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25C-143 (5) OWNER AUTHORIZATION FORM (Owns Name) owner of the property located at d19-- L4.1 � j ( roperty Address) (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering,to act on my behalf to otrta' v permit and to perform work on my property• 1 Owner's Signature E i i. ti _ u L4Dlq k4 s 41 i� i Tire Cotntnofntrealth of Massachusetts Depm-tment of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 -iviP ,.nz ass goi/di a Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business'OrQanizationlndividual): `sf�'�l. Li("� tti An �1.-��� L )�% � 6t J E%�Q:-H, L �t� Address: VA KV-(1 J . City/State/Zip: '/State/Zip: 1 ''1 o '_' 1. Phones Are you an employ-er?Check the appropriate box: Type of project(required): I am a general contractor and I 1.❑ I am a emploi�er with � G. ❑New construction employees(full and/or part titre). have hired the sub-contractors 2.;9 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition worldng for me in any capacity. employees and have workers g ❑Building addition (No workers' cotnp.insurance comp.insurance-1 required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all iYork officers have exercised their I L❑Phnnbing repairs or additions myself. o ,vorkets',com . right of exemption per MGL � S [N p I_❑Roof repairs insurance required.] c. lit_§1(1)_and we have no employees. (No workers' U.❑Other comp.insurance required.] *Any-applicant that checks box Rl must also fill out the section below showing their��orl:ers'compensation policy information. t Homeowners who submit this affidavit indicating iltcy are doing all work and then hire outside contractors must submit a new-atlida it indicating such. 1Contractors that check this boa 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. I ant an enrployer that is providing work-ers'compensation insurance for nri,employees. Below is the policy and job site inforrnadon. �^ , Insurance Company-Na. �.L V e_r=4; M i,{_ 'U,,A L i ,s Police##or Self-ins-Lic.#: u'j`__.^� ) ' : � �o),t7 ' (� t- Expiration Date: Job Site Address: 11 �� I I S T Q-'t:r City-/State/Zip:�Ior, ,. . ,M � A (� )0� Attach a cope of the wor[cers'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 crinninal penalties of a fine up to$1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day. against the violator. Be advised that a cop y of this statement may-be forn=arded to the Of of Investigations of the DI_A for insurance coverage verification. I do hereky cer dfi'under die pains and penalties of perjure that the information provided above is true and correct. Sinmature: Date: Phone M C, _ 3 i 3 a Official use only. Do not write in this area,to be completed br cio-or town officiaL City or Town: Permit/License r Issuing Authority(circle one): 1. Board of Health 2.Building(Department 3.City/Town Clerk 4.Electrical Inspector -5.Plumbing Inspector 6.Other Contact Person: Phone M SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Superviso/r�: Not Applicable ❑ Name of License Holder License Number v AuAnd-m MA oft) % o 1 a��� I � [�� Address: Expiration DateT— Signaffe 4F 8.Reallstered Home Im rovement Contractor: Not Applicable ❑ bffle Sa I bQtip Com an ame Registration Number Address f Expiration Date Telephone 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 building 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. 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) z-- Roofing ❑ Or Doors E3 Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding[O] Other[d] Brief Descripti n f Proposed i Work: �� L ,Ilr�IvSeo 2. 4Ln6 t' wI/s, 10yl Sills 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 s ? 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 as Owner of the subject property hereby authorize l�J to act on my behalf,in all matt rs relative to work authorized by this building permit application. Signature of Owner Date I, as Owner/Authorized gen ereby de tare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge bad-D lief. Signed under the pains and penalties of perjury. Print Name Signature o4l6meffgent 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: 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 a er been issued for/on the site? NO ® DONT KNOW U7 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW � YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO - IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,ex ion,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. 4 Department use only C)t,' f Northampton Status of Permit: i Department Curb Cut/DrivewayPermit \1 12 L ain Street Sewer/Septic Availability m 100 Water/Well Availability n9 m ton, MA 01060 Two Sets of Structural Plans p 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION 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 al�rd S 1 re�� Map Lot Unit ,�� �(1,�� Zone Overlay District 1�1 � Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ I bf It e� I Name Print) < Current Mailing Address: �� �VIJ &4-7 Signature Telephone 2.2 Authorized Agent: M A610s Name(Print) Current Mailh4 Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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 6. Total= 0 +2+3+4+5) P G> Check Number ot This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2015-0864 APPLICANT/CONTACT PERSON JAY BOLAND ADDRESS/PHONE 12 PISGAH RD HUNTINGTON01050(413)214-2414 PROPERTY LOCATION 41 ORCHARD ST MAP 25C PARCEL 143 001 ZONE URB000)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC&EXT WALL INSULATION New Construction Non Structural interior renovations Addition to Existing Accesso1y 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 INFORMATION 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 Signhfm,e'6f4WiIdiffig OTficial 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. 41 ORCHARD ST BP-2015-0864 GIS#: COMMONWEALTH OF MASSACHUSETTS MU.Block: 25C- 143 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-2015-0864 Project# JS-2015-001681 Est.Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO Const. Class: Contractor: License: Use Groin JAY BOLAND 101880 Lot Size(sq. ft.): 7666.56 Owner: PIAGGI ANTHONY&JULIANNE S SALZMAN Zoning: URB(100)// Applicant: JAY BOLAND AT: 41 ORCHARD ST Applicant Address: Phone: Insurance: 12 PISGAH RD (413)214-2414 WC HUNTINGTONMA01050 ISSUED ON.31I712015 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC & EXT WALL 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 3/17/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner