43-096 (2) s�� z
mass save
PERMIT AUTHORIZATION FORM
1,
1,1 S�'1 C1 c' , owner of the property located at:
(Owner's Name, printed)
(Property Street Address) (Cityrrown)
hereby authorize the Mass Save Home Energy Services Program assigned Participating
Contractor listed below to act on my behalf and obtain a building permit to perform insulation
and/or weatherization work on my property.
Owner's Signa r
ZL�Ll
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
Participating Contractor to the above referenced project:
Participating Contractor Date
Rev. 12132011
_ __ �l.h.`� .._.?�a �`' M1`'-._� � .. Mr�cfit t -r-�C$.".� �.=L���?.:;.`L:..;:�`•,.�'r3`n...:-�t e:o�'r��3�d,��ir
PART DE LARATIOMS
?enawal Cis T\Iur'nber 1'Q;:-VV
Policy No_ L081 001 04 5
gamed insured and iviailing
ay Boland
ome Energy solutions
Pisgah Road
-luntington
i�'olicy Period T-rorn 1-1,'01,12012 i I1'0 iI 17)1 3 at '12:01 A.M. standard Time at your mailing
addr"s slho%un aura=.re_
tNI RETURN' FOR THE PA';AIENT OF THE 't �.t4,1 ±v:�, rani-)SUEJEC T TO ALL THE TERtJS OF THIS POLICY,We AGREE
'aNJTH YOU TO PROVIDE i HE= INSLiR?>.INCE= AS S FATEC? IN THIS lIS POLICY.
EaoM Occurrence Limit S -11 -010.0010
Damages To Premises
Rented To You Limt % 11130,000 ,Any one premises
rAedical Ex arse !_irnit. S 5,000 Anyone person
Personal and A.dver-,ising In;ur?,Limit °., i, ltl7.C3t30 Any one person or organization
=nera! Aggregate Limit n 2,000,000
Products t Completed Operations -Aggregaate Lim"' $ 2'000 000
-FiiETR0AGTR.fE DATE(CG 04 02 ONLY) _-..---------
_^_nveragq A o :hia incurrnc:.dams not�Ppty to"l-.ao.t;.;nji,ry`':..r"prnneray damcq�"t•,xhich aac+�rs b^_fnt�the Rctrosi=Ylve Date
any, shown here-
DF_i�e?IP7If2tf OF S3lF1I=C. r=,tiy?
Individr ai j Dint venure partne'shira [ Organization (Other gran Partnership or Joint Venture)
�;.isiness Description":
'Door, Window or Assernhled f hi?hLOr E; s af7a'er_.n - lx�eaf xd
ocatiori of All premises You ���Vfi, Ren� Cr Occi-p,'-
2 Pisgah Road Huntington MiA 01050
REMIUt4 -- --- -
/+ Rate Advance Premium
Classification t t^rc. F l-. r"` "i ucaSiS —PY'ItEtJi`y t"'fii..CJ /x.11 C=fZr1 {� prico Al! Other
or, Windotiv or Assembled y i -r F 3-',t'00 017 21.592 20.141 $1814
$1692
InStoliatirn i.Tetal PR
See Attached ACD-GLS
subtotal For ACO-GLS S SO®_00
Total or Minimur'n Premium $ 4,006.00
a) area 11c) total cost ,•d t sslo ' r t --Cd:� i�a'' Dss scales u units f other —�
=JRMS ANO ENDORSEMENTS apph,,inta ?his Co -.rant_.part and made part of this policy at time of issue +:
--_
SCHEDULE OF r=CF'.:v`IS AND _SE-r ? N t 5
=_:ntersigned
By _-
<:-y optional it 5howr!in 00M.-non ALAhorized Representative
ms ena F_naors._.mrn[s apr?i�:_br�. •.,..,�Covaraoc'--ar-:or",it4Cd it shown elsewhere in the policy-
ESE DECL ARATIONS t,,f,�il THE C0Z4%10!1i RC>E_sGV ic)?I.s,iF APPLICABLE,TOGETHER WITH THE CONIP,40N POLICY CONDITIONS,
C."ERAGE FORM(S)At,!D FORMS AND ENDORSEt,-. FJT.S, 4F:4,1Y,iSSiuE[j TO FORIM APART TNEPEOF.COUPLE 7> i NE HOVE:dutvSESEF2Eb
08-11 •�ccu^'.,...>.., vs.w...._.�.a:Q,'3-._cr�tY...Ser}eic�..;CeNC'u 1r--A:h L5 P=rmusiW1.
_ '✓`V L 1 tr.C-
The ComiS3oGG;l&eaIri VJ,.�
Dep'"'eme"s"'Ci ilTr dsf,.iik iw r I., a;Ie'fi>t.L
# r li' ,5. 3`4' co 2 #{.ensatior... las". <A 'C ' a.> S tx:=.....,.''... iE e 'per
f. Aiffi ..l i l— j., .• 4=
APP-LaCant 1110 ation plea-se Print Leg
Name {.E3usa_I'°,.tUreanarat�c.z�/�nc�i�;��s.
Ad&ess: 12 Pisgah Road
City/Sttate/Zii)— Huminglon, 11vipt 01050
fi 44
i _Are votk an ealf-Ars vek-`.' €he saf}arc,x -zJte ;tai of l w`€:� t'_ =s eC;a.t ret�}
I �� ;)
f-1..3 am a emplover �S'I,di
�
0111 lo-,ccz; fufi wi"A'r part-a'
a!# tI
s.'M'-L3 or._[L 4.E. U.c_� � ,t.. �� t.'£Ilti _ 2
IY I §i17 xt St3ii (�iC��J -tetr_lr or par`iier-
_itip and iaaN e 11Q er�:tplcr'ees v
l4-E1I",i�.IL°� vi ST3C ill.WIN C.e�Daci£� =i'i�i.;30i ..� �.,.,,�.1--;I, - -
UiJ
PN J 11 Ui.fsrS 4=o.t'I?i_. II?.sti.Cc�7.
required] � r s E tr1Ca1 f P �rs of additions
�
f :am a.1oint or
IMse1E. rNfo wnrk-ecs Coil 3_ riL"at -i A'; a
lllsur-mce
I�f ai
irSU atiC3rt
_ U th -- -- —
�.kny applicant il?at checkb Lo; I Maas¢ats0 511 C-�.a?he swr€ ,r b':10 v sho-. m
Homeow-ners who mibr7 t this affidavit in4u_i--'n_,t'ec r:arc.6„i 7,1 ;4 o r k: .,, -..._ _ _ , n;: - . _.?...,. ' ,
Ctanzraclo,s that caeca:this box Tnust aiiached zm additional aar,x A.a t_ _«c kc=6cr€r nr�t tilasc tit es it tS=e
trI7717it1vCi'•S. it£iiC SL7.;'1-C-L+P.T1Ct.0 FS iicl'G tilu'�'n!s_
Y is M7 lJii - :... ..._..i Nj d z
2sra✓l =ci =xsui es z t +rt4?t11 'A4 }YCer3 CC1+ 7 :> ,7t'Lx?dP x d5a. :T. ? t;m3. f- ._ i++ wt:�. '1 i.'i5 sus?f}€?dL i" (.+Jflr 58t_�r
LFd�rlP77LCt�dfldZ_ y � _ _
I nsurance Company ?acme: '`Masnric--nsualty Insurance Company �yy
,cf Self-ins,- fit- L 8 i 00 €k�a'-`r5 .EEO i/1 J
�'Ll€iG`,' rr v^C felt°ally �.'C_ "
Jou
Attadi it copy of the workers7 cornpensa n-ion policy f t-I arairip n Faze ,1>Idl„?L-d' ci3C#expiradop iY4fi k.
Failure to SGGLIrG'CC3L'C Fi e as iE'f[Iiti.Cd itrs('is -ecti:Fihw?A of i 'w. _e 5. ±tt P; Y.L oil of C?.`+m Iidi penalties of L?
'i:ne up to$1,500.00 in&/or one-,'ear impnsonmer:I_as tiff:?ai as cl 3 � x.=.:; L : ..: r<_ t.. 1' S-',—OP V'/O tK ORDER DER and a one
of alp to$250.00 a day :gami st talc:violH3or_ E�4 ciCi4'�( €lit i.: iE -'„ t>i 1_. . .t__ _ fbF- .Udo LO the O fPc,of
hivesugations olf the.DIA forifnir.ii"`mce coverage veijf3c<9 I S_
I do hereby C@f 1 3 d rider Z°hepaims l7,rj d p£'Ttfi��?7'-s 9f�dl'�aTd#.*) has rft ax .c.. '._.... t t.._3l a.c of?Z' C 1r?f,�C i ,L�G�.
Ic�iiiLtYe: - s * _ , �i3
Phone-9:
Off�TraI zi e(.Jlt1r. Dt/mw write in fL}is(I3'L't.'a t`T`be T,r,?Pler'2'ji3_?.`
1. I
i{I �i��`C➢i' �.c13�'si. _ _ �`�l-ilaet �.ie:�ts::� -
#?2Er£i of Health' ?_Building 3ep&t3 i yen _ Firy U If°Fi ttFL,.. -?-. LxC�' rz.. ii Yt t '> j_ ' £L:3i€JDit TrS 3££idTi'
'� �.Other-
Contact ersou. it
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction'Suppervisor:(�� Not Applicable s*❑
' ,
Name of License Holder: �)� 1 3[��(\ 16 1 k S v
License Number
Address Expiration Date
4 u-�oK k fn Pc
Signature S-- Telephone ( )
9. R ist A . Im rovement Contractor: Not Applicable ❑
A LA r i(,p toD3
Company Name Registration Number
U2� f ` ) I —
Addr ss �z l Expiration Date
Telephoned
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,A ffidavit Attached Yes....... 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 pernut 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.
ibility for compliance with the State Building Code,City of
The undersigned"homeowner"certifies and assumes respons
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 Q Replacement Windows Alteration(s) E:] Roofing
Or Doors 1:3
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [p Siding[o] Other[a
Brief Description�LProposed
Work: ��G"-icsr'1 arr Se ;[ t F1 C
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 addition to existing housing, complete the foifowing:
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 .
1. 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
as Owner of the subject
property
hereby authorize SO 1 t U-41 ots -
to act onnmm'yf,behalf, in all matters relative to workaLkhorized by this building permit application.
Signature of Owner Date
1 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.
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required b-, Zotuur
This rolunua to be tilled in b%
Building Ikepartment
Lot,Size
Fronta;ae
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
r Lot mea minus bids&pati eel
arlung)
4 of Parking Spaces
Fill:
(%ohnue'Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW { YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (D YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation,or filling)over d acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
APR 2fi 2U13 Building Department Curb Cut/Driveway Permit
13 212 Main Street Sewer/Septic Availability
TIONS
Room 100 Water/Well Availability
D) NORTHAMPTON'MA 01060
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
4 ��2 I-�-}-� �� S-���_— Map Lot Unit
1 Zone Overlay District
Ekn St.District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
S-t3�7=Vie- �L� � � i,�h�*U-4- Si In re-n e e.
Name(Print) Cur nt Mailing Addre
iii �l `k I
Telephone
Signature
2.2 Authorized Agent:
Name(Priall Current Mailing Address: i )�
q 13-Le4e--7 -2), 3 D IDS C�
Signature " Telephone
SE TION 3-ESAMA6 O STR ON C ~STS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 60D ,CCU (a)Building Permit Fee
t J
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) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
( Building Cornmissioner inspector of Buildings Date
File#BP-2013-1006
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 43 WHITTIER ST
MAP 43 PARCEL 096 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL INSULATION/AIR SEAL
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License 101880
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
F 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
De
m C
Sign of Build ng 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.
43 WHITTIER ST BP-2013-1006
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:43-096 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-2013-1006
Project# JS-2013-001682
Est.Cost: $600.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use GroML JAY BOLAND 101880
Lot Size(sq.ft.): 61419.60 Owner: SIRECI STEPHEN G&LYNN M SHELLEY-SIRECI
Zoning: Applicant: JAY BOLAND
AT. 43 WHITTIER ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON:51112013 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL INSULATION/AIR SEAL
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 5/1/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner