30A-046 (9) OMER AUTHORIZATION FORM
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(OwnWs Name)
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hereby sutaim
an authorizer[subcomadw for RISE EnghwAM to act on n y behalf to obtain a building
Permit and to perform work on my properly.
ti's Sigriature
Data
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Property Address:
Contractor �---�
Name:
Address:
City, State: ��_
Phone: �}
Property Owner
Name: ,
__-----------Address;.-----L--�—' ---------� � - `- -��-
City, State: �('�,.1` \�`Jt`�, � `\- \) ?�`�-
(contractor)attest and affirm that the building I intend
to insulate does not have any open air(knob'and tube)wiring in the spaces to be insulated and
that I have provided the properly owner with a copy of this affidavit.
Contractor signature
Date,
City of Northampton 212 Main Street, Northampton, NIA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work:
The debris will be transported by: C� > 5� T 1�' ►
The debris will be received by:
Building permit number:
Name of Permit Applicant
Date Signature of Permit Applicant
r. City of Northampton
Massachusetts
l �t DEPARTIWNT OF BUILDING INSPECTIONS ,
212 Main Street • Municipal Building
Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEWTION 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 any person(s)who seek to use the home
owner exemption, to act as their own construction supervisor, to be aware that by doing so you
become responsible for compliance with state building codes and regulations. The inspection
process requires that the building department be called to inspect work at various stages, which include
foundation/footin s before backfill sonotubeoles before our a rough buildinginspection
(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 permits 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)
will call to schedule all required building inspections necessary for the building permit issued to me.
Date
Address of work location
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
F 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): F
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.47 I am a employer with V� 4. ❑ I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' g ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.]
5. ❑ We are:a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.�,Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners 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 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 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date: '
Job Site Address: 1 ���T � City/State/Zi � �—�
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 t enalties of perjury that the information provided above iss true and correct
Si ature:
Date: V J 1
Phone# �--- 3
Official use only. Do not write in this area, to be completed by city or town official
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: M Not�Applicable £
Name of License Holder: N\
License Number
Address Expiration Date
Signature Telephone
Not Applicable £
9,Registered Home Improvement Contractor �:. _ ... :....._ . PP
(�o
Company Name Registration Number
Address Expiration Date
Telephone 1 l6
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..Zk£ No...... £
11. . :I3o-me0wner 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) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other(�]
Brief Description of Proposed–= 1l
Work: l\ --0--
Alteration
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 addi&h to'exisfin
q hbustng complete the following:
a. Use of building:One Family-ver— 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 stories?
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
I, \4 —1 -
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.
a---T -1
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 underthe painend peen\alfe of perjury.
Print Name
Signature of Owner/Agent Date
r
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 --- l r-----^— I
Setbacks Front l_..-
Side L:�--��� R:= L=--f R:=
Rear (� 1
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 Q YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 0 YES 0
IF YES: enter Book f Page and/or Document#, i
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW E) YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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
r that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton 5fatusafPermttu� r a y
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Building Department ctrb�ettr/Drt�ceuva� ernst#" �x ,� E 4
FEB � , tr�� 4 k'
212 Main Street Se M,'Ppti NNila`fiiflty
Room 100
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DEPT.OF BUILDING INSPECTIONS
NOFITHMIKON.MA01ow Northampton, MA 01060 Two Sits af�5ttttckuFal Pta s xMc
phone 413-587-1240 Fax 413-587-1272 Plof75ife Plans'j' 't;; w d
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Thh section to be comPlefe. etl by office
Lot
t
, Overly is .1C
_Elm$t DistrictCB Distract
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS. .
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit 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=(1 +2+3+4+5) 3��' Check Number 3
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissionedlnspector'of Buildings Date
File#BP-2016-0978
APPLICANT/CONTACT PERSON URBAN&SONS INSULATION CO INC
ADDRESS/PHONE 385 LIBERTY ST SPRINGFIELD01104(413)732-3922
PROPERTY LOCATION 37 LEXINGTON AVE
MAP 30A PARCEL 046 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid t' v:)
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildin¢Plans Included:
Owner/Statement or License 106062
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved 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
Sign e of uilding Of cial 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.
37 LEXINGTON AVE BP-2016-0978
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-046 CITY OF NORTHAMPTON
Lot: -00 L PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0978
Project# JS-2016-001661
Est. Cost: $1367.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: URBAN & SONS INSULATION CO INC 106062
Lot Size(sq. ft.): 15812.28 Owner: SOUTHERLAND MICHAEL&DEBRA HERTZ
Zoning. URB(100) Applicant: URBAN & SONS INSULATION CO INC
AT. 37 LEXINGTON AVE
Applicant Address: Phone: Insurance:
385 LIBERTY ST (413) 732-3922 WC
SPRINGFIELDMA01104 ISSUED ON:2/5/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC 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 2/5/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner