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20-007 ,SC.REPAIRS!WSTRIPIINSULIOTHER: (Note: Any and all other measures will be negotiated per application.) Negotiable Misc. Repairs: Estimated: 1 Negotiable Misc. W /Seal: Eslirnated. Negotiable Misc. Instil: Estimated: Negotiable Misc. Other: Estimated: HEALTH & SAFETY REPAIRS: (Note: Any and all other measures will be negotiated per application.) Estimated: HEALTH /SAFETY /B.DOOR /HEATING SYSTEM INFO.: HEATING SYSTEM: HEALTH & SAFETY: 602A/11 P'(1 w Asbestos A/O Net Stack Temp. '' T Q / Lead Paint ON /K Smoke C G Back Drafting 0 }02 9) Moisture 6 6� Draft O 4 7 4 5 Volatile Organic Compounds !M0 Efficiency ' 4 1 -/‘ ' Knob & Tube /1/6 BLOWER DOOR: Six rYI >Z CO TESTING PRE POST Initial / 3 cD l/ Ambient Q Final Water Tank '1"N /Z4/5 Heatinc, r (7/2008) page four of five Job: Initials: COMMUNITY ACTION 393 Main Street Ems, rgy Conservation Office Greenfield, MA 01301 WEATHERIZATION FIELD SHEET /ATTACHMENT A f/ I. This Agreement concerns Job# (Cf iereafter called "Job" and located at: Name DA N 2. N e72 Telephone Address /(9 � L lf�i S � I p44 NCL- Cf/ 0 Apt# Directions II. This Agreement is made by and between: Y� John Michonski, 66 Conway St Shelburne Falls MA 01370, an individual dba John's Home Repair, hereafter called "Contractor" and Community Action, 393 Main Street, Greenfield, MA 01301, hereafter called "Agency ". III. The Contractor agrees to perform the work specified herein in accordance with the standards, specifications and provisions of the Commonwealth of Massachusetts DHCD/DCS Weatherization Assistance Program Technical Manual, April 1, 2008, and the Community Action Agency Technical Manual, which are hereby incorporated and made a part of this Agreement. Any violation of the above standards, specifications, or provisions will be corrected at no additional expense to the Agency. IV. For satisfactory completion of the Job, the Agency will pay the sum indicated on page five. V. In Witness Whereof, the parties have executed this Agreement as the date written. Agency (9 lk,Or % Date /6/0 �,0, Contractor may : • Date b o�.( �j :6/01/2009) page one of six Client Educ: - @7 /17,' 2CEl'3 11:08 1413625::121.0 BLACK 1ER IN51_IRAhd PAGE Al ESSUCD EY 1HE STOCK INSURANCE COMPANY r HEREIN CALLED THE COMPANY AGENT NUMBER POLICY NUMBER 3RANITE STATE INSURANCE COMPANY 0072375 -00 WC 007 - - 2715 13102 • 013 -66- 0509 -00 INf:ORrOrtR1ED LINDER 1HE LAWS OF ' ► : i Ei ENi 1. NAMED ieJSURED: MAILINU ADDRESS IDENf f ICATION NO.: JOHN MICHONSKI 66 CONWAY ST SHELBURNE FALLS, MA 01370 -0000 EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610 LD-# • MA Uf #; BLACKMER INSURANCE AGENCY INC WORKERS COMPENSATION AND EMPLOYERS 1000 MOHAWK TRL LIABILITY POLICY INFORMATION PAGE SHELBURNE FLS, MA 01370 -9705 INSURED IS PREVIOUS POLICY NUMBER INDIVIDUAL _ NEW OTHER WOR 'LACES NOT SHOWN ABOVE: SEE EXTENSION OF ITEM 1, QF THE INFORMATION PAGE - WC990610 ri'EM 2 POLICY PERIOD 12:01 A.M. standard time at the insured's dialling address FROM 05/28/05 TO 05/28/10 ITEM a A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Lew of the states listed here: MA B, Employers Liability Insurance: Part Two of the policy applies to the work in each State listed in .item 3.A. The limitS of our liability under Part Two are: Bodily Injury by Accident $ , 100,000 eaCh accident Bodily injury by Disease $ 500.000 policy limit Bodily Injury by Disease $ 10Q each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, fisted hero: SEE ENDORSEMENT — WC200306A. D. This policy Includes these SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WC990612 ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. EvtimeLd Total Rate Per Estimated amun eretion Premtu Ctassificatians Coda Yumber R 5100 OF Re r �� i - ( Annual 0 Yeer muneration © Annual L--r 3 Year { SEE EXTENSION OF ITEM 4. OF THE INFORMATION PAGE - WC7154 TAXES /ASSESSMENTS /SURCHARGES $120 EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE EYSTATE) �. $ 318 MA minimum PREMIUM $ ,00 MA TOTAL ESTIMATED PREMIUM 2 0 H indicated below, interim gdlustment$ of premium that b e made: 0 Semi - Annually Quarterly Monthly DEPOSIT PREMIUM — f , -0°) 06/09/09 ASSIGNED RISK 66 '- Issue Date issuing Office Authoriz Representative WC 00 00 01 39967 (Rev'e 04/0$) • • SECTION 8 - CONSTRUCTION SERVICES • • 8.1 Licensed Construction Supervisor: /� `, Not Applicable ❑ Name of License Holder : r J offil/ / A „��ii�� / L "104/5 / • Jan/1i S Wo/ie 4E /ig /A S.elx License Number C6.vw/t y sr G _ Address 6.#44 Axe /. mss' gm O )3,7 ! Expiration D ate • 6 Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ 7 • • Company Name Registration Number • Address 0%3) 9 Expiration D / 2c/e2 S/Y!-/5t' f1/ LL$ j /7 Telephone 4/! ...__9- • SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT M.G.L. c. 152, § 25C(6 • Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will res .t in the denial of the issuance of the building permit. Signed Affidavit Attached Yes X No ❑ • 11. - Home Owner Exemption • The current exemption for -- homeowners - was extended to include Owner - occupied Dwellings of one (I) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license_ provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside. on which there is. or is intended to be. a one or two family dwelling. attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official. on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will he required from time to time. during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated. you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner” certifies and assumes responsibility for compliance with the State Building Code. City of Northampton Ordinances. State and Local Zoning Laws and State of Massachusetts General Laws Annotated. • Homeowner Signature • • • • • • y i SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition I ( Replacement W1ndows Alteration(s) [ I Roofing Or Doors Accessory Bldg. n Demolition n New Signs [D] Decks [[l Siding [DJ Other Brief Description of Proposed ,47, /A/,% 4/4 /9 r10 'Y G i i al) I# - Q -'Al Ce/11 .e�f ` 3 % s AL Work: j) cael.<$ f - /r4/ 4 _ Pt/ 4 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: /C°14 a. Use of building : One Family Two Family Other 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? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction Is construction within 100 ft. 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? _ _ Yes No I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Av\.14,, L 1F1Y1 es- as Owner of the subject property �� hereby authorize 'n�� 1 r t �� Crf1"Y.., t o act on 'ehalf, in all matters relative to work authorized by this building permit application. Signature oft _ I. Date /0 I, , as Owner /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 Signature of Owner /Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to he filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building, Height Bldg. Square Footage • ? Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: — -- (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DON'T KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, �e�xcavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO \J IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: f V Building Department Curb Cut/Driveway Permit 21=2 Main Street Sewer /Septic Availability Room 100 Water/Well Availability `;,f1Orthampton, MA 01060 Two Sets of Structural Plans 'phope 587 -1240 Fax 413- 587 -1272 Plot/Site Plans ��� 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 5 `/L t , .5 ,, tz g I` Map Lot Unit J Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 er of Record: Name (Print) Current Mailing A3��: _ // 3 / r/ I(L J j C Telephone Signature J! �� , Grd l y j¢G / 4Ny Cj 17",f L;e 4/j 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (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) V) l y/ q. Check Number 0 This Section For Official Use Only Building Permit Number Date r: Issued: Signature: Building Commissioner /Inspector of Buildings Date • File # BP- 2010 -0497 APPLICANT /CONTACT PERSON JOHN P MICHONSKI ADDRESS /PHONE 66 CONWAY ST SHELBURNE FALLS (413) 834 -7725 PROPERTY LOCATION 494 SYLVESTER RD MAP 20 PARCEL 007 001 ZONE RR(100) / /WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 5� Typeof Construction:_MISC INSULATION,INSTALL 3 REPLACEMENT DOORS & WINDOWS,BLOWN IN CELLULOSE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 94376 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INIa lti<ATiON 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 Demolition Delay 1/7 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. BP- 2010 -0497 G1S q: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON I or: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0497 Project ,l JS- 2010- 000686 Est. Cost: $4419.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN P MICHONSKI 94376 Lot Size(sq. ft.): 13852.08 Owner: LANGER DANIEL L MAIL TO: EDWARD BRYANT JR Zoning: RR(100) / /WSP II Applicant: JOHN P MICHONSKI AT: 494 SYLVESTER RD Applicant Address: Phone: Insurance: 66 CONWAY ST (413) 834 -7725 WC SHELBURNE FALLSMA01370ISSUED ON:11/5/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:MISC INSULATION,INSTALL 3 REPLACEMENT DOORS & WINDOWS,BLOWN IN CELLULOSE 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 11/5/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo