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17D-021 (6) illrfrt .0„,.....N i ip; 11 i I mass save COIIIRACNIt ia..3 snow vMrav flrrmncl PERMIT AUTHORIZATION FORM I, Nch u. itC lid-- , owner of the property located at: (Owner's Name, printed) i OS S Ave, Flo rtn e , (Property Street Address) (City/Town) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and /or weatherization work on my property. ,r ..< • Owner's Signature ... 0- 5E -1- e6 L3 Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project Participating Contractor Date Rev. 12132011 The Commonwealth of Massachusetts ,N,, Department of Industrial Accidents it? 1 - = ,`l . -=: Office of Investigations .7.1.':701 = 1 Congress Street, Suite 100 :77 Boston, MA 02114 -2017 ,1,7.7-1!:::::_s.t.7? www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Anplicant Information `.� e �J' � E-.111/es- Please Print Legibly Name (Business/Organization/Individual): / (/ "v (_) 4_ Address: PO ,& /c City /State /Zip: _ -i . LAS =• / v Phone #: Are yo n employer? Ch the appropriate box: Type of project (required): I. am a employer with 4• ❑ 1 am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑ New construction 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. 0 Demolition working for me in capacity. employees and have workers' g any p comp. insurance.: 9. ❑ Building addition [No workers' comp. insurance p' 10. ❑ Electrical repairs or additions required.] 5. ❑ We are a corporation and its 3. ❑ 1 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 12.0 Rpef re insurance required.] t c. 152, § 1(4), and we have no p employees. [No workers' I3 Other l-'7 -' comp. insurance required.] *My 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 tContnactors 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ? l,t>EW,i insurance Company Name: . Policy # or Self-ins. Lic. #: C / - 3) �5 7 �� 7 v� ` ( W Expiration Date: OS ` /3 Job Site Address: A k, tJ AL, i e i- City /State /Zip: 0 j cr ,,,,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 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 5250.00 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 certi the p .' ' penalties of perjury that the information provided above is true and correct. Si a.: L I,a . Aid Date) L_ Phone #: / y/3 -.)-,tb r c/7 / L' . 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 1 6.Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction S,u /�pr 6)4 Not Ap licable ❑ Name of License Holder : / d �r�e C o L/ Y J License Number Address Expiration Date /17 1/4 — 57- 7‘ C Y Si ature Telep one . Retlildered Home lmoroventent Contractor: Not Applicable ❑ 7 SA1 p ct— r - /6 r ComparlG me / Registration Number ' PC- f OK 7c)-76 C 4 4 3 ppc3-), 10176 — a u_ ((/ Address Expiration Date j � ZZ %a Telephone`� )J- 7 - 5 — SECTION 10- ' ® RKERS' 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 � No ❑ 11. - . :Bonne Owner Exemption,, 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 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors ED Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [ 1t•IG Siding [D] Other ] X 5 Brief Description of Proposed Work: /1"� c/� Nr h /f Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. if New house and or addition to existing housing,: complete the following: 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. 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 - ---<`! r7 ke , as Owner of the subject property hereby authorize �J C(2' 44 L to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, it A , as /Authorized Agent heresy .eclare that the sta ements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under,; paiin and pe alties of perjury. Print 1 ame Ainir Av -7 1 ? Signature • -gent 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Findi ever been issued for /on the site? NO 0 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Regi ry of Deeds? NO 0 DON'T KNOW YES 0 IF YES: enter Book Page, and /or Documen #,, B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES Q IF YES, has a permit been or need to be obtained from the Conservation: Commission? Needs to be obtained Obtained Q , Dat Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, exca tion, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES (C) NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Depa use t)y City of Northampton tat df'Permit REC��V�D - Building Department Curb Cut/Dnveway Permit 212 Main Street Sewer/Septic Avai :lability $ Room 100 WaterAell Availability rthampton, MA 01060 Sets of Str aural Plans • • • • = 41 - 587 - 124 0 Fax 413 587 -1272 PlottSite Plan Egli Duo F a n Ugr APSON NMp oCO6o Other Specify APPLICA TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Add This section to be completed by office �� J � '� �� J � Q Lot Unit l� ,/1 Zone Overlay Distr / / E lm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: LANCE BLACK 105 STRAW AVE Name (Print) Current Mailing Address: SAME Telephone "C / 7 Signature l//3" S 9,_ ,0 2. Autho ' ed A nt: n (:)/6c)--1 itt 11, Name (Pant) Current Mailing Address: ei /3—.Va 5 t X` Si Telephone SECTION 3 - EST ATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) toc be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated C Total Cost of Construction from (6)_ 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) �'; Check Number /(' a //5 Th Section For Offi cial Use Only Date Building Permit N umbe r : Issued: Signature: Building Commissioner/inspector of Buildings Date File # BP- 2013 -0910 APPLICANT /CONTACT PERSON JEFFREY BRADSHAW ADDRESS/PHONE P 0 BOX 1276 CHICOPEE (413) 427 -5481 PROPERTY LOCATION 105 STRAW AVE MAP 17D PARCEL 021 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out / j `� `V Fee Paid / / / `( J Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 094734 3 sets of Plans / Plot Plan THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 • .ti■ Dela / 9 , ‘?/--,-/3 Si! p e of Building icial 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. 105 STRAW AVE BP- 2013 -0910 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 021 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2013 -0910 Project # JS- 2013- 001555 Est. Cost: $2258.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEFFREY BRADSHAW 094734 Lot Size(sq. ft.): 9583.20 Owner: CAHILLANE RITA M Zoning: URB(100)/ Applicant: JEFFREY BRADSHAW AT: 105 STRAW AVE Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427 -5481 WC CHICOPEEMA01201 ISSUED ON:4/10/2013 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL ATTIC 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 4/10/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner