13-034 (3) 400 NORTH KING ST BP-2020-0771
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13 -034 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-2020-0771
Project# JS-2020-001327
Est. Cost:
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq.ft.): 31188.96 Owner: CAMP ANGEL LAURA
Zoning: Applicant: JAY BOLAND
AT. 400 NORTH KING ST
Applicant Address: Phone: Insurance:
233 COLLEGE HWY (413) 203-2454 O WC
SOUTHAMPTONMA01073 ISSUED ON:1/2/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.•I NSULAT ION
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 1/2/2020 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Versionl.7 Commercial Buil-din Permit May 15,2000
g h gDeparYmett usearr
City of Northampton S[ vsofPeGrrrt
Building Department Curb CutlDnveway;PeCrrtii z
212 Main Street
Seuver�SepbcAvailability� �� � ° � �, � �g
Room 100 Water:WWAvaiCabElity 4
L �t
Northampton, MA 01060 Tvuo sgts of"Structura(Ptarts
phone 413-587-1240 Fax 413-587-1272P[otlse Flans:
Otber�Specifjr����� ��
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE,CHANGE THE USE OR OCCUPANCY'OF,OR DEMOLISH ANY BUILDING
OTHER THAN A ONE OR TWO FAMILY DWELLING
'SECTION 1 SITE INFORMATION'
1.1 Property Address: This sectron tO 6e completetl 6y ofhce
Maps Lot' Unit , x
W0o N. C,
e'.11s
Zorae Overlay D�stnct
W,_ 5
Elm Str(]ISt[IC CB.Distract
._.. ........ _.� . �_ .. w
SECTION Z-:PROPERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
L AURA
Name(Print) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 11-ESTIMATEDCONSTRUCTION COSTS:
Item Estimated Cost(Dollars)to be Official'Use:Only;
completed by permit applicant
1. Building (a),Building;Permit Fee:
2. Electrical
(6)=Estimated Total Cost:of i
Construction from: 6
3. Plumbing Building:Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Sectlora:For,Official Use Only
Building:Permit:Number Date
Issued
QP - ao . 7`71
SignatuPommisLslonerl
OL/ a
Building; lnspactor'of:Bui gs: Date:
r3 03
SECTt 114:=C0[�SEtt1GTfONSER�[iCES "
8.1 Licensed Construction S ervis Not Applicable ❑+�'
Name of License Holder:
License Number .
'IaALI Mq 010
19 Z-wc�16
ddress 18
Expiration Date
Aik
Signa `e Telephone
t i
r9.� a u�ter�d;-6#orsse�t Eontractor`� � �ti s Not Applicable ❑
lu
Corn.do Nam .e � J Registration Number
I I I &
MA- 61 .3
ddresb 4 Expiration Date
I Telephon o t
I
SiECTtQI+f 5 1IYORKERS COMPENSATMONINSURANCE AFFtDAYI3'fM GL. c 452;§25c(s}}
WorkeCompensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result
in the.Zial of the issuance of the building permit.
Signed Affidavit Attached Yes....... i" No...... ❑
Brief D jscription of Proposed Work OTE INSULATION ONL
1 10WA all
1kuJ I as Owner/Authorized
Agent.h reby declare that the statements and information on the foregoing application are true and 'accurate,to the best of my knowledge
and belief.
i
i .
Signed
Ender the pains and penalties of perju .
Print Narie
Ld
Signatur i of Ownert Date
! P
II
i, �uv o, cj� as Owner of the subject
prope�y ��l�.ul
hereby,authorize
to act,on my behalf,in all matters relative to work authorized by this building permit application.
;A
Signature of Owner Date
j I
f i
City of Northam
Massachusetts
DEPARTAWNT OP BUXZDZNG ZNSPECT,ZON3
212' Main Street :# Huriicipal;Suiiding
, , '' Northarnptonp MA OSObO
Pro ,ertyAddress: d 40 e4 f` rl", S+
Contractor
Name:
Address:, (O
City, State: �►� MA i
Phone:.
Ali a�3 asp
Property Owner,
mama )V C0yUl Y'
t ,
Address: G U G✓��^ l�'l
city, stet:
(contractor).attest.and,at'firm that the bwldinintend.to
insulate does-not have any open air(knob`and tube)-wrong h the spaces to:be:insulg:l ated and 'that 1,have
provide.6the;property.owner with a.cb y of this,affidavi� .
Contractor si nature
Bate h 2
i
Docu5ign Envelope ID:7509C465-AECD-4EEs-90A1<D7601$BAEE73
RISL
ENGINEERING
OWNER AUTHORIZATION FORM
1, Laura Camp
(Owner's Name)
owner of the property located at: -
400 North King Street ,
(Property Address)
Northampton, MA 01 060 ,
(Property Address)
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.
DoeoSigned by:
'��a store
9/16/2019 1 2:17 PM EDT -
Date
I
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton, MA 020211339-502 6335
www.RISEengineering.com
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irmp[osieme�riS,Before rriovtnQ:.forwarti.:ptease tol(oev-aU'the instructzons:be!ow=toreIn'le*w-jto r:irwea. ;l�aa ersi '
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2 Suirmrt 3s5ned SEI eompiPtd tdp es of this a(m arsci a ccaY oft{aetd cdr)tra tcZt rnvpic�is�wsthm 6fl. s 9f YW r Home anergy
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3 The weattterrzadon utc=ntYvO vinU tie iiEa{actec3 from ttl8 L'ttstDmer¢o-aayment amomtof the vreathgrua:. , vrork A r�taate,etsec!<'
wit be rssued m itis event i tie amoutrt exceeds the•costomer s c pnyme�t srrstsunt
4 comptete th+�rerommendtf vfeaFherizatron frfsp+`oirerr+ents. '
customer lqa ie LauCB C AM ,lie,;t, or 5ce ri $2 55;
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ro"detar+nitie tf ti+ere is aay acsve t<no irpa tutkewir�ngr the;Co�tracia.x1311 s�a�uae a tottcw, acea5 ate ! rhe Mass 5iva.
weatherizatlan recornm�ndauons twv ;txen madeNE€ IILL
�,ruct��Ftoor;o�atr'.vstatr.o;oiucssope rtor'inr�l:��senieat �t�ziierSLO.PESJ = er
!have partormed,my itupeeticn and i3eterminear there ss do".active iiito�anC:tut+a xurmg iz<:theareas seieeted
liAttse FtoorAtgc Wath Atbc Slope iExtertor SII :lsrsetttent. Other _ Cher
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Contracto�'Name ,: tUN
Addressr�� � stares;
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s measur2cl ar the cT!d�yod£fits has crz oeiaw TOfl;Parts er'rnrN�rt�tpt?rrl).
Draft Failure Contreetdr is to correct the oraiCin ttx selected fluets7 Rsferto tabEe As reverse t act eGtapie . . .rdnges
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AMR
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E9-featetsnttactar Ls to cc�xea ti a spitta5a nrflus;cases in;thesei3ctenxectianical SYten,(s} >st'nQt sP6� 6Useiids ot.op:raitioti
nCSysiein% t2 Hot:Water Hauer b". ther
!� +nY�i�eciior?acid hzwe corrected ttr@?3elns acted�n tt�e areasa,rEte2ted!atsage:
Cl,1ira�re;t dand'agieetattieTears'jiiidCoirditionsoritlSebacirctti 't6Riiz
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City of Northampton
Massactsetts
DEP 3' OF BUZEDIM 21ITSPSG3 CW
212 Grain street •Municipal SuUdiag 06
a 8osl3sampton, PSA 01060
Debris D i spozal Leif f it avi t
In accordance of the provisions of MGL c 40,854, i acknowledge that as a condition of the building
pemtit all debris resulting.from the construction activity govemed by this Building Permit shall be disposed
of in a property licensed solid wastedisposal facility„as defined by MGL c 111,S 150A.
The debris from construction work being perforated at:
Go YLmAk L In( 54
(Please print house manner and sivet name)
Is to be d t:
disposed of a
MCA A -'}' CMMU
Irl )
{Please .n a artd{ocabio I'
I
Or will be disposed of in a dumpster onsite rented or leased from:
(Company-Name.and Address)
s�'�
Signature of Permit Applicant or Owner Date
If,fir any reason,the debris will net be dished of as indicated,the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The,Como»weaJih ref Jl�assreehrrs;+rtts
Doartrrner t of irt4trst'r W A<t.
2 Congress StI"eet,StFte`3001
Hostiarr,>AiX 4rJ2I, -2t?17
www.
Workers'Compensati6n insurance AffiitlavFt 8uIWrs/CdntrectorsjElectridol sJPlumbers
6.81E f11io Ui rrWTHt:PERMtTnNG AI31` oRny.
Appl omt 1ofommli.
ome,�Ener Slalations Inc j
Name fBusinessJc3rganiziationa!/I�divldual)..:H ��.
Address:233 Cnllego, city:'Sduthamptpri
iVIA # 073.
Zip:. . 4'!3 20,3 2454 .1
State: Phone#
I
Are;you an employsc?:Check the appropnate`box; Type }a ode t(r pelted):
1. I am an employer virithL_:.:.lemployees(full and/or part time)* 71 New-construction
2. i am a sole proprietor or partnership and:have no employees working for me In any 8 Remodeling
capacity:[N6 workers'co- mp;=insurance repuired.j
Demolition -
ED3. 1 ant a homeowner doing all work myself.[No workers',comp.insurance reauiredi t 1 Ii0, S ilding addition
LA i am a homeowner and will be hiring contractors to conduct all work on my property i ! 1. Electrical repalrs;or additions
I'M ensu 01 atallcontractorseither'have-vaz�vrs';compensationInsuriii or are, {
sole proprietors with;no,employees♦ El
a Plumbing:repairs,or additions
5, 1 am.a general contractor and 1.have hired the sub-contractors listed on the attached 13. Roof Repairs
-sheet.,These sub.�c6ntractors have 6.. shears a co oration and itskers hplayees-and haveworkers''comp:tlsurance.
rp ave.exerciseiitheir right o€exemption perrillGL, Other
c.152;,§l{ti)�and;vde have no eirplayees.[No:iuorkers'cpm .insurance re ulrea.). .:.
" ny appikarit that checks tiox 3i1 rriiast aisb#ill,�rut the settli3ri"belosni sisi3 rir>g their u oriiers'-comperisat an policy irif6rniation,
t»vriieowr 6s who subinit this affidavit,wltating their are doing all w6rk-and then f ire outside contractors must submit a new affidavit indicating such.
tCotitractr%r that check-ibis box,rriUsY attar ori addiYiorial sheat`showing tl3e.name o#xhe sub toritractttrs artd.stats wtietharor irot those erititfes have.,
employees.;If the sub=contractors have emi;16 cies,they must provii9e tfielr worker's'comp.policy ni r laer.
1 om an eroployer thatis providing workers'cornpensadon insuronre,for my emplowes, Below Is the p*14 and Job.sfte.informption..
Insurance Company Name
W',
Gawr InS�ran ,Co,
1/4/20
Policy#or 5e1€--Ins,LiC,# H011ttC0 50 �Expllon Date:
Job Site:Address; Q 4 ( S4 1717 O 6d
Atiach a copy a€the uvprkers'-' trripensation epic cy deelarairlort:page{shaving the poiicynurnber and expirationdatej.
Failure to secure coverage;as required under,MGL c.A52,.§25A is a;,criminal,violatlon punishAble:by,a fide up to$1;500.00 and'/.oeone-year
Imp>fsonment;as veil as clvil:penalties,in,the€arm of a STdP WORK'DRDER and a€ineaP up tt%r$2S0 tJ0 a day against the violator.`A copy of this
statement may be farararded to the�7€fice of Investigations of the RIA for insurance coverege verietion I
m
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1 dm heri +te�r under tt porins d penrilttes r►/per�r that the irifprmar3on provided abtwe is true r�rs9rrecta»z!th€rt cltrk3»g tfits
chbiwcr»tt rpfirrB trnarfie #€e #ic► +tiy111trct s�sfncriure
Nara , Slltn fthell [late. ..
4`,l 29W, hi mla€�ni rXV,��wt n w l�ner n t ;
Phone.. �. Emai1.
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