44-105 (2) 399 ROCKY HILL RD BP-2019-1478
GIS N: COMMONWEALTH OF MASSACHUSETTS
Maa:Block:44- 105 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
Cateeorv:INSULATION BUILDING PERMIT
Permit 4 BP-2019-1478
Project N JS-2019-002393
Est.Cost:$900.00
Fee:$71.50 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: JOHN MICHONSKI 49376
Lot Size(sp.ft.): 77972.40 Owner: TOWLES KATHLEEN
zonine: Applicant: JOHN MICHONSKI
AT: 399 ROCKY HILL RD
Applicant Address: Phone: Insurance:
66 CONWAY ST (413)834-7725 SOLE PROPRIETOR
SHELBURNE FALLSMA01370ISSUEDON:&25/10790:00:00
TO PERFORM THE FOLLOWING WORK:WEATHERIZATION
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 Sienature:
FeeType: Date Paid: Amount:
Building 6/25/20190:00:00 $71.50
212 Main Street,Phone(413)587-1240,In:(413)587.1272
Louis Hasbrouck—Building Commissioner
,vsa�•9rsv 41 7f
Department use only
- — City of Northampton Status of Permit:
�-r Building Department Curb Cot/Ddveway Permit
212 Main Sheet Sewer/Septic Availability
!�. Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413587-1240 Fax 4 7-1272 PlouSite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER SH A ONE OR TWO FAMILY DWELLING
SECTION I -SITE INFORMATION `AVIV �oa`l7Q,I`7qu
1.1 Property Address: OPPT CU7,9 Is to be completed by office
N'04"'
Lot Unit
399 Rocky Hill Rd. Florence rOA'M PEroHy Overlay District
li SL DhaNn CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Kathleen Towles 399 Rocky Hill Rd. Florence Ma. 01062
Name(Pdnt) cunem"a"Ad"a"': 413-387-9173
Telephone
Signature
2.2 Authorized Agent: ,� P lrvtt cNN cask; y� oo•COt^^
aboe.e�Cl�tls we..
(Ptlm) Current Mailing Add 01,310
�YI ' N 13•'S34 -»?r
nature Telephone
SECTION3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Ol6clal Use Only
completed by permit applicant
1. Building $900.00 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee n tr�()i
4. Mechanical(HVAC) U {("'
5.Fire Protection
6. Total=(1 +2+3+4+6) $M.00 1 Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature: y-Z/• ( I
Building Commiselonarllnspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTIO : CONSTRUCTION SERVICES _
5.1 Construction Supervisor License(CSL)
License Number Expiration Dec,
Name of CSL Holder John Mlchonsid List CSL Type law below)
66 Conway St .,. -;__ _..Desnipaon -
No.and street Shelbume Falls,MAO]370 ' cu
U I Unrestricted(B'didings M to 35 000 ca$.
R Resnictedl&2Famil Dw
CitY/Town,State.ZIP M Mas
onry
RC Rootin Cov '
WS Window and Siding
SF Solid Fuel Burning Appliances
I Nsaladon
Te] one Email address D Demolition
5.2 Registered Home Improvement Contractor(HC)
HIC Company Name or HIC RegistrantName -MC RegwtationNumber Expirman Data
No.and Snnct Email eddruxs
City/Town, Stele,ZIP Tel hone
SECTION 6:WORKERS'COMPENSATIONINSURANCE AFFIDAVIT
. _ . . . ,..... - ...(M.G.L c 152.§ 25C(6))
Workers Compensation hssm nce affidavit must be completed and submitted with this applicatiom Failure to provide
this affidavit will result in the denial of the Issuance of the building parmit
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 7a:OWNERAUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIMS FOR BUILDING PERMIT
1,as Owner ofthe subject property,hereby authorize
to act op my behalf mall matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEle OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the paras and penalties ofperjurythat all of the information
contained in this application is true and abcinate to the best of my knowledge end understanding.
Prim Owner s orAotlroneedAgent's N4Wc(Eleclronic Signature) Date
1. An Owner who obtains abuilding permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(fUC)Program),will nothave access to the arbitration
program or guaranty fond undarMO.L.c. 142A.Otber important information on the IRC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work isplanned,providetbe ioformationbetow-.
Total floor area(sq.it) (including garage,finished basement/attics,decks orporch)
Gross living area(sq.ft) Habitable room count
Number of fireplaces Nmnber ofbedrooms
Number of bathrooms Number ofhalf/baths
Type ofheating system Number of decks/porchm
Type of cooling system Enclosed Open
3. `Total Project Square Footage"maybe substituted for`Total Project Cost"
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicablel
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [q Siding 10] Other[IZj
Brief Description of Proposed Waaawhrl9tion General heat Ins meawres- air waling- "sow am door:
Work:
Alteration of wasting bedroom_Yes No Adding new bedroom Yes No
Attached NamaWa Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
as.H New house and or addition to existina housina, complete the following:
a. Use of building : One Family ✓ Two Family 69WAW-4�'
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?
t Method of healing? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 fl.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? Yea_No.
I. SepticTank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of am subject
property
John Michonski DBA John's Home Repair Servios
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owns, r Dole
I. as Ouner/Authorized
Agent hereby declare that the statements and Information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
-a o
S re of Ow+w/Agem Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of Liwnsa Hold,r. JOhn MIChonskI
Uoense timber
66 Conway St. Shelburne Falls Ms. 01370 94376
Eaplradon Date
�A1y 4p� 6/11/2020
Cirgralure Tellp v
413-834-7725
9.Replslered Home Improvement Contractor. Not Applicable ❑
Company Name Registration Number
s-,\,—'3 �-6,, _ 142709
Address , l Expiragon Date
66 Cn w s1 � �p se e V w Telephone I -Tt -r SW020
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L c.15Z S 2x(11))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this afidevit will result
In the denial of the Issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
i
City of Northampton
Massachusetts --
lb
DBPAATP6NP OF BUILDING INSPSCTZONS i, ^
313 Win Sfi * M ici"l Bulls ing
Borthru n, W 01060
Property Address: 399 floe.Lj NI 11 Ze"Y. �oYcr.eL ..rva .
Contractor
Name: .3a% . S 1-�, a 911pwL, .Ndk, IM,rS..0 Slt•
Address:
City, State: ol2-21%
Phone: 4 13-Qa4-7 79..s
Property Owner
Name:
Address: 3Sg {"ek. . X11 'T1bTtnea w1A .
City, Stale: V'. C lci -
I, (contractor)attest and affirm that the building I intend to
irVate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature �J-
Date
6 -ao-9oy9
City of Northampton
qct
'
Massachusetts
s
D212 Main
OF H.I icG *l SP dire,
}t 213 Nain Stunt • Municipal auilaina uJ ��
NorNan,ton, ML 03060
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 most be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the-reconstruction, alteration,renovation,repair, modemizadon, conversion,
improvement, removal,demolition, or construction or an addition to any pre-existing owneroccupied building containing
at least one but not mora than fourdwelling units....or to stmdures which era adjacent to such residence or building'be
done by registered contractors.
Note:Ifthe homeowner has;contracted with a corporation or LLC,that entity must
� d
be registere
Type of Y Work: Wu prr'L�rv� ,, r �+ Est.Cost: 9(70, 00
Address of Work: 3 3Qr t0e.1E.. . 110 G4 1-I.,rC.n
Date of Permit Application: 6- 'aSD-Ad i 7
T 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 OBTAU41NG THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE ROME 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 RESPONSIBILITES FOR ALL WORK
PERFORMED TINDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
P"I'hereby apply for a building permit as the agent of the owner:
6-2.ca-0%0)Ct .1o\.�CFbnv.,t ��..�r Itila*>nq
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
City of Northampton
r�
�
Massachusetts
DSPAB2}IBaT OF BDILDING INSPSCIIGNS ;t
212 l in Stmt •W.icipl 6uilQ.g
MOrU,a ten, MA 01060 ✓W y�+�
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 debris from construction work being performed at:
42c'cls \car ��. ��
(Please pnnt house nu r end street name)
Is to be disposed of at:
(P WA
se pont me a—n&tion otfaciliry) '
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
(J�! 1�WI.r Y1 1CY Ja-ao - 201c,
VSignature 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.
The Commonwealth ofMassaehusetts
Department of Industrial Accidents
I Congress2ASuite
Boston,MAA 0011!4-4-100777
www mass.gov/dia
W urken'Compensation Insurance Affidavit:Builders/Contractors/Electridans/Plumben.
TO BE PILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Ledbly
Name(Bmineocorgaairaaardadividua0:John's Home Repair
Address:66 Conway St.
City/Stateibp:Shelburne Falls,Me.01370 Phone#:413-034.7725
Areyea as emptoyerl Camls me.Pprnprlan bur: Type otproject(requlred):
I.❑1 woo.o'layerwiM employceschal eMrapw-rinowt. 7. ❑New construction
221 unasoleprapnnaror ppmershipardhave noemployees world" forme in 8. ❑Remodeling
any capacity.IN.worscrs'comp.inswaacc mus rcd.l
3.F1 1 rm a homeowner doing all work myself(No worsen'come inu ante restated I t 9. ❑Demolition
d.❑I an a homeowner and will be hiring moa..to conduct all words on my pmpaty. 1 will 10❑Building addition
ours that all cmowarea either have woken'compcomhon inearam rc so
na ale 11.❑Electrical repairs or additions
pmpneums with no enr,flc a 12.[]Plumbing repairs or additions
SC]lana gravral mnaacwrand l have hired the Stab-canawlors listed on the reached rbm. 13❑Roof in
Thew su4conlrectors have amyl%ees and have workers'court.insurance.: t�
6.[]W52area),andw haMiboionrshaveexmisWtheir,,.i mance ptimper MGL C.
14.0+ Other�ATHERIZATION
152,§Ild),and we have no corp!%cess IN.wasas'camp.insunnmrcNuimd.l
*A%,applicant that cheese box N most also fill out the section below showing d eat workers'mmpmaalian policy information.
t Homeowners who submit this affidavit indicating th%am doing all wok and Men him wtside contracwrs must submit a new affidavit indicating such.
:Ccourour,that check this boa vaaached an adda,owl steel showing the name of the sub-mnaacmrs and state whether or not Mow,entities have
employeesrthe sub.:mtmm�rs have engloyees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below A the policy andjob site
information.
Insurance Company Name:N/A
Policy#or Self-ins.Lie.M Expiration Date:
Job Site Address:399 Rocky Hill Rd. Ciq,/StatdZip:Florence Me. 01062
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration dam).
Failure m secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the four of a STOP WORK ORDER and a time of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of investigations of the DTA for insurance
coverage verification.
1 do hereby§c(�� derfy under thep(��ains rmdpened des ofperjuty that the information provided above is true and correct,
.1{
Signature' Lyy j, . , Date: 6-3D• �1 Ci
Phone# L I 3—7 --2 S� _
Official use only. Do not write in this area,to be completed by city or town offciaJ
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department J.CityTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
b.Other
Contact Person: Phone#:
CammnweaNh of Massachusetts
DWIS en of Professional Lkensura
Board of Building Ragulsttons and Standards
Conetrq*06d'96pervisor
CS-094376 Expires'. 06111r2o20
JOHN P MICHONSKI
SS CONWAY ST
SHELBURNE FALLS pMA 01370
Commissioner
V� 7
Office of Consumer Affairs and Business Regulation
One Ashburton Place - Suite 1301
Boston, Massachusetts 02108
Home Improvement Contractor Registration
Type: Individual
istration: 142709
JOHN MICHONSKIf IF
RE�iT11ra0on: 0510312020
D/B/A JOHNS HOME REPAIR
66CONWAYSTREET
SHELBURNE FALLS,MA 01370 y
Update Address and Return Card.
Btat O aRFpJfi
. irv�unAtirrWi�if�`.✓�
OMes of Consumer ANdn i Buslneae Raguledon
HOME IMPROVEMENT CONTRACTOR Registration v.IW for Individual use ordy
TYtrE:Individual before One expirstlon data. N found return to:
ExOinstion OfOce of Conwumm Affairs and Sudrurss Regulstlon
03N3=20 Ons Ashburton Rau-Suite 1301
JOHN MICRO1 Boston,MA 02105
D/B/A JOHNS HO
JOHN P.MICHOM210CONWAY STREET
FS U
SHELBURNE FALLS,. M. Undersecretary Not Valid without signature