24D-118 (2) Property Address: � �� kz f—.
Contractor
Name
Address:
City, Stater l
Phone:
Property Owner --�
Name:
Address:
City, State:„
(contractor)attest and affirm that the building I intend
to insulate does not ave 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.
r
Contractor signature
Date
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines"Homeowner"as, "Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building:department for the City of.Northampton wants person(s)who seek to use
the home owner.e-emption,-to act as their owrr-construction-supervisor,'to be aware that
by doing so you become responsible for compliance with state budding codes and
regulations. The inspection process requires that the-building department be called to
inspect work at various stages,which include foundation/footings(before backfdn.
sonotube holes (before-your).a rough budding inspection(before work is
concealed),insulation inspection(if required)and a final building inspection.The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical,plumbing&gas)-the
homeowner will be.responsible to make sure that the trades hired secure their proper
�ermits in conjunction to the building permit issued,and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
.(Home owner,/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued tome.
Date
Address of work
location
The Commonwealth oflylassachusetts
Department of lndustrial Accidents .
Office oflnvestiaations
600 Washington Street
Boston,MA 02111
www.mass govldia
-Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
APPUcant Information Please Print L2�hly
Name(Rolmesi/Orgaai mflndividvat}:
Address: .zS
City/State(Zip:s` Phone.#-
Are you an employer?.Check the appropriate'box:
Type of project
1&I am a lo- with 4.. Q I am a general con t<actor and I 6. Q New constivction
�P .hn . have hired the
- employees(fall and/or Part-time)-*.
2_Q I aai a sole proprietor or partner listed on-�e:attached sheet 7. Q R
. emodeling
These sub-contractors have
shill-�.hour na� -. $. Q DemoIibion '
working for is any capacity a Io._yees and^have workers'
me a acitY
9; aiin
] 5_ El.We are a corpa. on and its 1 o Q£lecincal repairs or additions
offices haveetCased their 11.
3.Q 1 am a homeowner doing all work Q Plumbing repairs or additions
right of exempiron Per MGL Q
myself[No words'��?P- - I2: .Roof'
insurance raquired:]t �c-152,§1(4);and we have no -
employees:[No w`arrrs
ij`j�(�'_ ,
.3p insibranx.
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Insurance Company Name: . RZ
Policy#of Self--ins.11c..0.%W��e � _ ��. Date:
Job Site Address: �\ C_ \
Attach a copy of the workers''compensation policy decbrifon page(showing the pgTcy number and expiration datej.
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OffCW use only. Do not wrfte in this arse,tb be comp _ by ctty or town ojia L
.City or Town- r6mAVUeense#
Issuing Authority(circle one):
J.Board of Health 2.Building Department 3.City/Town Clerk .4.Electrical Inspector 5.Plumbing Inspector
6.0ther
Contact Person: Phone#:
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SECTIONS-DESCRIPTION OF-PROPOSED WORK tthiwkialf aaoitcablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Rooting ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [0 Siding[0) Other%
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
a. Use of building:One Family 5,\ 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 constriction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masschedc 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. Wip•.buikiing conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a -OfidINER_ik 01sumION, TQDE_C pt D tlllFlEN _ -
OWNERS AGED).-OR CONTRACTOR APPE,M FOWx- H!!)1NG#�ERMIT
as Owner of the subject
property
hereby authorize 'JN
to act on rn behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.,
Print Name Lt
Signature of Owner/Agent 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 '*
Frontage
Setbacks Front
Side L:= R:= L:= R:= g�i----�
Rear l—!
Building Height
Bldg.Square Footage
Open Space Footage
(Lot area minus bldg&paved
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:_
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES ® NO 0
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
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 0
IF YES,then a Northaam ft Storm Water Management Permit from the DPW is required.
willaing uepartment
212 Main Street
S Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, ll� `tF` ONE OR TWO FAMILY DWELLING
4 1
SECTION 1 SITE INFORMAT[ON.;
1.1 Prooertv Address:
Th t3on to be completed'by office
� r Electric, Plum s1t{Spgt�pns Lpt
U rtnm�
�?�e OVeGla-�D'�sirtct
E(m SrE DfSQfC't` `� t;B�tsMcf
SECTION 2-. PROPERTY OVIN.ERSHIPfRitt EtOt t ED AGENT
2.1 Owner of Record:
Name(Print) Current MaiDng Address: 1�
Telephone `-
Signature
2.2 Authorized Agent-
.
Current Mailing Address-:: p�
Signature Telephone
SECTION 3-ESTIMATCkONSltICTION COSTS
Item Estimated Cost(Dollars)to be - - OlRdal Use oil
completed b permit applicant
1. Building (a}°Building:Pemttt fee
2. Electrical (b}'-Esbmafed lntaf Cost of
Construi�ion fom
3. Plumbing Building Permit Fee _
4. Mechanical(HVAC)
5.Fire Protection
OL
6. Total=(1 +2+3+4+5) '-')—7 S c? Check Number
This Section Forfficial'Clse On
- 3ate
Building!Permit Number. Issued:_
Signature:
Bui{dg_Commissronernnsor of_Buildings Date
AM
28 2014
Electric Plumhin �;-Ua 1r„
File#BP-2014-1129
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD (413)732-3922
PROPERTY LOCATION 11 CHURCH ST
MAP 24D PARCEL 118 001 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
Fee Paid P
Typeof Construction: AIR SEALING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildiny,Plans Included:
Owner/Statement or License 101877
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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
D
olitlQn D
Signature oMuil8inf0ft1ciaI 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.
I 1 CHURCH ST BP-2014-1129
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D- 118 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2014-1129
Project# JS-2014-001923
Est. Cost: $777.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. 1): 7100.28 Owner: HANNAH RACHEL&PAMELA BOCKOL
Zoning:URB(100)/ Applicant. URBAN & SONS INSULATION CO INC
AT. 11 CHURCH ST
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON:51112014 0:00:00
TO PERFORM THE FOLLOWING WORK:AIR SEALING
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 Sienature:
FeeType: Date Paid: Amount:
Building 5/1/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner