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17A-052 m!a,is i PERMIT AUTHORIZATION FORM I, Sandra Wolosenko ,owner of the property located at: (Owner's Name,printed) 156 Oak St Florence (Property Street Address) (City) 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. p� x Owner's Signature Date FOR CSG OFFICE USE ONLY Conservations Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Di For Office Use Only Rev.12132011 .�� fniy � ':W:. •vim. O;' f •�g1."arn^awn5s r�cictj.:�ea's> -.`T^' is Evi-`a�e:Zi:S _ .�--.-e-•-____ 1'�-'z�-r-- •+' ..:s... ..�.r.'r:•.^ �ir.�•i:acv" fie 'ltf3°L�?°� i 1.eiic,.Pfrc; LnQ [, 105.-L� ==v�� . 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T °t"f 'SS A^'47� r•:t ni2?f ii-fbi sil7.ided o sro t..+—ce vi 1 l:.il ^ut�F C n t i.a_. iII?189i?°ES�O1Lz G�iin6 rR�:#� si35 3i :fry^O: ZS. �:e,.4 --won. `iOg1-:M21•f-Zelllffil ..,-dd?5.:,3sL-f! t_ri -,-& 'Z �U_,c�r_t r.--. r._.r r:j`":�";'fi'°_-r�{'%r.� s: i'f'_i "'� �_ ""j='•` ::i _anti _ 1: �� e.-'{...fad.Lit: horm= �-4 i7j— io�'j�3' 3� 14 if v.,Xy°•irFis{[z-=•:'.'`fib%!. ?.�{t ark`.t,L'e'�i: .:T t:::S G17C i ;,: .vz ..___2i'c£;':-' L:3: - +. s._ sK,ari:.�t. `i AZ dasv-.=zy s 5_ E;aa.atrzg _s�ea;�r 14 CL odaes- Version l.7 Commercial Building Permit May 15,2000 SECTION 10-STRUCTURAL PEER REVIEW(780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No SECTION 11 -OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR c�BUILDING PERMIT ✓ ��c) as Owner of the subject property 6o s hereby authorize 6—A 4 my— to act on my behalf, in al afters r lative to work authorized by this building permit application. 3 �s Signature of Owner IDate as Own(Authorized Age ereby dec are that the statements and information on the foregoing application are true and accurate,to the best of my knowledge belief. Signed u der the pains and penalti'f perjury. v Print Name Signature of OwrWAgdW Date SECTION 12-CONSTRUCTION SERVICES 10.1 Licensed Construction u rvisor: Not Applicable ❑ Name of License Holder License Number � �- IDS Ad ress Expiration Date . , l'� �DS� 9 Si nature Telephone SECTION 13-WORKERS'CO N ION INSURA CE A VIT(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 a No 0 Versionl.7 Commercial Building Permit May 15,2000 SECTION 4-CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs❑ Additions ❑ Accessory Bull ing.Q, Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other "�7t Brief Description Enter a brief description here. Of Proposed Work: 61, Atfi(r t' I/U'r t A— a(r'v41) 1 f SECTION 5-USE GROUP AND CONSTRUCTION TYPE USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A-2 ❑ A-3 ❑ 1A ❑ A-4 ❑ A-5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B ( ❑ F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 38 ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY Floor Area per Floor(sf) 1 St 1 St 2nd 2nd 3rd 3rd 4 t 4"' Total Area(sf) Total Proposed New Construction (sf) Total Height(ft) Total Height ft 7.Water Supply(M.G.L.c.40,§54) 7.1 Flood Zone Information: E7.3Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ al ❑ On site disposal system❑ Versionl.7 Commercial Building Permit May 15,2000 8. NORTHAMPTON ZONING 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/Finding ever been issued for/on the site? NO Q DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DON'T KNOW 0 YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW (D� YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O NO O 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 Q IF YES, describe size, type and location: E. Will the construction activity disturb(clearing, grading, excayation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only ity of Northampton Status of Permit: uilding Department Curb Cut/Driveway Permit [ 212 Main Street Sewer/Septic Availability Elec�ric. F Room 100 Water/VVell Availability rthampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANG USE OR OCC OF,OR DEMOLISH ANY BUILDING OTHER THAN A ONE O TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: '4I 3- -�3(e` 3(o6l'f L!13­-6 `q`f Signature Telephone 2.2 Authorized Agent: Name(Print) �� Current Mailing A ss: LI(3-UV( -3t '3>0 Signature ' Telephone SECTION 3-ESTIMA C STRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 6T) (a)Building Permit Fee i 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Building Permit Number Date Issued Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-0988 APPLICANT/CONTACT PERSON JAY BOLAND ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414 PROPERTY LOCATION 156 OAK ST MAP 17A PARCEL 052 001 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 Vor (500 Fee Paid 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 INFORN JATION PRESENTED: pproved 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 D o 'tio Delay Z71K Sig re f u' d' g Off 'a 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. 156 OAK ST BP-2014-0988 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 17A-052 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: BuiWjag DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2014-0988 Project# JS-2014-001710 Est.Cost: $1000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sq. ft.): 6229.08 Owner: WOLOSENKO SANDRA L Zoning:URB(100)/ Applicant: JAY BOLAND AT. 156 OAK ST Applicant Address: Phone: Insurance: 12 PISGAH RD (413)214-2414 WC HUNTINGTONMA01050 ISSUED ON:312712014 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 3/27/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner