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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� -. $. Q DemoIibion ' working for is any capacity a Io._yees and^have workers' me a acitY 9; aiin ] 5_ El.We are a corpa. on and its 1 o Q£lecincal repairs or additions offices haveetCased their 11. 3.Q 1 am a homeowner doing all work Q Plumbing repairs or additions right of exempiron Per MGL Q myself[No words'��?P- - I2: .Roof' insurance raquired:]t �c-152,§1(4);and we have no - employees:[No w`arrrs ij`j�(�'_ , .3p insibranx. s aPP :mat f -bcm A-IIIISE dso fiR out the sw ian bd a*sbowkg ft*Wodmm' LOQ poNcy hifimodon. - . - . tt0.*,,..H,_�o��ID� C�O�.�WIIQS R'170 S�L�1S�iYit:7ii�$�atG d@IDg7II WDrJ[8��6.�e OQ S iIA15CSR�L S S�:RC-�Y127�IC�1Rg 511f�r . ' dirt check this box=ustanaebed=additicm Shed d owing me==of me Sob-CD*act=md Slate Whe&m-cw=td7DBtGIIl1=bate . e4loyem'If me lab-coin s bsOe MWkYUS:ftY mu[prwide Bra voodoos'comp-PoLCYz-vba - rinn an employer that ispmvMW workers'compemation insr wwe for.jay empleyem Below is tke policy and job.site informabox 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. Failure.ta•seciae coveaage:as ieoif dd°i r.Sechtron 23K-of MGZ c 152 can ra&6&e `of"c ii�a a of a fine up to 51,500.00 and/or one- i6v6scUMC4.as oven as cavil.penalties in the form of a STAR WCTLg-tIRDIIt ar.-a f w of up to 3250.00 a Aay against the violator. Be advised brat a copy of ibis statement maybe.fbtwarded to*C)ffev Of r}3 moons of the IA --' --_� -vennc auon: _ fur mstnranct coverage cu}Y xder tht pars aPau alties of thaf tke it foraarovidettve cstru� riec�-_y- Phone#� '�� -- ---- - 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#: 23o;snZIS 3ane►damdg pa3E3ourrd SA%R j Iwouao suasngoE zWjo olgS pus sME'I SunroZ leawl pm amS`=uwTjo ucndureg31ON 30 13`apoo Sulplmg ale3g aq3 q;lM aouc►Idaroo jo3[41pgisuodsoj saunvm pue sagnm„jauMO=O'L,pauS!srapun 0111 -Imnad slip japmr noel ao3 3poM mwjjod of wR noA (s)uosjod ao3 algae aq sai no `pamouud stAvI lwouar,)snasngoesseyq ag;3o(gpoa u!Suulnsw Sou sa! nftq ao3 s=Aoldwg o3 sj2Aoldurg3o f1!Ilge!'I)£SI ja3dego pue (uolmuadmoa.Sjoipot )Z9 jaidmo of a3U=Ja3 g3!M;eq;Pas!npe aq oW 'pans!si 1!t=d sup golgM 103 330M ag330 uOgalduroo uodn pue Suunp`ouip o3 au$3 mop pamrbar aq IpA&a;ls goiag3 uo aouasajd moA 3511.►= ns n5gan3;snda Sugoe sy jlffj F.V nq alp 3apon pamjojjad 313oM gans Its 30;01 sit sa3 aq llsgs ags/aq lsgl Igog30 Su. prig aq;o3 olggdaooe ui3o3 a uo`lEloil3O Sutplmg aq;ol;tmgns llEgs„tauMOamog„gonS •3ane&oamoq s pa3aplsa33 aq;ou psgs you 3sa -orq e m amoq and asp;alom spu;snoa oges aos3 V sapipngs uue3.io/pue osn Bons o3 djoss000e sam3on4s pagolap 3o pagoene`Sunlamp All 3 oMi 3o auo E`aq o3 papua3ut�t.1 `s! aiag3 golgM uo`ap!saj o3 spua;u!.io sop!sw ags/oq go!gM uo pue13o lo=d a uMo oqM(s)uosnd:3anMONUGH 35 n ,, aQ 'T'S'£'SOT uopaaS adglpH glxlS OU 2INZY-li5su3 its se n3Z 32aMO aql lEgl POPIA0.1a`asuaoq E ssassod lou swop oqM a3lq 3o3 ImpinlpII!uE aSESua O3 3auMoamoq gans Molle 03 pue salllwg(Z)OM; jo (I)auo3o SBIR110MG pal nano-.ranato opnlau!03 papua3xa seM„sjauMOamoq„jo3 uogduraxo 3uauno aqy ❑ ......ON ....—SQA Parpeuv Mepwv Peu61S -pwrad&gppnq aru;o souenssl ayl;o Ieluap atp w Ilnsai pun Ilnepyle situ awwd of ajnlle3 uoueogdde slrg rpm paglurgns pue Malduroo aq Ism Ilnepyle aoue3nsul uogesuaduroc)Sic-woM ` ((91 §`Z51�`l-J�I111 ItnlFnld�3�N\RIElSNi-NQI�.�/sN3dNlci�,S> lYt:-Ot i�lOLL�3S' —� auoydalal ales u04e1dx3 SSQJPPd 411 J jagwnN u04e4sl6aH FUN AU11011105❑ algeotiddV ION _ tea n_ _. rJIM 1- owtldolal arneu&g mea uoaeJl&3 SSWPPV q 31 MwnN asuaoll U1 �Jc JMOH asu62 jo aureN ❑ algeollddb ION :jDsWwHS uolPnJPwO Paeueon re s3�1A213S NOLLf 1211SN03-8 NOLL33s 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