Street F�' / Sewer/Septic Availability Room 100 �,,� 6 Water/Well Availability Northampton, MA 0106Q7, ot-,, Two Sets of Structural Plans phone 413-587-1240 Fax 413-58, -R'}in ;-. Plot/Site Plans \Q ier Specify h` 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 `7 / CL �llr �s Map Lot Unit Zone Overlay District 1.Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: SIA--\.6N1 C.k)c . C .-.SZC-- 10V) E_\\\V\G--- c---( Name(Print) Curreni\ng_Address: �r, �o Telephon `-� Signature /-/y/(7, f 2.2 Authorized Agents Name(Print) 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 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) # 04 5. Fire Protection 6. Total = (1 +2+3+4+5) �{ c ""__..3 Check Number 1 014 This Section For Official Use Only Building Permit Number: g / aid 1.5 Date Issued: Signature: /".Z /2-/b1,0Z,/ 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 filled in by Building Department Lot Size r -----.---____._-I L-.__._._.- ._-_.__.... L___— ____-_--.--____=_---I Frontage Setbacks Front r_.. "__.,, Li I 1 Side L: _1 R:L_i L:____I R:_______.-.I Li L____ _I Rear L___I J I-----1 Building Height I C_-- 1 Bldg. Square Footage Open Space Footage I % (Lot area minus bldg&paved I�.__J 1_________I _ parking) . #of Parking Spaces El 1_____.1 [__1 Fill: (volume&Location) --i -__ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW Q YES 0 IF YES, date issued: 1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW la YES O IF YES: enter Book J Page 1 and/or Document #! B. Does the site contain a brook, body of water or wetlands? NO kt# DON'T KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained © , Date Issued: C. Do any signs exist on the property? YES O NO 0 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 'fit 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 Q NO e IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [1]] Decks [[] Siding[DJ Other iglki Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa: If New.:'house and or additioi to existing housinq;.completethe following: a. Use of building : One Family V\ 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? Jam. f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction �--7-1'' 0.\� �` 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. Will building conform to the Building and Zoning regulations? _ Yes No . 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 hereby authorize \ \ -\ C-----'\4\V to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date a iall I, 1Q ' ..N , as Owner/Authorized Agent hereby declare that the s atements an ' formation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains we-penalties of 'u . .\(-- VA V -Ii:-. \ C Print Name `\ \ J r` _- Signatur1eBf-9wner/Agent ', Date SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction+,Supervisor: � Not Applicable 0 Name of License Holder: 1 '� ` 1 t / b License Number 1- \ -1-- y \7 — \01_,-- cl_.----- Address \ Expiration Date 7 -ls Signs re Telephone 9. Registered Home`Improvement Contractor Not Applicable 0 ompany Name Registration Number \\QD S--c-t:* Address `_ Expiration Date Telephone I SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 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 X No 0 11. - Home Owner Exemption The current exemption for"homeavners"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 108.3.5.1. Definition of Homeowner: Person(s)who own a parcel of land on which he/she resides or intends to reside, on which there is,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 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 building 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 The Commonwealth of Massachusetts Department of Industrial Accidents M l Office of Investigations �r 1 Congress Street, Suite 100 Boston, MA 02114-2017 :5� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): V ` � ± SiL\S � 5\ u0LT Address: City/State/Zip:Sc4' `A\U--�' Phone#: �i �� 3� o O Are you an employer? Chec the appropriate box: Type of project(required): 1.R I am a employer with 1 - 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof re airs \ insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.1A Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. q Insurance Company Name: \1/4\ Policy#or Self-ins.Lic.#: '�0\�� 7" 1-1": —/ Expiration Date:Ck - �-- �-- z Job Site Address: 3'O ��,\AC�� y City/State/Zip:1 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 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 Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th• •am : • r,, •naltie Q(perjury that the information provided above is true and correct. Signature: '� \ Date: \-1,446 �` Phone#: \ Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 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 solid waste disposal facility, as defined by MGL c 111 , S 150A. Address of the work: The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant Date Signature of Permit Applicant • The Commonwealth of Massachusetts Department of Industrial Accidents Ziff r Office of Investigations 1 Congress Street, Suite 100 Cr,, i4. . Boston, MA 02114-2017 �,�s�•'�� www.mass.gov/dia Workers' Compensa ion Insurance Affidavit: Builders/Contractors/Electricia s/Plumbers Applicant Information Pleas Print Legibly Name (Business/Organization/Ind idual): i Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate box: T pe of project(required): 1.❑ I am a employer with 4. [] I am a general contractor and I New construction employees(full and/or part-time).* \ have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g. 0 Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. e are a corporation and it 10.0 Electrical repairs or additions 3. I am a homeowner doing all work o ficers have exercised the 11.0 Plumbing repairs or additions myself. [No workers' comp. ri:'it of exemption per L 12.❑ Roof repairs insurance required.] t c. 1 2, §1(4),and we .ve no 13.0 Other empli ees. [No wor.-rs' comp. ' surance required.] *Any applicant that checks box#1 must also fill out the section below sho g their .rkers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work a •the ire outside contractors must submit a new affidavit indicating such. (Contractors that check this box must attached an additional sheet showing the • e of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their wo' ers'comp.policy number. I am an employer that is providing workers'compensatio nsu nee for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensa 'on policy declaration page(' owing the policy number and expiration date). Failure to secure coverage as required un'er Section 25A of MGL c. 152 c. lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year ' .risomnent,as well as civil penaltie in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the vio .tor. Be advised that a copy of this sta -ment may be forwarded to the Office of Investigations of the DIA for insura'ce coverage verification. \\ I do hereby certify under the pai s and penalties of perjury that the information provided above is true and correct. Signature: D\e: Phone#: Official use only. Do not write in this area,to be completed by city or town officiaa City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: RISE ENGINEERING- OWNER AUTHORIZATION FORM Sandy Soderberg (Owner's Name) owner of the property located at: 66 Ellington Road (Property Address) Florence, MA 01062 (Property Address) hereby authorize Urban & Sons Insulation Subcontractor(to be filled in by office) 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 subcontractor, 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. )a-"( Owner's Signature Date/ICI RISE Engineering, a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 I Canton, MA 02021 1339-502-6335 www.RlSEengineering.com