31A-131 (3) 55 FORBES AVE BP-2019-0079
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 3 I- 131 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-2019-0079
Protect# JS-2019-000120
Est.Cost. $3500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sp.ft.): 12588.84 Owner: KLATZ DANIEL L&CAITLIN E
Zonin¢: URB(100) Applicant: JAY BOLAND
AT: 55 FORBES AVE
Applicant Address: Phone: Insurance:
12 PISGAH RD (413)203-2454 0 WC
HUNTINGTONMA01050 ISSUED ON.7/18/2018 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 N 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:
FeeTvoe: Date Paid: Amount:
Building 7/18/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
pap,aMmf use only
—' City of Northampton Statue of Permit
Building Department Curb CMDNvaawv Patent
( l'•-'t 212 Main Street Sewer/SepscAvehabdity
Room 100 WaterWell AvaiIaWdy.
•\ Northampton, MA 01060 Two Sets OfStrucbsal Plans
phone 413387-1240 Fax 413587-1272 PID'a
D
APPLICATION TO CONSTRUCT,ALTER REPAW,RENOVATE ORDEN DUS A ONE OR TWO FAMIL NG
2018
SECTION 1-SITE INFORMATION Q
1.1 ProoerN Address: Th t I
NORTHAMPTON.MAO!I6
Map nk
Zone Overlay DWUScIL
Em SL District Ca District
SECTION 2-PROPERTY OWN IER,,SHWIAUTHOPoZEDAGEilT
z rnll� n�e �� -5 ,) -,ekw1 Ale w/Aola�
Name(PmR) �MalLrg Mkaeae:
S gnepae
22 AutlrorFwd Aemt , e ''
Shat��n (�33 � Ile4z 1-{w/ .k�1�an1�m �ozs
Name(Print) � 73 " �
Signwurs Telephorw
SECTION 3-E37WATED CONSTRUCTION COSTS
(tem Estimated Cost(Dollars)to be Official Use Only
Iedby 80olicent
1. Bul1d'mg 0 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Cor swxvOn frau 6
3. Plumbing Building Permit Fes
4. MCUenkal(HVAC)
S.Fire Protection
B. Total=(1 .2-3+ 415) 00 Check Number 7,
Thin Section For Official Use Ontv
Building 7—W-
Pemd[ Issued:
Si re:
rwpwlOrof euildigs pate
EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION S DESCRIPTION OF PROPOSED WORK(chock all apalkablel
Nen Nouse ❑ Addtion ❑ Replaoanent Windows Alterstion(s) ❑ Rooting ❑
gr Doors ❑
Acceawry Bldg. ❑ 0.10. ❑ New Signa [C71 Decks [p Siding[01 Other 11"
w 'ok° "my'n°P rid Ins 4,,,, a;f sekll]84
Alteration of skating bedroom Yes_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ga.ti.New house and or additionto exisfilln housing,CORM AGIle the following:
a. Use of buikfing:One Femiy Two FamilyOther
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attad*d7
d. Proposed Square footage of rev,construction. Dimensions
e. Number of stades?
f. Method of testing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Messcheck Energy Compliance form attached?
h. Type of construction
1. Is construction within 100 R of wetlands?_Yes _NO. Is construction whin 100 yr. floodplain_Yes_No
j. Depth of basement or cellar floor belowfrashed grade
k Will Molding conform to the Building and Zoning regulations? Yes No.
L Septic Tank_ City Sewer_ Private well City water Supply_
SECTION 7a.OWNER AUTHORRATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMR
I, ((114II✓1 III( sriteII .ns Owner of the subject
properly
hereby au0ndze haw M I l
to act on my�m all matters relative to oak autier¢ed by this balding pet apphcelbn-
XW
SlgwWre of Dnw, Dna
1, c>hkwift MI-.e,lra 41 .as Ov /Autleraed
Agent hereby declare tlat the statements and information on the fore sang application are true and accurate,to the best of my knowledge
and bel ef.
Signed underthepairs;and penatiie£of " ry.
SfUAW
PrintHare /r
SECTION S.CONSTRUCTION SERVICES
&I Licarl"d Conshuction Suoerviaor: f Not Applicable El
IMPRO ofSaJ 1`3nlan0 IhlksrB
Llr Number
Address E, n Dale
a �!
5' Telsoxne
9.Registered Hamme bywroyeamont Co c . Not Applicable ❑
Shag Mt c� I 18 Wq
Registration NLmiber
cH Ilic 1 /3 l l9
Address /, Expiration Date
a33 Col ) r�aQIO�';Telephone r ) I
SECTION 10.WORIERV COMPENSATION INSURANCE AFFWAVIr(M.GL a 751,425C(S))
Woftm Compensation Insurance aFWavit coral be completed and submiked with fhfs application.Failure to provide this affidavit will resuk
in the denial of the issuaroe of the building perok
Signed Affidavit Atieched Yes....... No...... ❑
City of Northampton
Massachusetts
9 DNPA� OF naZWD nrse Xoim s
art creta .twat • 1!1X101avildi0q i
ntm
axttaap , n 0100 60 3�noC
AFFIDAVIT
Home Improvemest 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("NIC").
M.G.L.Chapter 142A requires that the"reconstruafta,sharetion,renovation.repaa,modemimtinn,convarsim,
improvement removal,demcation, dconabrrction Dian addition raanypre-enaUrg ownerocchrp7ed budding mrrtalnln9
at least one but notmora d mr 1burduu9ing wdts....or to structures which are adecant to such residence ortaddi a be
done by registered contractors.
Nose:If the hom/e�ocwner bw comiraded%ft a corporadon or LLC,that enXy mnsl be registered
Type of Work: 1�Q��1—,6 0 (� Est.Cost: GO
AddressofWork: �57� 'GY//bQSp I7U-Q
Date of Permit Application: q 1 k I n
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 142A.SUCH OWNERS ALSO ASSUME THE RFSPONSIBI ITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of pmjury:
I hereby apply for a building permit as the agent of the owner.
ShauA )�-KW
Date Contractor Nance 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
City of Northampton�P
xassacnus.tts +•s.�':- .s,O
ri9AR1' OF IW =G D1 ZC7XONa
Q 212 W4, 3t t •R jD ps 9 iAjeg ieo0s
RostLopeon, l 01060
Debris 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 property licensed solid waste disposal facility, as defined by MGL c 111, S 150A-
The
50AThe debris from construction work being performed at
'!�5 k()Aes Avg
(Please prim house number and sheet name]
Is to be disposed of at
F O a
(Please print nrPe and location of umuryji
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
J
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.
Columbia Gas
of MaSSkhUSettS 60 Shawmut Road, Unit 2 Canton, MA 02021
A NIS..C.m .Y
OWNER AUTHORIZATION FORM
I, Caitlin Mckinnell
(Owner's Name)
owner of the property located at:
55 Forbes Ave
_... .(street) _..
Northampton, MA 01060
(Town State, Zip)
hereby authorize
(Subcontractor)
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.
-Customer Signature
6hZbK
-Sign Date
06/12/2018
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Office of Consumer Affairs and Business Regulation
to Pads Pfama- Suite 6170
Boston, oft 02116
Home I actor Registration
m r J TYPE lCWPOMOW
Home Energy Solutions Inc _, ' 01/0312019
so Russellville rd `
Southampton, MA 01073
\A` UpdMs 0.tldnw uM rNum wp. MeM rwwn M Werlae.
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11 Addre+e ❑ReawWd n Employment ❑4oe1 Cold
HOME
yIMPRDMY1EMO ToCi7OJ&M`lIOR1AGACTOR n
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uw Only
TYPO. qerMoneWte. found
9101aft rOf onsturM N6Iro 80 Wetness Po
ulNlo
NPotehav-SuetTo
WOW.Ma 0
2116
Home Energy
60 RUMtWMIM
9wphmnpton,Mli,
undaroewelary Not valid wtthour alp artura
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333 a 9< Jay Boland
g . I ,II Om ID#2011.554
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Massachusetts Department of Public Safety
Ch ry 7L $$$!lIIII Board of Building Regulations and Standard+
License: CSSL-101880
g@ t@+ Construction Supervisor;pr•cialiy
p y A JAY ft BOLANO
ION HUNTINGT NNUNTINOTON MA 07060
p i f.l a / ;
%;w.rctre� 1n'a Expiration:
'Commissioner 12/27/2018
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