35-098 Property Address: r,JS /fft O /U62
Contractor JaH4/ ,' /1/ -No's (K
Name: v 6/3 Jo* ,A/ 's hi v.PIC= /6�,tiA9
Address: 6c Co vw,i y S r
City, State: -- CA4exBd env . / /1l/9 0/.370
Phone: �//3 - 83� - 77,z s'
Property Owner ,
Name: r J4 ,rich _£ / /4v1.q /roB4 J S
Address: �3 ,U Q� wsc •v v,�
City, State: _ f o4o - A/c //ft 0/6".2_,
I, 1/o /4/ ^e-tioa/SK / (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 property owner with a copy of this affidavit.
Contractor signature
A_ At
Date %L 1,4
WAP Work Order
Community Action of the Franklin, Hampshire Job Number: 10 -286
and North Quabbin Regions, Inc. Work Order Date: 12/21/2010
P.O. Box 1432 Ownership: Owner
Greenfield MA 01302
John's Home Repair Auditor: BRAD COUNCILMAN
66 Conway Street
Shelburne Falls MA 01370
Phone: 413-834-7725
Lawrence Roberts ARRA WAP $658.00
83 Drewsen Dr Bay State Gas $1,516.00
Florence MA 01062 Total $2,174.00
413 -584 -9292
Authorized °? Actual
Measure Description Comments
Qty Price Total "Qty ` Total
_
Attic Insulation ;
R -10 -12 unrestricted - settled 900 $1.24 $1,116.00
cellulose
Thermodome or Magnetic pull 1 $175.00 $175.00 McCoy "Laddermate" preferred.
down stairway box
Misc - Insulation
Domestic water pipe wrap 6 $2.50 $15.00
aMise Measures
Attic sealing with two -part foam 3 $75.00 $225.00
Blower door set -up with pre & post 1 $45.00 $45.00
tests
-
Other
Insulated glass repair 1 $40.00 $40.00
Interior caulking 2 $60.00 $120.00
Raise attic storage area 96 $3.50 $336.00 So as to accomodate full R38, create raised
storage area adjacent to pull -down stair.
Suggest 2x6 and 4x8 sheets atop existing
structure. Your choice as to method and
materials.
Date: 12/21/2010 Page 1
•
Workers' Compensation and Employer's Liability Policy
NorGUARD Insurance Company - A Stock Company
INSURANCE Policy Number JOWC119640
Renewal of NEW
NCCI No.[25844]
Policy Information Page
[1] Named Insured and Mailing Address Agency
John Michonski BOSTON INS BROKERAGE
64 Conway St 24 Federal Street
Shelburne Falls, MA 01370 4th Floor
Boston, MA 02110
Agency Code: MABOST10
Federal Employer's ID 26- 4838401 Insured is Individual
Additional Names of Insured
(N2) John's Home Repair
[2] Policy Period
From May 28, 2010 to May 28, 2011, 12:01 AM, standard time at the insured's mailing address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $500,000
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change
by audit. (Continued on another page)
Total Estimated Policy Premium $ 8,751
Total Surcharges /Assessments $ 649
Total Estimated Cost $ 9,400
INTERNAL USE DK Page - 1 - Information Page
MGA : JOWC119640 WC 000001A
Date : 06/09/2010
MANOTE
16 South River Street • P.O. Box A -H • Wilkes- Barre, PA 18703 -0020 • www.guard.com
7 Board of Buildin2 Re and randard
Construction Supervisor License
License: CS 94376
JOHN P MICHONSKI
66 CONWAY ST
SHELBURNE FALLS, MA 01370
Expiration: 6/11/2012
28400
e eom-iibo.iteveaid
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: 142709
Expiration: 5/1/2012 Tr# 293933
Type: Individual
JOHN'S HOME REPAIR
JOHN MICHONSKI
66 CONWAY STREET
SHELBOURNE FALLS, MA 01370 Undersecretary
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Not 7 ❑
Name of License Holder : J 0/1/1/ / "Ch`e2.C'i I) Q / / 3 / a
Sex vie-r' 0,43JO License Number
CG Gv vwrr ST sh`f64v0/1 /‘;5 /1/1 6 / // /,2 %Z
Address Expiration Date
/f. ie yi,3 - r »t 3
Signature Telephone J
9. sRegistered Home Improvement Contractor Not Applicable ❑
S/9 /Y2 762 9
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (NI 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 X 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) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [0 Siding [O] Othe J'
Brief Description of Proposed r
Work: f4 5 -' E /9/i< (jk.0 7ryrailf! - jio�
Alteration of existing bedroom Yes L , 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 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, L /4" 4 � 96g Q% S _ as Owner of the subject
property
kj d /91ic/Yoais!!/ o/b 4
hereby authorize JO//4 /fD/r/c kePA /Q G 4 //, c r
to act on a•ehalf, in all matters relatve to work authorized by this building permit application.
/) /.z / /.D /D
Signat e o f Owner Date
JoH,v
I, Jo/y4,5 io/!sf aQ - I Q - A J/ /G•e , 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 the pains and penalties of perjury.
ie, A/A/Srn //th oFr /Cr fi71, J
Print Name �f
A �/: i - / /1 �� � o /�
Signature of Owner /Agent , *ate
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 ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO (3 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
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 NO J
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES (3 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.
Departtr>ent use only
City of Nort hampton Stet" Cu of
B 212 M D Street nt Sewe ilability fl } ye+nray Permit
9 p
epticAvailability
ROOM 100 Water S lw ell Ava
0 [ i� Northampton, MA 01060 Tw of Structural Plans
phone 413- 5 -1240 Fax 413- 587 - 1272 Plat/Site Plans
Other Spe cify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMO A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
g 3 PA r w5�i1/ >v� Map Lot Unit
�p�4� /rJG 7i7/4,1
O/ '6 2. Zone Overlay District
l
Elm St. District CB rict
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZEDRGENT
2.1 Owner of Record: G�06.Z
Z „i!fv .vc � Li drl �a6r �js � 4 r�sc ,v Z ' f G0Q0 �/g/If P nt ~`"'�"� Current M ailing Ad
.
yi 3
i
�5 s'1— 9.z 9 <?
Telephone
Signature
2.2 Authorized Agent: Yon' l� /ff r G //ex/,f c'1
o/-
Jo��'s ,5I /6:-/1/1/4 ��P!/ /c.0 G6 c ' 4/ 4 Y - s�i`66.4ro.�r feu ft/
Name (Print) � _�� � � Curre Mailing Address:
Telephone
Signature
SECTIONS,- ESTIMATE CONSTRUCTION COSTS
Item Estimated Cost ( Dollars) to be Official Use Only
completed by pe rmit applicant
1. Building (a) Building Permit Fee
2. Electrical E C
Construction stimated Total from (6)
of
3. Plumbing Bu (b) ilding Permit Fee ost
4 Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ,z/ /7'1. O Check Number �0�� ASS
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
of Buildings
Building Commissioner /Inspector Date
BP- 2011 -0601
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP-2011-0601
Project # JS- 2011- 000965
Est. Cost: $2174.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN P MICHONSKI 94376
Lot Size(sq. ft.): 9016.92 Owner: ROBERTS LAWRENCE P & LINDA R
Zoning: SR(100) //WSP II Applicant: JOHN P MICHONSKI
AT: 83 DREWSEN DR
Applicant Address: Phone: Insurance:
66 CONWAY ST (413) 834 -7725 WC
SHELBURNE FALLSMA01370ISSUED ON:1/3/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL INSULATION & MISC
WEATHERIZATION
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 1/3/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner