10B-079 ea 1 -BC cn
TI u? C(111117ZOnFt or MassacittacaS
_DepartnzETY offizdustt
/1.4 I7:( Office of fnve.sfigations
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60t'.1 'it'asitinG Streei
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Worice.rs' Compensation fuso ranee Affidavit: BuildersiCantractursiElectricians1Plumber3
Applicant information Please Print Lealblv
Name (F3u6ne.sgior i:4t.-- etvmlaV
---7,..%_t-tkriD ---
..tNrst-lcire_:*.N, mALIT05
Addrc.;ss:
--- — -
Ci ty/S tate/2 ip: Phone #: 5.'7' / .1. 2 / y .1, -
Y - . ,
Are you an employer? Cheek the appropriate box: i I
1 i T.3.,-pe of project (required):
.4_ 0 J azti a garteral ccwit:rac auci 1 i ,
1.1 I I am a cmploycr with
I 0_ L j New coosnuction
have. hired the sub-conn 1
employees (full and/or part-time).''
li..cted. c.a the. :At :,..iiire-t.. i . 7. U Pserri-eling
2. I arrt a sole proprietor or pert-ilex I 1
ta
ship and have no emp These. sub-conrctors have
loyees I .8. n Demolition
ein end have wolfkers' il
working for me in ally capanizy. 1 I 9_ fl Milian addition
comp. ill5liraliCe..
[No workers' comp_ insurance I 1
required.] 5 ni We ZITC i'.1co and its / 10_r; Electrical repairs or additions
3. DE I am a homeowner doing all 1.v ot.Ticers have eercised their i * Fl Plusnbine. repairs or additions
1 1 i _____
inyself [No workers' comp_ right of e.... per MGT__ i i 12. 1 --- ) R oo / repa i rs
insurance re. ' c. 152, §IVI), anti :ve have no ; 1 " '
■ 1 13.0 Other
employees. [No tvorki.--rs' 1 1
< •
coi hisarance required.] 1 1
*Any applicant that cliccics box 41 rims! 2.13:o 511 out 'these-a:nu below s'auvritie 17 Wiiikt co: , policy/afar:ration.
Homeowners who submit this affidavit inOtr they are eiiiiiig ail wixiras th i'lm . vtizsidt consiliczcrs must submit 2 new affidavit indicating such
1 Contractors that check this hox must eta:Leh:A n she-.-t shovtine eria name of:de:sub-contractors and slats whether Dr not these entities have
employees. if ttic sub have errTioyces, they must pr-id u thch workers.' contri poltcr: cunnbr_--
1 am an employer that is providing- ritorker compen.vatioa insurance for ray employees Below is the policy and job she
infamation.
Insurance Company Name: _ L, i ,=7.". - 471 ,, - -t;;-,-/
• i
Policy 4- or Self-ins. Lic 14 14, ti ...k, ---3 i _ -; - .7 Z - _tr!' 7 — -',` `.... 17:4piration Date: / - 7' i /Z
Job Site A cldres-n: Cit'./State/Zip:
Attach a copy af the workers' compensation po.liev declaration page (showing the policy number and expiration date).
Failure to secure coveraoe as required under Secort 25.A. 0IMGi c. 152 can teed to the imposid0P of crinili- penalties of a
fine up to S1,500.00 tuldfor one imprisonment, as well as civil penalties in the farm of a STOP WORK ORDER and a fine
of up to $250.00 a day against the viola.r. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certin under the pains and peoalties af perjury that the informadm provided above is true iff nd correct.
Sig_nature j, : - r tc,--' ir .. Date: =z" =' - 4- <.
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Phone A: -,,, ir f 't ,
! ,L. i 41 '4., 4 / ..,# ___
7
....
offieiat ase oItiV. Do not write itt this trit rci i coiii 6y city VT fowl cffic
II
I
Cit Or Town: Perrnitit !cense
issuing Authority (circle one.); I
1_ Board 0:Health 2. Building Department 3. CitVITOWD Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Conga Person: Phone f---.':
Department use Only
City of Northampton Status of Permit:
r I RECEIVED Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Skii 2 Q 2012 Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
- - ;* e 4 3 587 - 1240 Fax 413 587 - 1272 Plot/Site Plans
Dot sane• '
•
Fi wo,oso
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
3- Map Lot Unit
LE-4.5, //M J Zone Overlay District
1 Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Air n e 416 re hln vSe 51 a -A-T�/ Sr,Re 57'� 2 Ee�•
Name (Print) Current Mailin AAdress:
Air / _ `.� Telephone
Signature
2.2 Authorized Agent:
116/ve fi er S i /, s . h Qa K
Name (Print) Current Mailing Address:
/3
6 7
Signature Telephone
SECTION 3 - EST1MA D CONSTRUCTION COSTS
Item /f1�S / U I iw Estimated Cost (Dollars) to be
completed by permit applicant Official Use Only
1. Building doll// /40a) (a) Building Permit Fee
2. Electrical 6 (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3+4+ 5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued.
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0674
APPLICANT /CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413) 214 -2414
PROPERTY LOCATION 54 WATER ST
MAP 10B PARCEL 079 001 ZONE URB(100) //WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 573 $
Typeof Construction: INSULATE ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 101880
3 sets of Plans / Plot Plan
THE FOLL G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
TION PRESENTED:
pproved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission - Permit DPW Storm Water Management
R - molitioDelay
A• 10
7 7 2 ''''''''
i5 ,/
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
2Y
54 WATER ST BP- 2012 -0674
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10B - 079 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- 2012 -0674
Project # JS- 2012 - 001163
Est. Cost: $1000.00
Fee: PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 11586.96 Owner: MOREHOUSE ANNE & MARY HURLBURT
Zoning: URB(100) //WP Applicant: JAY BOLAND
AT: 54 WATER ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214 -2414 WC
HUNTINGTONMAO1050 ISSUED ON:1/25/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: I NSULATE ATTIC
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 1/25/2012 0:00:00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner