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17A-093 /40-?it PUTICIPOINS mass save conmeroa Savatirx v1,0 401,111 SY oftx...4.y - PERMIT AUTHORIZATION FORM 'T E/2-0\-( ()n il/Z , owner of the property located at: (Owner's Name, printed) c iz,1'n (AA- ,ot ;oi (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. Owner's Signature M/5/0 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 r&e.ifC..:1:-2E.;42-0.71.11-2Z---:r4W2 :0 ,.0,c---tfesatts ..._.., Deparz1.7*e..L.lt C:t''f'I..t7 :. 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F.s.1...1 1, 1 ilf,..e.oF.,;44fi0ze1..-4r1.of r,:i....a,•kz. - 341.-g271._:71-.27.1=simt T : 7 ;-_,.. 4, --7..7.-... .-...r.-1 inspector r II t CtiBtratt f.71'erS3n.: . II II .-----__._...-......1_-_-_,. _____ SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: / DI 2Os le) P) Number S o ��h � c License D-7 e s Expiration Date Addr ( 3rd 0:c6 Signature Telephone / • elliigNie 9. Re ere Home Improvement Contractor: 9/V CO Not Ap lic,a^ble Company Name ( Registration Number )SO C-h leoa d j 0 D. S Address Expiration Date ,T-1,44\ ---pn MA D I OCD Telephone 6//3 4L/ -di/ft/ 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 buildi permit. Signed Affidavit Attached Yes No ❑ 11. - Home 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. Defmition 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) Er Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition El New Signs [0] Decks ED Siding[0] Other[D] Brief Description of Proposed 6r r 042141 0��44+) /� ,/� �� e Work: c� , (�/x 1.x (.c.� r s < C 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. Numker of rooms in each family unit: Number of Bathrooms ti c. Is there a garage attached? d. Proposed Square footage of new constr .ction. Dimensions e. Number of stories? --.,, f. Method of heating? `�_ i -'laces or Woodstoves Number of each g. Energy Conservation Compliance. Massch. k Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is constructio• 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 Ta-OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I ( Q-((L u 1 as Owner of the subject property 1 `( hereby authorize , CJ)&W, to act on my behalf, in all matt rs`relative to work authorized by this building permit application. �` Signet.e of Owner Date I, \Q (50)&4-d t-141; S S , as Owner/Authorized Agent hereby eclare that the stateirnents and information on thr� L-61 r going application are true and accurate,to the best of my knowledge and belief. Signed under the pains and pe f alties of perjury. 1 Prli NI a/AC Print Name I ..--.x. i 1 DJ-) i I k' • a Signature of Own- '.'.e Date Department use only City of Northampton Status of Permit: "' P., Building Department Curb Cut/Driveway Permit v y` '"} 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Csi M , , Northampton, MA 01060 Two Sets of Structural Plans "c. 1l1 phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLI•,TION 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 ry( &ia.i•cc v(E 1 �i Map Lot Unit �Y Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: -re.( ' .a rr C�Lftd cJ(.E ,S- . . �t/ncz, r' Name(Print) Current Mailing Address: al ' Chi. i Telephone ` �f c c Signature pl -� � O �J 2.2 Authorized Aient: r I Ait, 4D -fr*-)a. -0.tali. A -AA A tla-100__S Name(Print) Current Mailing Address: f1 ) J 41 erdimoc t4/3-D( Lf- i/(L( Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building ) Cg Db, 60 (a)Building Permit Fee 2. Electrical ` (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection A it , ,C; 6. Total=(1 +2+ 3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0665 APPLICANT/CONTACT PERSON JAY BOLAND ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414 PROPERTY LOCATION 24 GRANDVIEW ST MAP 17A PARCEL 093 001 ZONE RI(I00)/URA(100)/WSP(58)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out gL q Fee Paid i� Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 101880 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO MATION 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 Demolition Delay _ 41K /`°7- r:—/f Sign e of Building 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. 24 GRANDVIEW ST BP-2014-0665 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-093 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-2014-0665 Project# JS-2014-001142 Est.Cost: $1800.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sq.ft.): 11630.52 Owner: CARR CHARLES J&TERRY A CARR&CHRISTINE M CARR Zoning:RI(100)/URA(100)/WSP(58)/ Applicant: JAY BOLAND AT: 24 GRANDVIEW ST Applicant Address: Phone: Insurance: 12 PISGAH RD (413) 214-2414 WC HUNTINGTONMA01050 ISSUED ON:12/5/2013 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 12/5/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner