29-110 �r
mass save
PERMIT AUTHORIZATION FORM
owner of the property located et-.
(Owner'd Name, printed)
F e
(Propirty Street Address) (City/Town)
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.
Owners Signatu
i► %'ail+ �
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:
S X1'1 fl-? lel-19 ris- L C'
Participating Contractor Date
Rev. 12132011
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
;= Boston,MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): JASM ENTERPRISES, LLC
Address: P.O. BOX 1276,
City/State/Zip:CHICOPEE, MA 010121 Phone#:413-427-5481
Are you an employer?Check the appropriate box: Type of project(required):
1.Q I am a employer with 5 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. E]New construction
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'
9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I I.❑ 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 13.0 Other INSULATION
employees. [No workers'
comp. insurance required.]
*Any applicant that checks box#1 must 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:LIBERTY MUTUAL
Policy#or Self-ins. Lic. #:WC2-31 S-3727720913 Expiration Date:5/2/1�k
Job Site Address: City/State/Zip:
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 the pains pdpenalties of perjuiy that the information provided above is true and correct.
� a
Signature: �° ; r A �:. Dat e:
Phone-#: 413-427-548 ' x°
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):
I.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: R �f Not Applicable ❑
Name of License Holder: ��( IV r�"t S�a C 5 _`A A ��AI
License Number
PO 13OX 12 7& Cke-qee
Address Yj3 Expiration Date
10 -13 -15
y 2� SySI
Signatufj Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
_SASM fa 1e,- rises 1 L L /6 6 0 7 y
Company Name j Registration Number
}�0 �0X f2 & e°f);
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [OI Decks [[:] Siding [Ell Other[X
Brief Description of Proposed II �` t 0 x 1 2
Work: p p 6+tic li 5ulA ic)() `>t OCR 610w Ct?I�U�US� ��L�V T"1'
Alteration of existing bedroom Yes X No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family /X\ — Two Family Other
b. Number of rooms in each family unit Number of Bathrooms Z.
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
1 h q0 h t f VQ `r/ as Owner of the subject
C I
property {�
hereby authorize Je f3 r ac/5$ C(("J
to act on my behalf, in all matters relative to work authorized by this building permit application.
Sez A��-�aro2��7vn �arrh
Signature of Owner Date
I T Q(� /'u GIfR as Owne Authorized
ent ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under ains nd pen Iti erjury.
Print Name
Signature of Owner/Agent Dale
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
I his column to be gilled in by
Building Ucpartmcnt
Lot Size
Frontage
Setbacks Front
Side L.: R: L: R:
Rear
Building IIcight
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
park in
#of Parkin g Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DON'T KNOW O YES 0
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW X YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradincL excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
N Department use only
City of Northampton Status of Permit:
o Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
° Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
�j Other Specify
tUN A glti ATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
m
TE INFORMATION
1.1 Property Address: This section to be completed by office
�Z1231,11 9 14�-(1 R A Map Lot Unit
K:'Q'ncp— i),)k,:N O 10 (0 2 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Ahjj't orni t,Yely 58L! kyan Rd
Name(Print) Current Mailing Address {�
5QL . 6(.;Ao(-120 V'n po+ 1n Telephone 13 21 �i ro p
Signature
2.2 Authorized Accent:
J e "f" 6(-ac+(ak,' PO Bnx i2 -+(o Ck I copcz MPI of o2 l
Name(Print) Current Mailing Address.
1//3 412"1 54/81
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 15 1'2— ,sa (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) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0812
APPLICANT/CONTACT PERSON JEFFREY BRADSHAW
ADDRESS/PHONE P O BOX 1276 CHICOPEE (413)427-5481
PROPERTY LOCATION 584 RYAN RD
MAP 29 PARCEL 110 001 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
T_ypeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 094734
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN 9AMATION 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
Demo ' 'on Delay
Signa re 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.
584 RYAN RD BP-2014-0812
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 110 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2014-0812
Protect# JS-2014-001399
Est. Cost: $1512.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BRADSHAW 094734
Lot Size(sg. ft.): 22520.52 Owner: LIVELY ANTIGONI
Zoning: Applicant: JEFFREY BRADSHAW
AT. 584 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 1276 (413) 427-5481 WC
CHICOPEEMA01201 ISSUED ON.112212014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
POST THIS CARD SO IT IS VISI ISLE 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 REVOKI-i) BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 1/22/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner