36-105 (1) •
Property Address: ' 61 ,a (4R /75 A / /ea/91)
Contractor
Name: J,N41
Address: 6 C-ovA/Ay ST
City, State: S/Aet J- HL < / d /37C
--
Phone: " »� S
Property Owner
Name: I-isy LX <
Address: ' 3 / al/4/
City, State: /o 2.
I cJo,,r/ / , c. r'_c,C/ (contractor) attest and affirm that the building I intend
to insulate 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 - 7 a u
Date
Z/r/./
`' WAP Work Order
Community Action of the Franklin, Hampshire Job Number: 11 -009
and North Quabbin Regions, Inc. Work Order Date: 1/18/2011
P.O. Box 1432 Ownership: Owner
Greenfield MA 01302
John's Home Repair Auditor: BRIAN LEGG
66 Conway Street Email: blegg @communityaction.us
Shelburne Falls MA 01370 Cell: 413 - 834 -0632
Phone: 413 - 834 -7725 Phone: 413- 376 -1116
Lisa Leblanc ARRA WAP $2,774.64
851 Burts Pit Rd Total $2,774.64
Florence MA 01062
413 - 341 -3568
Authorized Actual` -
Measure .Description -- l7. Comments
Total t Tot l ;
Qsy Pri Q y
Attic Insulation =
R -10 -12 restricted - slopes /floored 488 $1.24 $605.12 Dense Slopes and under Unfinished Attic Floor
fill w /cellulose
R -18 -20 unrestricted - settled 424 $1.23 $521.52 Blow unfloored attic area & bring to R -38
cellulose
R -30 restricted - slopes /floored fill 80 $1.41 $112.80 Floor Kneewall Transition Densepack
w /cellulose
1
Basement Insulation _
Perimeter 2 in. foam board 360 $2.17 $781.20
Sill two -part foam w /fiberglass batt 90 $2.00 $180.00
Doors
Fixed Sweep 2 $15.00 $30.00
Repair Sliding Glass Door - seeleak 1 $100.00 $100.00
between panes
Repair/Refit Door 1 $50.00 $50.00
Weatherstrip s /Q -lon or equal 2 $43.00 $86.00
I
Misc Measures
Attic sealing with two -part foam 2 $75.00 $150.00
Date: 01/18/2011 Page 1
GuARD Workers' Compensation and Employer's Liability Policy
NorGUARD Insurance Company - A Stock Company
INSURANCE i Policy Number JOWC119640
Renewal of NEW
- GROUP NCCI No.[25844]
Policy Information Page
[1] Named Insured and Mailing Address Agency
John Michonski BOSTON INS BROKERAGE
64 Conway St 24 Federal Street
Shelburne Falls, MA 01370 4th Floor
Boston, MA 02110
Agency Code: MABOST10
Federal Employer's ID 26- 4838401 Insured is Individual
Additional Names of Insured
(N2) John's Home Repair
[2] Policy Period
From May 28, 2010 to May 28, 2011, 12:01 AM, standard time at the insured's mailing address.
[3] Coverage
A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation
Law of the following states: Massachusetts
B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed
in item [3]A. The limits of our liability under Part Two are:
Bodily Injury by Accident - each accident $500,000
Bodily Injury by Disease - each employee $500,000
Bodily Injury by Disease - policy limit $500,000
C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in
item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming.
D. This policy includes these endorsements and schedules:
See Extension of Information Page - Schedule of Forms
[4] Premium
The Premium Basis and, therefore, the premium will be determined by our Manual of Rules,
Classifications, Rates, and Rating Plans. All required information is subject to verification and change
by audit. (Continued on another page)
Total Estimated Policy Premium $ 8,751
Total Surcharges /Assessments $ 649
Total Estimated Cost $ 9,400
INTERNAL USE DK Page - 1 - Information Page
MGA : JOWC119640 WC 000001A
Date :06/09/2010
MANOTE
16 South River Street • P.O. Box A -H • Wilkes- Barre, PA 18703 -0020 • www.guard.com
• The Commonwealth of Massachusetts
3 / Department of Industrial Accidents
=Ai
! Office of Investigations
_Eel
1=41— — 600 Washington Street
Boston, MA 02111
� s ° www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): fp y, A /0"; 4tg/,7 < .— ,QI/ /U
Address: Go t/tr/1iY ..C./
vi31 U
City /State /Zip: S /L'Ada/ 1? "i7/45 /// . Phone. #: y/ 3 _ 839' - 7-7,2,5
Are ou an employer? Check the appropriate box: Type of project (required):
1. I am a employer with J? 4. I am a general contractor and I
employees (full and/or part-time).* have hired the sub- contractors 6. 0 New construction
listed on the attached sheet. 7. [] Remodeling
2. [] I, am a sole, proprietor or partner-
ship and have no employees These sub - contractors have ' 8: U Demolition
working ca employees and have workers'
g for me in any capacity. 9. 0 Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. [], We are a corporation and its 10.0 Electrical repairs or additions
i
h
i
have ave exercsed their 3. ❑ I am a homeowner doing all work officers 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.K Other 4/0 ///7f4'Q /,..Z/f/2
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1 Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: � t/ 4 A 0 L,vs y G40d, (it/o4 GUMI J2 ,T.vc v/1IfivGz Co J
Policy # or Self -ins. Lic. #: ,TQ&JG // 9`f /d Expiration Date: .37,2 f/ „ZO //
Job Site Address: 104 /14G f-ec //' T.. City /State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
_Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year ifnprisonment, as well -as civil p nalties_in the form of a S TOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si: azure: A1 ,J / • / C 0 / /% Date: G ; /I' O O _
Phone #: A// ' 8:3' - 7 %Z.-5
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Board of Bnildin2 Rt.s2uiations and standards
Construction Supervisor License
License: CS 94376
JOHN P MICHONSKI t a.
66 CONWAY ST
SHELBURNE FALLS, MA 01370
Expiration: 6/11/2012
( o nuni> i ncr T = 28400
9/e (am,fl? , ea /4 cr i42.;.;ac f.�,
Office of Consumer Affairs & Business Regulation
HOME IMPROVEMENT CONTRACTOR
�—� Registration: 142709
Expiration: 5/1/2012 Tr# 293933
Type: individual
JOHN'S HOME REPAIR
JOHN MICHONSKI
66 CONWAY STREET
SHELBOURNE FALLS, MA 01370 Undersecretary
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) j �. ._
yam / ihi/ 0/
71/z/ ,; i , � �, j License Number Expiration Date
Name of CSL - Holder
List CSL Type (see below) L,'
s ✓g 5 /
Address ! > i%7 / 7 7� Tv e Description
S l� '.ti iZ �: �r0 - 1�
li � Unrestricted (up to 35.000 Cu. Ft.)
R Restricted l &Z Family Dwelling
Signa ✓ f ie M Masonry Only
RC Residential Roofing Covering
( ele S ne ) �� ._ 77 5 ' f WS Residential Window and Siding
' SF Residential Solid Fuel Burning Appliance Installation
Residential Demolition
5.2 Registered Home Improvement Contractor (HIC)
HIC Company Name or HIC Registrant Name Registration Number
Addrs 114 —c ��C` / �d/
i ii ✓ L'� '77_3 - � 7 %-x.;i Expiration Date
S(g' re Telephone
SECTION 6: 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 result in the denial of the Issuan e of the building permit.
Signed Affidavit Attached? Yes No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I �
%i' ^, i7 ; 5 J as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf
Print Ninie /
Signa re of Owner or Authorized Agent Date
( Signed under the pains and penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basement attics, decks or porch)
Gross living area (Sq. Ft.) _ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
SECTION 5: CONSTRUCTION SER IC ; - ,
5.1 Licensed Construction Supervisor (CSL)
r
License Number Expiration Date
Name of CSL- Holder
List CSL Type (see below)
Address Type Description
U Unrestricted (up to 35,000 Cu. Ft.)
R Restricted 1 &2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor (HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: 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 result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ❑ No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
...RECEIVED
�!►t � �.owQ uas�
NONrNAMiPTo Ille jmmonwealth of Massachusetts
Boar o ilding Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR, 7 edition MUNICIPALITY
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January
One- or Two - Family Dwelling 1, 2008
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
53c/ B v4TS ,4T rev. o
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 Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Record: - ` C\
Na (nt) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner- Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ) Specify:
Brief Description of Proposed Work ALB*/.t/ it/ Gr Aid <orcG /4./.. 6 A O�CJ /¢77 /
)'7i6 4/.t' A TIS'a if/1/1 0'4/ An A/1" 5, eP
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ 3
❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List
5. Mechanical (Fire
Suppression) Total All Fe $
Check No. Check AmountbL' '✓ Cash Amount:
6. Total Project Cost: $ � 77,_5"
7 / /� 0 Paid in Full ❑ Outstanding Balance Due:
File # BP- 2011 -0722 '
APPLICANT /CONTACT PERSON JOHN P MICHONSKI
ADDRESS/PHONE 66 CONWAY ST SHELBURNE FALLS (413) 834 -7725
PROPERTY LOCATION 851 BURTS PIT RD
MAP 36 PARCEL 105 001 ZONE SR(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out «�
Fee Paid 0 3 5
Typeof Construction: INSULATE ATTIC,AIR SEALING & WEATHERIZATION BASEMENT & DOORS
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 F�ING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
Approved 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
Demolit D elay
•/
Sig . re o : uildmg • fficial 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.
851 BURTS PIT RD BP- 2011 -0722
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 105 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- 2011 -0722
Project # JS- 2011- 001192
Est. Cost: $2775.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN P MICHONSKI 94376
Lot Size(sq. ft.): 52533.36 Owner: LEBLANC LISA
Zoning: SR(100)/ Applicant: JOHN P MICHONSKI
AT: 851 BURTS PIT RD
Applicant Address: Phone: Insurance:
66 CONWAY ST (413) 834 -7725 WC
SHELBURNE FALLSMA01370ISSUED ON:3/15/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC,AIR SEALING &
WEATHERIZATION BASEMENT & DOORS
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 3/15/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner