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'Yn., (, ,' '� IC,7er'SFV ( '! �,, t : ,,;;, , ,,: „):.\\ (0 4 ( A , , 1 ;':it , !, Ada... ! „41, t""1, C� N Ili1 tj ff . .. eN1NwnYY , # s' T.! .': I t ,, t, P 1 t : :: , ,I i7t+., T 3 t , , } ea I ...,-.....-. -,-----.., TILE' Cot 17/ orritwalth of .41 D-(z irLflizilLutrial A cc& e:iiis R - ili -------- _,:, ,--- s7 - 1, gir „..-......,...„,,..,, Office of flivesitga.tioirs 0. ,. . ‘ t --- M 4 :,--., H 606' IVosfzifoil Sti s2 ,q kAi I 1. 7 f ' iii.4, 02111 .---.L i V 1.194 MaSE.gfrilidia Workers' Compensation fristirance Affidavit: BriiiciersiContrartiirsiRiecniCialisifilintherg Applicaqt 1 n fWi-MtitilD Piease PriRt Leaibly 1\.1:i2rne (Dosine&-L-JOrc-tiniorzibwil 1 -R_± . .N."17.- 4 4/.77ICN: MA Address: City/Statc.i.Zip: -.I , ‘...e .e. .. , _ Phone : 'V/ . Z- Are you an employer? Check the appropri:11.1 hrox-:. I 1 1 f 'Type of project (required): 1.1 i 7 a orn.picycr with , . , construct zoo have hire_ the sub-ccintractors i 1 l'-. L - T employees (tiall -alld_tor part-tiTrie):" !Lc -d cal 'di, a i.clizC.: .-13.:,....?-t. ; 7_ Li Rerneclinr -2. ' c• Lam a aple proprietor or parca 1 i ship and have no employees Mese.. - ,.. -- ob-eontr.!-ciors hav-c- 1 S- D Demolition working for rne in any .7.-apacii-Y. in arid i111.174f NI'OflittlE 1 1 Li aulltlIng addition {No workers" comp insura-ly;e coL,;_r_ insurance. 5 fl 'T zre corporerion and in ) 1 b0.11 Electeieel repairs or additions required. I 1 3. Li I am a homeowner doing all work ca.cers ilTave ex.--.. ilbeiT 1 i 11.11 Plus:thine repairs or additions myself. No ‘voricers ct-Jn,,-:. T of E. per i i 1 i /2.0 Ruof re--pairs insurance rege.iirecl A ' ,.:- 1.52 :1.( and we have no , 1 eolco..yees. (No workers' i i 13 i J Other comp. insaLrance require:IA 1 3 'Any applicant that citm.. x box fill namaisa rTfl Er.a. 7h.: 5 .-:-...riz tielesys ti.--i 1 ., w ri z , s - ac171 ,,,,,,ti ryi , p art,y infarn=lion. t HOMCOWit= WhO sub nit Otis . .tidairis imfi=3Eirm. they ..• .Z. 4coe..., d C..= 5I CO coraraczers nus..lt submit a nvw taidaviiinditing such. tc th c b c ct this bo ,,o.t54 o t--b.,..d an F.--Adfd s_11,.....-_-i 5 (ha mum. et thc sub-.. and stite. wit:-..thcr ar not thr.-:,le entities have einployes. If the sub hays: evraiio■,...r., they r.-1.1.51Ftwitit.-- their wart......-- ckHt.9.L piatien nune.-r-- = r. sw .,.. 1 arm arr employer char i's providing foorers' corn9ensadon Ens sly .e_er.oinTept_ Below Es the policy and pou e information. ,s ' __..:- I nsurance Company Name: ..,"-_,.- A ,-7" ,.:•-• is ... ,...- J.- ,,..,-..'.._-7,,, ________ Policy # Or Seif-ins_ Lic. "41 1111 C_ on Date: -el / f Job Site A ciciras-R: C it3iiStteiZip: Atm en a copy of the ,- "orliers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Se. 25A t c... i5 can ie-ad to the imposition of cr-irr,h.al penalties uf a Fine up to S1,500.00 andfor one-year •prisonment, as well as civil pemi;ies in the rin. of a STOP WORK ORDER and a fine . of up to S250.00 a day against the vioiator. Be advised that a copy of this szakerneua may be forwarded to the Office of Inyestigations of the DIA for insurance coverage verification_ I do It oraby corti"5 utyier the puin,,_c and ..-yet;ciiiies of perjury thi the iszformErdom pren.iried ab ova is true end correct. .4.' r _ ,_ . .._ L ,/ /3 Sianature i _ , : t "..? / *t. .1- S .. ' Dalt '.7.= : /II .,,, Phone_ 4: , -y / -1 ...L. / .f. .,..t. -,--..., ....., .,,-,. ___ , .1: .r.c.„ • z Official use 0714). Do not writs, bz this ar.:. A:, b e , ..-np le ny City or !awn oii.crak li 1 II 11 city or _ Tn i - frt: ;'ecfcense it: 11 ruing Authority (circle one): 1- Board of Health 2. Buildina Departmant .3. City/Town Clerri 4. Eiectricat inspector 5. Phimbing inspector I 6. Other 1 1 (ThrttaCt Person: Phone 4: i i - - .s -1'-a ag � 3 � t8toj„ =c { I -. - - - - - - - Pase4=a. - - - _ - - - =ask Saft00310 a C I . 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Fut PAANG_Iik t Si y -' -.-1' ., q.- - - ' , 1 (743, carliaZTATI MEM - ,e, r gi nO "%AV: t . .3 j (moraci zzei Idki. ISaVE1 ,f 11 44 0 11 - WIG ziaeti ,: ms` s 7,l .0 : SS d,: The Commonwealth of Massachusetts fil a,i' + Board of Building Regulations and Standards r ©tZ cv , r Massachusetts Stale Building Code, 7$43 CMR, 7 edition MttNIUSE �.. ush N Building Permit Applic ion To Conses. Repair, R enovate Or Demolish a Revised January 1TY Eil C") tine- or Two - Frrnt ly Dwellr L �oQs N �: � This Secti€m For f icial Lase o nto i ilding Permit Number bate Applied: 7 attire: Building Commissioned Inspectu- of Buihricp Date SECTION 1: SITE INFORMATION Q T I.1 Property Add � i)a � /` _ 13 As_�s ©rs Map & Parcel Numbers C�� _ Cl h_ la Is this all accepted street? yes oa t a Parcel Na nl 13 Zoning 7nfortiou: ( i Number I_4 Prape sy Dime,i ic, us: Zoning District Proposed Use Lot Area (sq It) Frontage (0) IS Building Setbacks (ft) Pcvm'Yerd Side. Yards 1 hear Yard Required i Provided I Required ' Provided 1 Required Provided I I 1_6 Water Supply: (M-G14 c. 40, § 54) I L7 Flood lone Information: I ES Sewage Disposal System: Public 13 Private 13 2M1M — 13r"SideFloact2o e? Municipal ❑ On site disposal system 13 Check ifyes0 suscrwort 2: FRII RTY OWNERsure 2.1 Owner' of rd: (....3 ft 8CIA 1-6.),n q_15 mityryi_Alleors ire (Print) Address for Service �' 11/3 5 '9 -7ciq Signature o Telephone SECTION 3: DESCRIPTION OF PROPOSED WORN?' (check nil that apply) New Construction ❑ Existing Building ❑ ` Owr:er- Occupied 0 1 RepaIIS(s) 0 } Aheration(s) ❑ 1 Addition ❑ Demolition ❑ , Accessory Birk. £ Number ©f Units 1 Other tiS Brief Description of Proposed Work r♦ r AIAWNSMAIllafffilliNALILNI 1 - SECTION 4: ESTIMATED CONSTRUCTION COSTS - Item Estimated C.ostm ) °Metal Use Only I_ Building g I I- Buiidl P uttFee: S Indicate how fee is determined: D Standard City/Town Application Fee c. Electrical $ I3 Total Project Cost' (Item 6) x multiplier x 3. Plumbing 1 $ 2. Other Feer $ - 4. M l JAC) . LSSt w iaaitt�;a.t 5. Mechanical (Fire $ ,,,/ Cash Suppression) �dt4 �i� All Fees_l ..� Check AitlflliQ i / Amount: 6. Total Project Cast: . C � / 0 13 Paid in Fall 0 011MViding Balance Due: File # BP- 2012 -0673 APPLICANT /CONTACT PERSON JAY BOLAND ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413) 214 -2414 PROPERTY LOCATION 95 MAYNARD RD MAP 31A PARCEL 161 001 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 0 Tvpeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 101880 3 sets of Plans lot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I _ ATION 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 mo 'tio a ela a ..- 7 '''' 7 ,,,, ,„,•; ,,..2 7,,- Signature of uilding 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. 95 MAYNARD RD BP- 2012 -0673 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A - 161 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- 2012 -0673 Project # JS- 2012- 001160 Est. Cost: $2010.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sq. ft.): 7579.44 Owner: BARTON SCOTT W & RANDI E KLEIN Zoning: URB(100)/ Applicant: JAY BOLAND AT: 95 MAYNARD RD Applicant Address: Phone: Insurance: 12 PISGAH RD (413) 214 -2414 WC HUNTINGTONMA01050 ISSUED ON:1/25/2012 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 1/25/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck —, Building Commissioner