38D-032 (4) 13 HARLOW AVE BP-2018-1235
GIs#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 38D-032 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv' INSULATION BUILDING PERMIT
Permit# BP-2018-1235
Project# JS-2018-002206
Est.Cost, $800.0
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq.ft.): 9583.20 Owner: LAPOUR LYNN E
Zoning URB(100)/ Applicant: JAY BOLAND
AT. 13 HARLOW AVE
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 203-2454 O WC
HUNTINGTONMA01050 ISSUED ON.•512412018 0:00:00
TO PERFORM THE FOLLOWING WORK BLOWN IN INSUALTI0N AND 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 OccuoancV Sienature:
FeeTvoe: Date Paid: Amount:
Building 5/24/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
e> P— ( 9 -
Department use only
City of Northampton Status of Permit:
Building Department Curb CutfDriveway Permit 212 Main Street Sewer/Septic Availability
'I. Room 100 Water/Well Availability
'- Northampton, MA 01060 Two Sets of structural Plans
phone 413587-1240 Fax 413587-1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER REPAIR RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION C E I V E D
1.1 Proaerty Address: This section to be completed by office
"-IOU N"'e- NAY 2 2 2018 aP Lot V /� Unit
13 ane Overlay District
DEPT.OF BUILDING INSPECTION!
NORTHAMPTON,MA 01060 EI Diebtel CB Dlawi t
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Ownar of Record: I'
Vn �A%�, 13 Harlow ALIk /VIA
mama tvnmt) Current Mfi2ipg3 dress_,,, 1oT
Q1 i (,
Telephone 'SS�it YY'- (X
Signature
2.2 AuUhorlrad Anent: -
S wi\ X33 c�lle4p I�AI �y�I MA
Name(Pnnt) � M Mailing Address: U'f
Cu73 - a a3- d4SU
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Itam Estimated Cost(Dollars)to be Official Use Only
m leted by t a licant
1. Building {(/,0 (a)Building Permit Fee
2. Electical OV (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Parrett Fee
4. Mechanical(HVAC)
5.Fire Protection V'
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Uss On
Date
Bu ding Permfi Number Issued:
Sigmdur : 2
Binding iss..nInspectorof Build.W Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all licabl )
New House ❑ Addition ❑ Replacement Windows Alto raUon(s) ❑ Roofing
Or Doom ❑
Accessory Bldg. ❑ Demolition ❑ New Signs 10] Decks [q Siding[O] Other[®
Brief De-TT of Proposed 1I T�
Work: 1'� lOt.r,�•-Irl �nS✓httM 0. air SPkI AI
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rail -Sheet
sa.If New house and or addition to existing housing, complete the following:
a. Use of building:One Family Twa 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 stodesv
f. Method of hashing? Fireplaces or Woodstoves Number of each_
g. Energy Conservabon Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
i. Is construction within 100 R of wetlands? Yes _No. Is construction within 100 yr. floodpiain_Yes No
J. Depth of basement or celler floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank CitySewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMff
Lowl as Owner of the subject
ProPertY S (��"
hereby authorize Vl� I Y I If
toact on my behat in all matters relative to work authorized by this bullring Permit appllcotion.
� k�a�� —lar lr�
Signature of Owner p I 1 I Date
as Owner/Authorized
Agent hereby declare that Me statements and Information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penaaiesr of oury.
Shaw N 1
Prim Name
Signature of Owrlar gem Data
SECTION a-CONSTRUCTION SF1eMES
8.1 Ucensed Construction Su�p rvisor. I Not Applicable ❑
m
Nae of Ucenag HnS
older cJ GtV I{aq 0 161 kkB
License Number
a CII oLolgil MA Nol�— i� w-115r
Address Expiration Date
a IV
Sig Telephone
.Registered H me Imp Contract r. Not Applicable Cl
,5 awn rel c�11 MIN
N
Nama Registration Number
c� vne_ hvx44 �I� I ovs InC_ 113 /if
Address IIExpiration Date
933 CrNfA= �TelephoneY13.a
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152,§25C(6))
Workers Compensation Insurance affidavit must be mmpleted 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...... ❑
Deptulptarf oflndaslrial Acede)rss
Offlce oflnvesffgadons
600 Washington Streef
Boston,MA 02111
www massgov/Afn
Workers' 'ompeustion himumAffidavit:Bel7dets/Coj&hWbor&UeMdft=Mumbers
A t Is I Pkm Print Lelubly
NameEA.9,rqtj Sol( (.
/�
Address: 6155, C0ll25t r11a'hl dN
City/stateMp: S— M96 V11A Q!a?3 Prone#
Are you ao emploW. Check the appropriate box: Type of prom(required):
1.M I am a employerwith 9- 4. ❑ I an a general contractor and 1 6. ❑New construction
employees(fnll and/or Pal-time) have hired the mbcamacrocs
2❑ Ism asoleproprietor orpattuer- listed on the attached sleet= 7. ❑Remodeling
slip and have no employces These sub-contractors have 8. ❑Demolition
working for me in mycapecity. workers'gyp. iusumxse• 9. ❑Building addition
[No worhens'comp.imiaance 5. [1 We are a corporation and its
reRuiTed_] officers have exacisedthea 10.❑Electrical repairs or additions
3.❑ I sur a homeo ver doing all work right of examption per MGL I1.❑Plumbing repairs or additions
myself(No workers'comp. 0.152,§1(41 and we have no 12.❑Roofrepeus
insurance required.]t empk yrees.[No workers' 13R]Other_
�P-insurance rte] '
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hvsurs=Company Nwnc:AMp)PMO'# Sz3urcmcf Gmpn4
Policy#or Self-ins.Lic.# WL y• Expimfion Date: W �1tq
Job Site Add.ma: 1B AI�Oc.) /y citrstwmp:0 juw�-�" 01066
Attach a cM of the workers'mmpemonflm policy declaration Page(ttbowiog the polity uamber aal rspiiatoa date)
Fadme to secme coverage as requited under Secfim 25A ofMGL a 152 t ,lend to the imposition of mimiinsi penalties of a
fore up to 51500.00 aorto.mo yes,hapriseomem,as well n civil penalties-,he form of a STOP WORK ORDER and a fine
of up t,5250.00 a day againattbe violator. Be advised that a copy of this statement may be forwarded to to Office of
Investigations of the DIA for insurance coverage verification
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10 Park Plena•SuBa al 70
Boston, M4*ohuwb 0211e
Home Improverrb( t3oMra0tOr Regkttration
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City of Northampton
Massachusetts
w 4
Na MMUINT OF BUZ=NG IN ZcrxONs
212 pain Street a p Cipal auildeg J
po�' M 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, 554, 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
(Please print house number and street name)
Is to be disposed of at:
� Illk<�Llw enw -d o M�
(Please p 'nt nipe and location of faciaW
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If,for any reason,the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
City of Northampton
Massachusetts
_ DEPAA4lffiVP OF BUILDING INSPECTIONS � 14
212 Main atreat Mv,iciPal BullAiag y�srCD
�;' NoryLemptov, 1A 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("RIC").
M.G.L.Chapter 142A requires that the"reconsbuclion, alteration, innovation.repair,modembation,conversion,
improvement,removal,demolition,or construction of an addition to any pre-exisllng oMner-occupled building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by redstered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must he registered
Type of Work:In- Q� i^� Est. Cost
Address of Work: 13 O111(j�cv l m Ai m
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 14M SUCH OWNERS ALSO ASSUME THE RESPONSIBILMS FOR ALL WORK
PERFORMED[RUDER TILE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
`Shaken W( keIf
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature