32A-040 (2) 12/28/2010 16:56 4136252824 . JOHN MICHONSKI PAGE 03/03
Property Address: - S.7 GIY �4' > r .1 '' 4/ ed/ c '.v
Contractor
`r0�'4/ P / "c/tew - ' " I.1I4
Name:
Address: o.� y S�
City, State: .S / ems �v r wry -:41Ax S' "ow e!"3 ' 'v
Phone: 'Y/3 j 'Y - 7
Property Owner
Name: I�1'f/ , 14_ 9 ‘7
Address: _ ' Giv00.2, 4:1
City, State: 4.r1&&. Ty/ . x".0 ' _
t,T nst, if f eke r/o, ;e - r 0'.10'
1, siVor•w Si c- (contractor) attest and affirm that the building t 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 i ,. /
/
J
Date ar -
4 - „2d // 0,7
fel _ 2, '
WAP Work Order
Community Action of the Franklin, Hampshire Job Number: 10 -270
and North Quabbin Regions, Inc. Work Order Date: 12/6/2010
P.O. Box 1432 Ownership: Owner
Greenfield MA 01302
John's Home Repair Auditor: BRAD COUNCILMAN
66 Conway Street
Shelburne Falls MA 01370
Phone: 413 - 834 -7725
Athena Stylos ARRA WAP $965.00
57 Cherry St Bay State Gas $1,441.15
Northampton MA 01060 Total 52,406.15
413 -210 -5205
a:w ,F w. ! ,.. "K' -'' ' .�r u e. r �, C a.� ew.rw ,w + wi +ax*n.mrpmr i t su.. aa�+ .•xw s
, s �. ,,�.. -:- �,AFS• a.y a'S�a+ i.� '� Z +w.F �. ,z' :
Ieasure Desenption � . comments
x � .Pnce r Total otal �:
AtticTnsulahon
R -18 -20 unrestricted - settled 255 $1.23 $313.65 First floor ell - if feasible.
cellulose
•� ,ttic entilat on ✓_ -" °s' # s t- e c �` =' a
'� .•a
ex..i.- �zs
Rectangular gable vent 1 $88.00 $88.00 For access to first floor ell - if needed.
Basemen Insulation
6 ml poly on ground 160 $0.75 $120.00 r Beneath ceiling repairs - not basement
Perimeter Wrap R -5 reinforced foil 225 $1.82 5409.50 Il
or vinyl faced ductwrap
Doors"
Automatic Sweep 3 $22.00 $66.00
Weatherstrip s /Q -lon or equal 3 543.00 $129.00
1Visc Mea I
Attic sealing with two -part foam 3 $75.00 $225.00 Close attention to chimney chase.
Basement sealing with two -part 4 $75.00 $300.00 Close attention to chimney chase as well as
foam foundation (where accessible).
Date: 12/06/2010 Page 1
Gu A R D Workers' Compensation and Employer's Liability Policy
NorGUARD Insurance Company - A Stock Company
eg I Policy Number JOWC119640
It GR Renewal of NEW
OUP 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
.? Board of Bid Wino Rt..iliation. and .
Construction Supervisor License
License: CS 94376
JOHN P MICHONSKI
66 CONWAY ST
SHELBURNE FALLS, MA 01370
_ — Expiration: 6/11/2012
28400
er.Towemc-reeveaid /.ci.;%zzefr
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 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: (70 /r4 / "6/710/f/,soe/ q / 3 76
/ 3, 0 License Number
GG - ,€i,'ty .Si crritAest2"H4" / 6� /r��iL
Address Expiration Date
y/3 - 8".3Y - 7 , 2
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
LTC/MI 5 L / o s 1 r QCPi9 i ‘ g.CQ die c //7 1 7
Company Name � >� Registration Number
Address / Expiration Date
Telephone y/3 '8'y » -S
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 result
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 (1) 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 on 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 - vear 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 be 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 EmploN. ers 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
SECTION 5- DESCRIPTION OF PROPOSED WORK jcheck all applicable)
New House 1 Addition 1 1 Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition n New Signs [1E1] Decks [E] Siding [D] Other
Brief De cription of Proposed
Work: al /11 C.6/.4X O4.6 /4/51;6/tf/o f2 fi /yfi6G
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: /1/44,"
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
i. 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 wet City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, %/fit NA c5 S , as Owner of the subject
property 4 /' /fl /ef o4ix,e/ o hez
hereby authorize JO/1,i/:5 / /O/J1C , t/ s,64 j// lit
to act on my .ehalf, in all matters relative to work authorized by this building permit application.
Zz z/i
4o s 0 er a uke Date
, JONA/ r` /r/ iG NoA/f/C , 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.
A Date P
PI I 2- Z Z/I u /� A/ �o /P
Sof Owne ap� /
tvJ
Section 4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be 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 0 DON'T KNOW S. YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO €�
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 g
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that wit disturb over 1 acre? YES O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
Room 100 WaterJWellAvailability
Northampton, MA 01060 Two Sets of Structural Plans_
phone 413- 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 7 c/i Qa y
Map Lot Unit
/f/p, riblof J ,i 01/1- Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: O /O‘ ,� 1
A7 D S 15 fl't- 57 G•y` Wad r��.�l� '7
Name (Pri t). Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: Ih c , � P /27iG/.4oes,e/
_ O/ Q
,vj» LToryr/d #ooze ,4 ` Sc.Q d /cr" CG Co v01/4-Y -s7 SrtE<BVQ.dr /50 S A7/7
Name (Pri• ) Current Mailing Address:
r y73 - 8 -
• ature Telephone
ECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
co pleted 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) Check Number 9
J
This Section For Official Use Only
Building Permit Number: Date
Issued:
f _
Signature:. / / ✓ � /�
Building Commissioner /Inspector of Buildings Date
•
A -: fir* BP- 2011 -0576
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP- 2011 -0576
Project # JS- 2011- 000950
Est. Cost: $2400.00
Fee: $110.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN P MICHONSKI 94376
Lot Size(sq. ft.): 8276.40 Owner: WEBER WILLIAM R
Zoning: URC(100)/ Applicant: JOHN P MICHONSKI
AT: 57 CHERRY ST
Applicant Address: Phone: Insurance:
66 CONWAY ST (413) 834 -7725 WC
SHELBURNE FALLSMA01370ISSUED ON :12/27/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK: INSTALL INSULATION & WEATHERIZATION
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 12/27/2010 0:00:00 $110.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner