29-300 (4) 438 ACREBROOK DR BP-2018-1369
GIS#: COMMONWEALTH OF MASSACHUSETTS
mak:29-300 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv: INSULATION BUILDING PERMIT
Permit# BP-2018-1369
Project JS-2018-002428
Est.Cost: 52500.00
Fee' $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groun: JAY BOLAND 101880
Lot Size(sa fl.): 17859.60 Owner. HOWE TED
Zoning: Applicant. JAY BOLAND
AT. 438 ACREBROOK DR
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 203-2454 0 WC
HUNTINGTONMA01050 ISSUED ON.612012018 0:00.00
TO PERFORM THE FOLLOWING WORK BLOWN IN INSULATION 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 Signature:
FeeTvpe: Date Paid: Amount:
Building 6120/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck-Building Commissioner
T-nSula4-(' a
Department use Daly
City of Northampton Status of Permit
Building Department Curb.CullDdvewmy Permit
212 Main Street Sewer/Sepac Availability
Room 100 Water/Well Availability.
Northampton, MA 01060 Two Sete ofSbuctuml Plana.:
phone 413-567-1240 Fax 413-587-1272 PlovsdoPlara
Other specify_
APPLICATION TO CONSTR OR A ONE OR TWO FAMILY DWELLING
SECTION,-SITE INFORYIITION b O- YJ— ���
7.7 ProoartnAddress: U11 eTh/�is section is be comp"by oiNce
Sts AGr�brow L D,. d9 Lor_H 1rV17_Dnit
�lwcnct, flop- OICG� OraNORTHAMP ON.Mnoia�so�s
Overlay DWWW
Elm SL Dfeakt CB Dlealet
SECTION 2-PROPERTY OWNERSMIAUTHORED AGENT
21 : (�
�d a(a1e. 3`S �}Gfebmd- Dr. FLrlence A114 (91062
o
Telephone
Si9naWrs
2.2Autlmrtred Aasnt _
S r\ a33 Ilene I �wJ �/h�
Name(PrMt) L1 Malrg�'� —�
Y/3 - a 33- 9qS(l
Signedm Tebpaam
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be OMcisl Use Orgy
aookam
1. Building I i Too (a)Builting Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Balding Permit Pas
4. hlacllaniCal(HVAC) 5
5.Fie Protection
6. Total=(1 +2+3+4+5) 60 Check Number
This Section For Official Use Only
Dae
Building Permit Number: Issued:
Sg atu
Butldrg of Buildings Dare
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK ldwdr all aoolirablal
New House Addition ❑ Replepm ud WMdowe Alearsiion(s) ❑ Roofing ❑
Or Doors
Accessory Sldg. ❑ Demolition ❑ New Signs RM Deeks Siding= Other 11q
=Dascdpg¢noro`JP\ropers�ed IE�s 4,.y\ d,J air Seale
Alteration ofU'e)&Ung bedroom Yes_No Adding new bedroom Yes No
Attached Narrative Renovating wrfinished basement Yes No
Plans Attached Roll -Sheet
ga.If New house and or ad6tion to OXWUlm housing,COMPIOte the following:
a. Use of buikfirg:Ona Family Two Famgy Omer
b. Number of rooms in each family unit: Number of Bathrooms
c. is there a garage attached?
d. Proposed Square footage of new consimcdon. Dimensions
a. Number of shies?
f. Method of heating? Fireplaces or Woodstoves Number of each_
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
1. lsconstruction whhin 100 fLof wwtiands? Yes _No. Is constnwtion w,mer 100 yr. flooddain_Yea_No
J. Depth of basement or cellar floor below finished grade
IL Will building conform to the Building and Zoning regutations? Yes NO.
I. Septic Tank_ Cly Sewer Private well_ Cay water Supply_
SECTION?a-OWNER AUTHORIZATION-TO DE COMPLETED WHEN
OVjr4M AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. ,(Z Q, ,as Owner of the subject
properly I
hereby aumodre V haw n M li' 11
In act on rtry be in all metiers relative m work erNtlror¢ed by this building perms�ppLrehor,j v
�k�ae� a /// // a
Signature of ownu I Date
as OwnerfAWroraed
Agent hereby declare that the statements and worrration on the foregoing appiic on are We and accurate,to the best of my knowledge
and belief.
Signed under the pains acrd penalties of rjury.
's (0.w
Print Name
SECTION 8•CONSTRUCTION SERVICES
5.1 t.Mvnewe Ce*�+±--a. Not Applkabl® ❑
ymnaftmeasomw lad 1alF 11
�� W'cenee Number
Ula h
Addres9 � ogre
9.scal l Noma ruc Not ApwkaCle 0
Sha.wv� MI ciuL l 1El-11
Number
A*dm
came �n�X .�L, _�� I I s 19
L� olo��Tal�p� 4
SEC7M 18•oris'COMPENSATM assupAum AFFMAVIT pLC.t c 151.§UC(6))
W-kors Compensa5oa Insurance af5daAt must be can~end subndded wah this appWkadon.Failure to~a this affidavit wN rasutt
N the denial ofthe>s8rlm Gofthe buRdirig pemdt.
Sienod Af8dev8 Atladmd Yes.._._ X Na..... ❑
City of Northampton
Massachusetts
I l• G
' MAR31aarT Oil BVILUIIrG ZaSPBCT�
F
312 Win scxe.c •Nmieipa] Building =� 's
F+
1bsfLoptnv, a 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I admowledge that as a condition of the building
permit all debris resulting from the construction adivity 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.
The debris from construction work being performed at
N Cie�rod� Ly
(Please print horse number and street name)
Is to be disposed of at ll
1. 0. MA gmml , Qrlfi V+
(Please print nqMe and location of Tacilaw'
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
Hassachusetts .• t,,
DWans7mrr or r+m>zoamc nrsPacrzons
212 iNin seCpn 0 auiid g =
sorthup , 10 01060 1^oo
AFFIDAVIT
Home Improvement Contractor Law
Suppkment to Permit Application
The Office of Consumer Affiins and Business Regulation("OCABIV�regulates the registration of contractors and
subconhactO:s 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 brprovement Contractor("HIC").
M.G.L.Chapter 142A requires that the"recawlrudka,aCeragm,renovegoo,repay,modemimtion,conversion,
mPwvemonK removal,dormoanorr,Oroonahucaon of an adMon to MY Pre-e+vsli ig owrauaccupled b,*ft cmieinbrg
at least one but not mac Clan fora dwaft wdta..-or to structures*IdCh aro aYacent to such raskbnce orbLmW'be
done by registered contractors.
Able.,Ifthe Gomroamer halscosnaded with a carporadon or LLC,Cwtmast
candy masbe/r�eg�issttered
Type of Work: I,�1 QY'I Q'n EsL Cost
AddressofWo& (h'�/C/b(Odd
Date of Permit Application: G
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):
_Bw1dmg 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
TINDER M.C.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBI ITES FOR ALL WORK
PERFORMED UNDER THE 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:
,Shawn M,ekaU
Date Contractor Name IHC 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
DgffAU etOfbAwsbidAeddewts
Off"Oflrrw M
600 waskbwm S&ed
Bosma,MA 02111
www.maMSIFFINa
Wtlrkers' ' ImramAffidavW
Name WanweE l + .
Address_�(p(�2�e _ iA try (/ 1
cityis�- mo/a„ V6 (&t-43 Pbonelk
Are yousm empiogx?Clerk the apprepaisfe be= Type ofProject(rte=
149Iamamployerwilh C- 4- ❑ Iare agtamlconbsesorandt 6. ❑New
oonamuction
mployem(fA M&mport-rime)L• bsve Land Ilse mb�
L❑ Iamamkleopriemra paha- bad an the attached sheet 3 7- ❑Rmodelmg
ship sad have no employees Them sdl-caobsclwahave 8- ❑DmoMon
wig farmoiamyapacity- Wodaers'Comp-Wsmance. 9. ❑B11iWingaddidm
(No wad= coop,iaeomace S. ❑ We we a oapo aIlna abd it&
rimed-] officers baveasem®edgm 10-❑EICOWC1lrepairs ofadditions
3.❑ Iawn a bomeoap doiag a0 work rlghtof—ptionparMOL II-O Plumbing repain or additions
mysew Dio wares'omR- a152,§1(4),andwebaveao 12.❑Roof repens
hmuaoce>*ke&]t employa (Ido wodmm' 13,®Ohba
gyp-inammce requim&I
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bsa�ce Compsny Name~'AILI1 'C.IPJet.✓'j �(l r^Gn[r t-ffHdPa�d
Policy#or Self-im-Lic-#: t�(t�L���}f{' BMbmfm DownoJen r-e /�- ('J g�O
.Job see Addaac-3K A see- 662-Le Ov' G1ty/SavJGp: m ! r2
Attach a espy of the wwkMW com x=WAaa Pasty deeiarWrea page(Showingtbe Polley member sad exPbmdm dame)-
Fahlmem secure eovempw regsiaed mdw Soc6aa25A ofM(3Lc. 152 can lead m the impasi6ion ofehimmal pasaboes of
fineupIs$1jKMsad/oroe yewimpdsmmjam,aswellascivilpeasltiesinHoofoamofaSTOPWORKORDERandafine
ofnpmSM.00adsysgaiasethevi bOw. Be aModtha e,copy of this stermentmay be fohwmded so the Office of
(ave of the DIA for imamece anwago verificahas-
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r:l; Office of Consumer Affairs and Business Regulation
' 19 Perk Plaza-Suite B770
Boston, Msssachusetts 0211e
Home improvemah'toontractor Registration
�e2letretloonl 1724etbn
Horne Energy Solutions Inc < ' dptMdonl 01/03/2018
98 RusselWllle rd
Southampton, MA 01073
Updem Address and relum ood. Mork reason for ahan2o,
.MA1 O xusmni
(.1 AdHrneA n Penawel f1 Rmplaymont f]lost Card
..y�, 1.�uuw..�..e a/IJ,//,..%%nnin.✓i,e.!$
���' mlrfae or Ceneumer AHekaLewlnen RquMNen
,!'':' ;.• HOMO IMPROV6MBN7 CONTRACTOR Reglefmamn valid for Individual we Only
TYPea cowatlm tufare tlu ugked"date. It bund mourn to
ReIDM4 a 2aaum t
Olaae al CawumM Affair,and aualn.ee Reeuletlon
1BIr72A 01NON01e tOPuk P 6170
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Home Energy BoWone lrro ' /r
Shawn Mltchelf66 Rumblaa rd
!�
8-11mimptmn,MA 01073
Undemecrelary hot'valid whhoul aignalure
i
I
t
Jay Boland
ID#2011.554
'ill Ill tit-It xilip, Kvo,,Olnr -W.
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Board a BWNiin6 pWatlons and Stand s 1
Wool 6 WO11681
canmtnJotkul8apsrvlsor 6pwlsNy I
JAY N NOLANb
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RO
NUNTIN6701i MA 01000 �
'�,jarN"aVOAas.— explrsllwlt
mmissleher 10Po7180'Ii
Columbia Gas
or Massachusetts 60 Shawmut Road, Unit 2 Canton, MA 02021
A NISoucs Company
OWNER AUTHORIZATION FORM
Ted Howe
_... (Owner's Name)
owner of the property located at:
38 Acrebrook Drive
(Street)
Florence, MA 01062
(Town. State. Zip) _. . _....
hereby authorize
(Subcont or)
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. This form is only valid with a signed contract.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's
responsibility to close out this permit by contacting their municipality at the completion of this work.
l
Customer Sign ur3t eU ry v
-t l-1 Y
Sign Date
411112018