13-056 (3) 26 LAUREL LN BP-2017-0200
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13 -056 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MOLLcc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2017-0200
Project# JS-2017-000338
Est.Cost: $1504.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
use Group: JASM ENTERPRISES LLC 108517
Lot Size(sq. ft.): 22999.68 Owner: ALBANO SANDRA F
Zoning: Applicant: JASM ENTERPRISES LLC
AT: 26 LAUREL LN
Applicant Address: Phone: Insurance:
P O BOX 1276 (413) 427-5481 WC
CH ICOPEEMA01201 ISSUED ON:8/16/2016 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 8/16/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0200
APPLICANT/CONTACT PERSON JASM ENTERPRISES LLC
ADDRESS/PHONE P O BOX 1276 CHICOPEE01201 (413)427-5481
PROPERTY LOCATION 26 LAUREL LN
MAP 13 PARCEL 056 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT ���
Fee Paid SS/
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 108517
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
/4pproved 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
itio Del 7/11(
Offici 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.
Deoattmen useony
ccENED a rnj of Northampton S a:us of Permit
RB. ilding Department �cor0 cuvonve Nay Perrlrt -
2n\6 '12 Main Street SewerSephAvailab0ify
��� F Room 100 WateriWeil Availabdiry
horth:mpton, MA 01060 Two S5LS!lt S(rucrur IPlans..
ole' - Ms-58'-1240 Fax 413-587-1272 Plot/Slte Plans
DEPC°FmnMPiurv.MP �
1 noe Othel Sped- -
-
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.t Pro er,r Address' Thi section to be completed by office
/6I Laurary/tan,21-
A/or IA ((m1/Qrt — Overl yDl=_;nct
Elm St Gstrct E_B Dstr_ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: L
r lira /✓1
i hate
Name(Print) crk Mailing Address:
342 A1ion r2ahon }pfd] Telephone
Signature
y/3- 586"/S2 V
2.2 Authorized Amen '
,,�� /` ./
ecu J✓rc�s`ic• r io 80X /77C; CL ,cpc, inn 6i024
Name(Print) Current Mailing Address:
4//3-26d-4/7 V
Signature— Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
ani
I Building � "3 C3� (a) Building Permit Fee
2. Electrical Estimated
/ (b) Estimated Total Cost of rr/� 3 G
Construction from(5) %JG
3. Plumbing Building Permit Fee
4 Mechanical(HVAC)
5. Fire Protection i
6 Total=(t +2+3+4+5) ,Check Number .1oG / F
This Section For Official Use Only
Date
Building Permit Number: Issued
Signature:
Building Commissioner/Inspector of Puiiaings Dale
is
tna1 °
Section 4. ZONING Alt Information Must Be Completed, Permit Can Be Denied Due To incomplete Information
Existing I Proposed I Required by Zoning
This column to be tilled in oy
Budging Depmment
Lot Size ,. .-_ ,-, ..._
Frontage
Setbacks Front t
Side L: R .__ L , R .,_ . „.
Rear _ __ -
-Budding Height ___ 1 __
Hldg. Square Footage t
VV / ____ _ _
Open Space Footage _ - % ___. —_
(Lot ream:nut bldg&paved t I I ..__t
parlors)
K of Parking Spaces . —` ---'
(vola
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES O
IF YES, date issued:I
IF YES: Was the permit recorded at tee Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book : Pagel and/or Document de
B. Does the site contain a brook, body of water or wetlands? NO x. DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained >Q Obtained 0 , Date Issued +_
C. Do any signs exist on the property? YES . NO /=`C
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO X
IF YES, describe size, type and location
Will the construction activity disturb(clearing, grad,no, e avation, or filling)over 1 acre or is if pad of a common plan
that will disturb over 1 acne YES 0 N0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
,
1 1
•
SECTION 5-DESCRIPTIOPI OF PROPOSED WORK(check all aooIicable)
New House Addition ❑ Rep acement Windows Alteration(s) 7 P.00idng
Or Doors C
Accessory Bldg. E Demolition ❑ New Signs iEl] Docks i❑ Siding [El) OtherM
Brief Description of Proposed [L c e)I 16 S t F 2
Work: Q-Fr7C P/C if- Oj12n low VI /U Z
Alteration of existing bedroom Yes No Acding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Oa SIf New house and or addition to existing housing. counplete 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 farm 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. , as Owner of the subject
property
hereby authorize j£e A, 0 rl -Lc f U r tin
to act on my behalf, in all matters relative to work authorized by this building perrat application.
Signature of Owner Daze
5eark a rat4 - as Own; /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best . •• •.- -dge
and belief
Signed under the pains and peek.ties of perju
rc
Print Name
Signature of Owoer/Airda Date
S
1 SECT1OCd a-CONSTRUCTION SERVICE'S
8.9 Licensed Construction Supervisor: I Not Applicable £
Name ofUterieBelem Scct.\.( 4rrids // eJ CS- 10851'
ticeace Number
24/6. conALL a - ?u¢. c. ,h n, hid mil J2Aofzafg
Address CJI to 1. EaWrafion Date
915 250 '-/ 1,4,
Signature Telephone
9 ,Remstered Home Improvement Contr''actor - _ Not Applicable E
5ASOB <4ierpIT:so LLC /!o (oo ? `1
Company Name Registrration Number
P.0 BOX Ir % 04ic ep1Vv Y-2 ]- zoite
Address U i 014 Expiration Date
Telephone...'r(/31301 &GC§
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 IIM affidavit will result
in the denial of the issuance of the building permit
Signed Affidavit Attached Yes E No £
9' . — Htome ®weep i renin nils
The current exemption for`homeowner'was extended to include Owner-occupied Dwellings of one(1) or two(2)families
sod 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 109.3.5.1,,
Definition of Homeowner.Person(s)who own e parcel ofland 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 he considered a homeowner
Such"homeowner"shall submit tothe Building Official,on a form acceptable to the Bolding Official,that he/she shad be
responsible for all such work performed ander 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 Ciupter 152(Workerc'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 persons)
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
I
The Commonwealth of Massachusetts
=-Mt= Department of Industria lAccidents
I Congress Street,Suite 100
--4:1114—= Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applaaant Information Please Print Legible
Name (puniness/organirationandividual):JASM Enterprises. LLC.
Address: P.O.Box 1276
City/State/Zip: Chicopee, MA 01021Phone#: 413-301-8010
kreyou on employer?Check the appropriate boa: Type of project(required):
1.0I ai.x employer with 9 employees(ma an&or part-time).*
7. 0 New construction
'_❑le-,.a sole proprietor or partnership and wemployces working for me in 8. El Remodeling
o
any capacity.{Na workers'comp.ilres net required.'
DI ann homeowner doing all work myself. No womencomp.insurance required] 9. CI Demolition
a.❑l lot a homeowner and will be hiring conaacton to conduct all work on my property. I will O❑Building addition
ensure that all contractors either have workers compensation insurance or are sole 11.❑Electrical repairs or additions
propdcmn with no employees 12.0 Plumbing repairs or additions
5❑1 rnr general contractor and I have hired the suheontrumrs listed on the attached sheet.
U.- subcontractors have employees and have workers'comp.ivwtt3
anI3.1:112oof repairs
6.0 w, !,a corporation and its oMcen have exercised their right ofexemp[ion per MGL c. 14.DOther insulation
i.. ala).and we have no employees.INo workers comp.Insurance required)
iv appl:.'nr that checks box el rust also fill out the section below showing their workers'compensation policy information.
who submit this affidavit indicating they are doing all work and hen hire outside contractors must submit a new affidavit indicating such.
,rmractor' hat check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitle have
..ployxo. '.:the sub-comracton have employees.they must provide their worken'comp policy number.
. ..2n an player that is providing workers'compensation insurance for my employees. Below is the policy andlob site
ram- 'ompany Name: Liberty Mutual
Scif-ins.Lia#: W C2-SI S-372772-015 Expiration Date: cc — /7
Site 'dress: City/State/Zip:
�rh n•.qty of the workers'compensation policy declaration page(showing the policy number and expiration date).
• e r, .cure coverage as required under MGL c.152,§25A is a criminal violation punishable by a fine up to$1,500.00
vicar imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
ihe violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
lification.
her. certify under the ins an entries of perjury that the information provided above is true and correct.
• Date: .7 o2.— &D i e
113-301-8010
ie only. Do not write in this area,to be completed by city or town official.
"n: Permit/License#
.b. uthorify(circle one):
.f Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
• `,rson: Phone#:
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
(Property Address)
IL5 e VetM�1-orll MA— 3 t o ( fiNt
(Property Address)
c
hereby authorize
f.Crp%t>cS (LL
(Subcontractor)
an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building
pemdt and to perform work on my property.
•
• , s Signature
L 'A-`Z - t 5
Date
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
Address of the work: 2L' /ou re( lh
The debris will be transported by: us deate s{er
The debris will be received by: US i dotps Ar
Building permit number:
Name of Permit Applicant L Set 11. (Vac-ISLA}
4001 Date gnature of Permit Applicant