18D-011 ! ] 0002/0002
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07/22/2015 16:23 14135871272 N7pN BLS} DEPT
` Property Address: •
Contractor
N � r
Name:
Address: .�—�--
city, state:
Phone: �.... �°
Property Owner---,
Name:
^--�
Address.
city, State:
(contractor)attest and affirm that the buf{din 9 I intend
to insulate does not have any opens air(knob and tube)wiring In the spaces to be insulated and
that I have provided the property owner w6 a copy of this affidavit
Contractor signature
Date
C)
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
C-� Aje�
(Property Address)
too� -P - ,
(Property Address)
hereby authorize
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
permit and to perform work on my property.
• u
qwner's gnatu
Date
` The Commonwealth o`Massachusetts
Department of Indttstrial Accidents
r =' Office of Investigations
600 Washirr-ton Street
-- a
Boston, MA 02111
wwwanass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leaibl
Name (Business/Organization/Indi vi dual):
Address: C3�
City/State/Zi " 1-4+ Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working or me in an capacity. employees and have workers'
g Y P n'• 9. ❑Building addition
[No workers' comp. insurance comp. insurance.f
required.] 5• ❑ We are a corporation and its 10.❑ Electrical repairs or additions
f
oficers have exercised their
3.❑ I am a homeowner doing all work 11. Plumbing repairs or additions
myself. ' . right of exemption per MGL
Y �o workers comp. 12.❑Roof re irs
insurance required.]t c. 152, §1(4),and we have no Sv l
employees. [No workers'. 13.;4\Other 1`7
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the nacre 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 am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information. y\
Insurance Company Name: ��� S;I-A
Policy#or Self-ins.Lic.#: Expiration Date:
�� A
Job SiteAddress�` IL
��- City/State/ZipNkZt -.� ��v
Attach a copy of the workers' 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 criminal 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 copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the poi _ penalties of pecjut that the information provided above vis�true and correct.
Sienature: Date:
Phone#•
Of use only. Do not write in this area, to be completed by city or town offcciaL
City or Town: - - Permit/License#
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#:
01
" M
Version 1.7 Commercial Building Pen-nit May 15,2000
SECTION 10-STRUCTURAL PEER REVIEW(7S0 CMR 1!10.11)
Independent Structural Engineering Structural Peer Review Required Yes No 0
SECTION 11 -OWNER AUTHORIZATION-TO;BE COMPLETED': WHEN:!
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, r_. __ . ...... .... ...._ as Owner of the subject property
hereby authorize` _......... . _ _._.... _. _.__. . _ to
act on my 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 qhe...pains d penalties of perautryh ,�-, „ _ _.-,- ,,, ,-�, Nr,,,
Pint Name _...
Signature o wner/Agent Date
SECTION 12-CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor Not Applicable ❑
Name of License Holder: � N��-
License Number
ddress Expiration Date
Signature Telephone
SECTION 13-WORKERS`COMPENSATION INSURANCE AFFIDAVIT(M G.L,c.1527§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 0
Version 1.7 Commercial Building Permit May 15,2000
SECTION 9-PROFESSIONAL DESIGN AND CONSTRUCTIOWSERVICES-FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116(CONTAINING MORE THAN 35,000 C.F.OF EKLOSED SPACE)
9.1 Registered Architect:
�__.�.... _,,_._.._. ........ . .....__._ __._...__ _..__._.._,.._..�...._____._._._. ._.____._ .- Not Applicable ❑
Name(Registrant): _... _....... .. ........:.... ,._._....,.,
_._.._. _.. _.. ,._.. ..._... - .-
Registration Number
Address
Expiration Date
Signature Telephone
9.2 Registered Professional Engineer(s):
__...
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name Area of Responsibility
Address Re istrabon Number
I �
Signature Telephone Expiration Date
i
Name Area of Responsibility
t
t
Address Registration Number
_.. _......_ ... . ....... .. __.
Signature Telephone Expiration Date
.......... ........... ......._
......_.......
Name Area of Responsibility
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable ❑
Company Name
Responsible In Ch4qlge of Construction
-Address,
Telephone
Versionl.7 Commercial Building Permit May 15, 2000
S. NORTHAMPTON ZONING
Existing Proposed Required by Zoning ,
This column to lie 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 DONT KNOW 0 YES
IF.YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW,.__., YES . ......_
IF YES: enter Book ' Page and/or Document#1
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES
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 0 NO
IF YES, describe size, type and location:
_ .......-;
D. Are there any proposed changes to or additions of signs intended for the property? YES I NO
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 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Version 1.7 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 Building❑
Exterior Alteration ❑ Existing Ground Sign❑ New Signs❑ Roofing❑ Change of Use❑ Other S� I
Brief Description ;Enter a brief description ere � ����- ''- IC,
Of Proposed Work:
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 ❑
I,
E Educational El 2B F-1
F Factory ❑ F-1 ❑ F-2 ❑ 2C ❑
H High Hazard ❑ - 3A ❑
I Institutional ❑ 1-1 ❑ 1-2 ❑ 1-3 ❑ 3B ❑
M Mercantile ❑ 4 ❑
R Residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A ❑
S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑
U Utility E] Specify.
M Mixed Use ❑ Specify ,
..,... m. ........
S Special Use ❑ Specify
COMPLETE THIS SECTION IF EXISTING: UNDERGOING RENOVATIONS,ADDITIONS AN D/ORI.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)
_....... 1st
2nd ,.. _. _.... . .. 2nd _
3 rd 3rd
4 h . .,..._... ,...___.___ _ 4m
Total Area (sf) Total Proposed New Construction s
Total Height(ft)
Total Height ft
7.Water Supply(M.G.L.c.40,§54) 7.1 Flo od_Zone,Information: 7.3 Sewage Disposal System:
Public ❑ Private Zone Outside Flood Zone❑ Municipal ❑ On site disposal system❑
Version 1.7 Commercial Building.Permit May 15,2000
Departme t use only
ity of Northampton Stat us at 06rmit
w j uildin Department Curb`Gut/Driv6v a Permit"
2 2��� ��.� 9 p Y
212 Main Street Sewer/SepticAvarlabrfity
Room 100 Wate'60§l Avallabi i
Flect ic, C ( spEC1!
•_ ,o R1� hampton, MA 01060 Two,Sets of StructuralPlans
�pfiorte -587-1240 Fax 413-587-1272 Plaf/Sife Plans``
Other Specify .
APPLICATION TO CONSTRUCT, REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR 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
L
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
rt
Name(Print) Current Mailing 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) Check Number `D 5
This Section For Official Use Only
Building Permit Number Date
Issued
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2016-0082
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD01104(413)732-3922
PROPERTY LOCATION 1 COOKE AVE
MAP 18D PARCEL 011 001 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 V?V7 VET
Fee Paid
Typeof Construction: INSTALL ATTIC&WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101877
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF911MATION 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
1
6
Sign re of Building Official 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.
1 COOKE AVE BP-2016-0082
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 18D-011 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-2016-0082
Project# JS-2016-000153
Est.Cost: $7738.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 101877
Lot Size(sq. ft.): 15899.40 Owner: WATSON DONALD E JR&TIFFANY J
Zoning. URB(100)/ Applicant: URBAN & SONS INSULATION CO INC
AT. 1 COOKE AVE
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON.712412015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & 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:
FeeTyne: Date Paid: Amount:
Building 7/24/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner