18C-033 Property Address: COO V Lgeokv4v-, LeAt■-.
Contractor
Name: 1 1\A t 0 v&'
Address: S
• City, State: 111.
Phone: 33 V
• Property Owner
Name: L . C;v\ r5e,0 ) u
City, State: bc4-4\ A
I, VV C.1 4 01". Qa• L j ; (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
Date
_ _ _
r
The Commonwealth of Massachusetts
Department of Industrial Accidents .
11 �� ft Office of Investigations
�_ 11 1 600 Washington Street
Boston, MA 02111
o
..r � www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Q Please Print Legibly
Name ( Business /Organization/Individual): _ _ e . ...:u _ r J . • -
Address: b C, '(.plot ,J IA t6 S� .
City /State /Zip: ,S,INe_lLot e. V z. U , Phone #: y/ 3- q- 2 Y. 77S
Are you an employer? Check the appropriate box: Type of project (required):
1. []rl am a employer with 3 4. 0 I am a general contractor and I 6. ❑New construction
r, employees (full and/or part-time).* have hired the sub - contractors
2. (J I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
9. Building addition
[No workers' comp. insurance comp. insurance I
required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.D Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no A'
employees. [No workers' 13.0 Other (,Je,AtNlt'12A9vt
comp. insurance required.]
*Any applicant that checks box #1 mI tst 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 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: , _ C . - - r - , ` r • • N cc- i - ..
Policy # or Self -ins. Lic. #: J t LaS "Q bZ b !4 t4 . Expiration Date: J 0 - 1 3
Job Site Address: Li . - Pt 2, 4A„.......,..._._ , tA14, City /State /Zip: a It, 6b
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 cove: i'a.ee verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. .
Si t ore: 1 ,,P,,,,,,, g (C f Date/ - / 9- > a _
Phone ##: G //3- 73 V- 7745
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License # .
il
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 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
yq 3 �6 b- i�- /
•
License Number Expiration Date
Name of CSL I-Iold
John's Home Repair Service List CSL Type (see below) U
• ' •
No. and Street _ 66 Conwa y Type Description St
Unrestricted (Buildings up to 35,000 cu. ft.)
t" _• Shelburne Falls, MA 01370 R Restricted 1 &2 Family Dwelling
City/Town, State, ZIP M Masonry
RC Roofing Covering
- -- WS Window and Siding
SF Solid Fuel Burning Appliances
1 4/3-531y- 77' s yva, Cow. I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor (HIC) N 705
• ��. HIC Registration Number Expiration Date
HIC Company Nam- - • st i aAOrne Repair Service
o Michonski fit'' w1► �S-�a�' ��. , cAt•.,
No. and Street gild= onWay t. Email address
Shelburne Falls, MA 01370
City/Town, State, ZIP t/ f , ' - AA.v-MTIkphone
SECTION 6: 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 19' No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
— /1 _/
Print •wner's Name (Electro/ Signature) . Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Z Wi. -1ovs V • J 1 - 1 _ S -
Print Owner's or Authorized Agent's Name (Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov /dps
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) _ (including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms __
Number of bathrooms Number of half/baths _ _
Type of heating system Number of decks/ porches
—
Type of cooling system_ Enclosed _Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
The Commonwealth of Massachusetts
A Board of Building Regulations and Standards FOR
x: . ; Massachusetts State Building Code, 780 CMR MUNICIPALITY
° USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One or Two - Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official (Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
q C Core Pvt. -(QPk NKKIeter" rho --
1.1a Is this an accepted street? yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private CI Municipal __ Outside Flood Zone? Municipal ❑ On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP
2 Owner' of Recor
` , t 4,r iv ICY 1r.'`',t7 %s/13, ✓ )14 D l
Name (Print) City, State, ZIP
3 ‘70:e7 / ft ' s - .iei 9,48 -,d &0s7� hW
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner- Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units ___ Other lin Specify: t_ - L.3
Brief Description of Proposed Work t; , 4, t4 �� — $ _ t /Cp. / Ai/
DTA s.tv- _ , - p si- [k'3.o,-$2IN, lat +,c)
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how feeds determined:
❑ Standard City /Town Application Fee
2. Electrical $ s
❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All F es: $
Check No. Check Amount Cash Amount:
6. Total Project Cost: $ . 3 13 6. 6 D ❑ Paid in Full ❑ Outstanding Balance Due:
File # BP- 2013 -0568
APPLICANT /CONTACT PERSON JOHN MICHONSKI
ADDRESS/PHONE 66 CONWAY ST SHELBURNE FALLS (413) 834 -7725
PROPERTY LOCATION 34 COOKE AVE
MAP 18C PARCEL 033 001 ZONE SR(100)/WP(72)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out , LD V} Q
Fee Paid
`�`��'
Tvpeof Construction: INSTALL BASEMENT, ATTIC INSULATION & AIR SEALING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 49376
3 sets of Plans / Plot Plan
THE FO NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
D- olition Dela
/ ///9—/
S : - . e 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.
34 COOKE AVE BP- 2013 -0568
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 033 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- 2013 -0568
Project # JS- 2013- 000916
Est. Cost: $3300.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN MICHONSKI 49376
Lot Size(sq. ft.): 27181.44 Owner: BUSHEY ROBERT D & CONSTANCE J
Zoning: SR(100)/WP(72)/ Applicant: JOHN MICHONSKI
AT: 34 COOKE AVE
Applicant Address: Phone: Insurance:
66 CONWAY ST (413) 834 -7725 WC
SHELBURNE FALLSMA01370ISSUED ON:11/19/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL BASEMENT, ATTIC INSULATION & AIR
SEALING
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 11/19/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner