25C-143 (5) OWNER AUTHORIZATION FORM
(Owns Name)
owner of the property located at
d19-- L4.1
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( 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
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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