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17A-092
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POLICY T\ t Liberty tf Mutual-, INFORMATION PAGE Liberty Mutual Gaup 175 Berkeley Street Boston, MA 02117 LIBERTY MUTUAL FIRE INS'•.:CE 16586 .:tuber WC2- 31S- 375297 - L .office 181 AL OF: WC2 -31S- 375297 -0: 10 -11 -11 Number 1- 375297n1 0000 used and Mailing Address FEIN 412197245 AY BOLAND :BA HOME ENERGY SOLUTIONS �2 PISGAH RD RISK ID 172538 `UNTINGTON MA 01050 Status 01 - INDIVIDUAL Other workplaces not shown above: SEE ITEM 4. =` _' ` j V - DCTENSION OF INFORMATION PAGE Policy Period: The policy period is from 11-01-2 1 to 11-01-2012 1a.01 A.M. standard time at the Insureds mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the po i :v applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy app! =es to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 5 0 0 , 0 0 0 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 200306A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy win be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per $10o Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 10,407 Premium will be billed ANNUAL Producer 0004 - 048718 FINCK & PERRAS INSURANCE AGENCY INC 6 CAMPUS LANE EASTHAMPTON MA 01027 Sales Representative 3000 Sales Office Name WESTON ©1987 National Council on Compensation Insurance.inc_ WC 000001 A All Rights Reserved Ed. 07/01/2011 Insured Copy 0 ,- -- - ., , ' / " ---- e 66k2n4reoctr,c ..._,=.--,-_,ir • ; :- 4t, 4- ' 2, Office of Consumer Affairs and —11siness RPtralatinn 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration , .:......:. Regisuation: 164603 Type: DBA 1or26/2013 Tr* 216603 HOME ENERGY SOLUTIONS .,--- ,. . ,, :i ' JAY BOLAND 12 PISGAH RD. HUNTINGTON, MA 01050 .. -, Update Address and return card. Mark reason tbr change. Efi Address 0 Renewal El Employment 0 Lost Card S-CA1 0 50#404/04.0101216 ofne*astwiewasetighitatitget , License or registration valid for individul use only t11 HOME IMPROVEMENT CONTRACTOR before the expiration date. if found return to Registratkin: 164603 Tyne: Office of Consumer and Business Regulation Expiration: 5006/2013 DBA 18 Park Plaza - Suite 5170 Boston, MA 02116 HONE ENERGY JAY BOLAND 12P1sGAN RD HUNTINGTON, MA 01050.--- - -.--f- undersecretary Not valid without signature .. - • - -\ Ni.a_NsiichtiNett - IN.:fiat iii Pliblis: 7 ‘1..t...--o-,i4:11..citA. - lit- .....11 ni ?V .84...trd Of Building Regulations and Standard 1 , Biiard of Buildin.. Re and Staittlards - , License: CS SL 103443 - License: CS SL 101880 Restricted to WS . • Restricted to IC . JAY BOLAND +. A ... . JAY BOLAND 12 PISGAH RD 12 PISGAH ROAD HUNTINGTON, MA 01050 HUNTINGTON, MA 01050 • ... . . _ . '4 ---os-----ef, . Expiration: 12/2712012 ca --.zo--.. Expiration: 12/2712012 • Tr: 1034 - ( , ,.turni.,,iorier ' Trte: 101880 ( (FMMiSSiigler k. ...... . , N., 4,•■■■■•■•., e 1 iv 4 yi -;? iq Y.5 . .. . „,........ - - 5.1 Licemea COnStnictiOtt &Innis' or (CSL) i / i , 7 gel; ..,-;- ii I Li ea= . Expiortion Name, et t....V., 1-10kka- - List CM- Type (see below) I C 6 ' . 7 Addras5.-. / Tp - Description Clov 'r 4'401'4f/e / il0/1 41/of? v,"..tv,:mte, .'%. 1 4 11035 , 000 Cu- Ft-) I 11111 Ra 1.-.7:2F ' Dv4faig S.;,..4 „, la M / r 11 • . ..r.. - ee.„-_.....- _ _ RC Rerdent ' ial Roofing Covering i T - / ' , ne WS Residential Window and Siding SF RsuintranA'ISlid Intl limning Appliance Ins#ffiatio ‘1/ -.1 PI W 7:- o . D Residential' Demolition 5.2 Registaraeliltanalasprawarnant Caapartar OWE) • v - .. i X ere9_,i HIC Company Name or INC Registrant Name - •eostration Nwaber Address • - 1.11PtSSAN ROAD HUNZINGIOIR, 1M DV //J i .. F .2 V. , Expinmion TZ - . Signature _ Telephone SECTION 41- WORKERS COMPASATION INSURANCE AFFIDAVIT (MG."... e. 152 § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure toprovide this affidavit will result in the denial ofthe Issuance ofthe building permiL . . - Signed Affidavit Attached? Yes ..-.. ..... . El No 13 . SECTION 7a: OWNER. AUTHORIZATION TO B COMPLETED WHEN - • . - OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING rlERMIT - ...‘-z--. L CI' 4N e lacheci - , as Owner of the subject property hereby • authorize - h Ai 1 i e i* , e #41v . i' .., r /4.1r 41 i 1 f ' ' - to act on my behaiL in all matt= relative to work authorized by this_btit&g permit application. , „ .. P --ia/ __ . - f2_ - .. . Signature of Owner - - - - -. - - - SECTION 7h: OWNER' OR AIIIHORIZED AG DECLARATION - -- - - • - . . : ' 80/k - , as Owner or Authorized Agent hereby declare that the s ..Anients and informenin on fee application are true and nourate, to the best of my knevilge and _ - ..._ „ i .,,.. .. - . . . . PritNam. ' - • . -,- 4/ ..” .. , ,. _ VVVVVV Signets.= of e :- - . - ,.;'..,-. _---= : ' (Signed H. # - the and penalties or-perjury) . _ . , - - . 7. An Owner who obtains a buildin g permit' to (Jo hingter own wyr or az owner who hkesEn unregistered contractor (not registered in the Home Improvement Contractor (HIC) Prograrn), will not have access to the rceoination V program or guaranty fluid under Iv1.01.. C. 142A. Other important intimation on the HIC Program and Construction supe Licensing (CCI.) can be found in 7Ittl Cle. Regulations 110-R6 and 119.R5, respectively. 2. When substantial work is planned, provide the information below: - - c Total floors area (8q. pt) • (including garage, finished basement/atti s, decks or porch) Gross living area (Sq.-PO - , - lilabitable room count Nunitier of fireplaces - Number of bedroomi - • Number of baths - . Thunber of loafibat.....hs - - - Type of heating system Number of des-l-si parches - Type of cooling system v - V V V Enclosed ' Open - 3. - total Project Square Fixitage may be substituted for "Total Project Cost' . • - - - . - -- cI P. I? U . :. The Commonwealth of Massachusetts r-- 1 Board of Building Regulations and Standards FOR N Massachusetts State Building Code, 780 CMR, 7 edition MUNICIPALITY USE Ijl N Builc Permit Application To Construct, Repair, Renovate Or Demolish a Revised January One or Two- Family Dwelling 1, 20118 This Section For Official Use Only CC tilding Permit Number: 1 Date Applied: S' ature: Building Commissioner! Inspector of Buildings Date SECTION 1: SITE INFORMATION 1.I Property Address: Assessors sessors Map & Parcel Numbers Or 1.1a Is this an accepted street? yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards t Rear Yard Required Provided I Required s Provided Required Provided I 1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public ❑ Private D Zone: — Outside Flood Zone? J municipal 0 On site disposal system 0 Check if yes© SECTION 2: PROPERTY OWNERSHIP' 2.1 t of Record:,. ° i `t,�) - t 1 4') ) Si, Fievei —. Name (Prim j Address for Service: CI ce.A.p Li/3 , 6 .1 / l q Signature X . Telephone SECTION 3: DESCRIPTION OF PROPOSED W ORK (check all that apply) New Construction 0 Existing Building Q Owner - Occupied 0 J Repairs(s) 0 J Alteration(s) ❑ J Addition ❑ Demolition 0 Accessory Bldg. 0 Number of Units J Other (H Specify: Brief Description of Proposed Work': SE ON 4: I TED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) r 1. Building $ I. Building Permit Fee: S Indicate how fee is determined: 2. Electrical $ 0 Standard City/Town Application Fee o Total Project Cost' (Item 6) x multiplier x i 3. Plumbing I r 2. Other Fees: $ List ,( . Mechanical ( S JA n1 4 iY ecihallical (TI VAC) AC) e$ 5. Mechanical (Fire $ Total All F Suppression) . Check N . i? Check Amour Cash Amount: 6. Total Project Cost: ( 9_666 $ � 0 Paid in ull 0 Outstanding Balance Due: ) File # BP- 2012 -0824 �/ APPLICANT /CONTACT PERSON JAY BOLAND a V J g ADDRESS /PHONE 12 PISGAH RD HUNTINGTON (413) 214 -2414 �9 v c PROPERTY LOCATION 22 GRANDVIEW ST MAP 17A PARCEL 092 001 ZONE RI(100)/URA(100)/WSP(15)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �n l� Fee Paid ,/ �J Typeof Construction: INSTALL INSULATION 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I F 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 Dem. itio , . D ela - t ? — 27— / gnature of Building O' icial 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. 22 GRANDVIEW ST BP- 2012 -0824 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 092 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 -0824 Project # JS- 2012 - 001452 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sq. ft.): 11630.52 Owner: DIMMITT CATHERINE L C/O BRIAN P TOOHEY Zoning: RI(100)/URA(I00)/WSP(15)/ Applicant: JAY BOLAND AT: 22 GRANDVIEW ST Applicant Address: Phone: Insurance: 12 PISGAH RD (413) 214 -2414 WC HUNTINGTONMA01050 ISSUED ON:4/3/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL INSULATION 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 4/3/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner