35-084 ,__*7„,____.E_I imw x Office of Consumer Affairs and usiness Regulation
Sri 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 164603
Type: Individual
Expiration: 10/26/2011 Tr# 289971
HOME ENERGY SOLUTIONS
JAY BOLAND
12 PISGAH RD.
HUNTINGTON, MA 01050
Update Address and return card. Mark reason for change.
Address Li Renewal D Employment 0 Lost Card
DPS -CA1 Ci 50M- 04/04- G101216 ,��s/
Jitie Z�omtmosru o ✓6�xekhzeitadetZt
z Office of Consumer Affairs & Business Regulation License or registration valid for individut use only
�� ,t b efore the expiration date. if found return to:
e r HOME IMPROVEMENT CONTRACTOR of Consumer Affairs and Business Regulation
(( Registration: 164603 10 Park Plaza - Suite 5170
.,;" Expiration: 10/26/2011 Tr# 289971 Boston, MA 02116
Type: Individual
HOME ENERGY SOLUTIONS
i /
JAY BOLAND �l
12 PISGAH RD. u� > -- /
HUNTINGTON, MA 01050 Undersecretary p si
of va li d w out signs re
•
Massachusetts - Department f Public Safet∎ �
t ` • \1asssichusctts - Department of Public Safety
li
Board of Buildin!a Regulations and Standard Board of Building: Regulations and Standard.
Construction Supe-v:sor Specialty License Construction Supervisor Specialty license
License: CS SL 103443 License: CS SL 101880
Restricted to WS Restricted to IC
JAY BOLAND JAY BOLAND -
12 PISGAH RD 'rt 12 PISGAH ROAD
HUNTINGTON, MA 01050> HUNTINGTON, MA 01050
6e-- - ---' Expiration: 12127/2012 q� - -y - - '' ., Expiration: 12(27/2012
('onunisioner Tr#: 103443 ( unutti..ioner Tr#: 101880
AR WCIP Ili*" Liberty.
ISSUING OFFICE 181 tf ' Mutua Workers Compensation and
INFORMATION PAGE Employers Liability Policy
ACCOUNT NO. SUB ACCT NO. Liberty Mutual Insurance Group /Boston
1- 375297 0000 LIBERTY MUTUAL FIRE INSURANCE CO 16586
POLICY NO. TD /CD ' SALES OFFICE CODE SALES CODE N/R 1ST
WC2- 31S- 375297 -019 XX X WESTON 102 I REPRESENTATIVE 3000 1 YEAR
ASSIGNED , 2009 J
Item 1. Name of JAY BOLAND DBA HOME ENERGY SOLUTIONS
Insured FEIN 41- 2197245
Address 12 PISGAH RD
RISK ID 172538
HUNTINGTON, MA 01050
Status 01 - INDIVIDUAL
Other workplaces not shown above: SEE ITEM 4
Mo. flay Yeas Mo. Day Yeac
Item 2. Policy Period: From 11 -01 -2009 to 11 -01 -2010
12:01 AM standard time at the address of the insured as stated herein.
Item 3. Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed
here:
MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. 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 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE END WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
Item 4. Premium - 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.
Premium Basis Rates LINE 110
Per 5100 Estimated
Code Estimated of RE- Annual
Classifications No. Total Annual Premiums muneration Premiums
SEE EXTENSION OF INFORMATION PAGE
_ Minimum Premium $ 500 (MA ) Total Estimated Annual Premium $ 2,363
Interim adjustment ofpremium shall be made: ANNUAL
This policy, including all endorsements issued therewith, is hereby countersigned by
Authorized Representative Date 12 -08 -09
T
Loc. Code Term. Oper. Audit Basis Periodic Payment Rating Basis Pol. H.G. Home State Dividend
12 -08-09 NR , MA NEW
GPO 4030 RI Copyright 195T Narfonaf Councif on Compensation Insurance WC 00 00 03 A
Insured copy
•
The Commonwealth of Massachusetts
, — . :e l
D of Industrial Accidents
Tie `j = Office of Investigations
n
rr _ 600 Washington Street
Boston, MA 02111
:,„ www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/lndividual): J ,,t g,!,,, . , ,:. 2: . , ,(
Address: ,.
City /State /Zip: ,el„ �' ' ' Phone 44: ..
Are you an employer? Check the appropriate box: 1 Type of project (required):
1.10111 I am a employer with 3 4. Q I am a general contractor and I
employees (full and/or part-time).* have hired the sub contractors 6. Q New construction
listed on the attached sheet. 7. D Remodeling
2. Q i am a sole proprietor cr parer
ship and have no employees These sub - contractors have 8. Q Demolition
working for me in any capacity. employees and have workers'
9. [1] Building addition
[No workers' comp. insurance comp. insurance.$
required.) 5. 0 We are a corporation and its 10_0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.11 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. [ Other
comp. insurance required.] '`'_ , r " ' • „ .:i . C , f P7 '
*Any applicant that checks box #1 must also fill out the section below showing their workers' conversation 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.
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 andjob site
information.
Insurance Company Name: L. , 6 e , !! ` j , 'V , - ,
Policy # or Self -ins. Lic. #: V:2 <-- _ S ° Y 75 7 - 0 1 9 Expiration Date: / / / a i /
Job Site Address: 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 imprisonment, as well as civil penalties in the form of a STOP 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 certi# under the pains and penalties of perjury that the information provided above is true and correct;
Signature: �to -_ -` Date: ., c" `
Phone #:
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 #:
5.1 Licensed Construction Supervisor (CSL)
7 �t ci4 •� , License N b Ear,' ion
°
Name of CSL- /r + Holder ,/ e9 3 4" 3 ,
lot n11 o . � r A) , List CSL Type (see below) / C / •1 ui 1 U 1 Unrestricted (up to 35,000 Cu. , vii./ y ` i n /es / eft o R Res�io0ed 18c2 Farm ' Ft)
Sic,.:,7 M lY Dwell >n8 Masonry Only •
!�
- . RC Residential Roofing Covering
Te. -: , WS Residential Window and Siding
y (-2 ' V `/ v/r.- D Residential Demolition Appliance Installation
5.2 Registered Home Improvement Contractor (HIC)
HIC Company Name or HIC Registrant Nary Registration Number
HOW sway sOLIf 7AId,
f 6 J1 /
Address NGTON, MA `+r /3 .. y' .1 y, y ca tion le / -
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 ; Er No . ❑ .
' • SECTION Tat OWNER AUTHORIZATION TO BE COMPLETED WHEN '
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -
I, , as Owner of the subject property hereby .
• authorize - # Az , f Si ✓ A-4 jy/ ‹A,4. 'X / !1 t • • to act on my behalf in all matters
• relative to work authorized by thisbutldfng permit application. . . . .
•
0 • • - - • -
Signature of Date '
- - ' SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION - • - 1, J ;t y R 0/Q rc / .. - . - , as Owner or Authorized Agent hereby declare .
- that the statbments and information on the foregoing application are true and accurate, to the best of my knowledge and
- behalf. •- .. .
•
Signature of c _ ■ uthorized nt - ' Date - .
. (Signed no : - the , • 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 lathe 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 110.86 and 110.85, 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 rood' count
Number of fireplaces : : Number of bedrooins - -
. . 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" -
•
•
IZ,, The Commonwealth of Massachusetts
:0 ' Board of Building 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 /, 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
1,2-) 7 /7 vrfj/ f`/ ti
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:
J1 l 4'ac' /I--/2 x3,,07 1 e t etg
Name rint) Address for Service:
Signatiue Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner - Occupied ❑ Repairs(s) ❑ Alteration(s) E( I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: .
Brief Description of Proposed Work 9• o , 14.1 vt'ii reef
in f0.C. 44. e -fY 14 'i 4 , 0 4 0 ., r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1. Building $ i ((to 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ 0 Total Project Cost (Item 6) x multiplier . x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List
5. Mechanical (Fire _ $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 6 ,2 tr 0 ❑ Paid in Full ID Outstanding Balance Due:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9 Ratijater dilktitia lmpro reiiHit aitiidai , , s" Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 ❑
The current exemption for "homeowners" was exten. - • to include Owner - occupied Dwellines of o. - or two(2) families
and to allow such homeowner to engage an individual for : e who does not possess a lic - • . -, . rovided 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 . • :. which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelli s • . . ched or deta - - d structures accessory to such use and/ or farm
structures. A person who constructs mo an one home in a two -yea • eriod shall not be considered a homeowner.
Such "homeowner" shall submit to : uilding Official, on a form acceptabl- o the Building Official, that he /she shall be
res • onsible for all such w • • • erformed under the buildin • • ermit.
As acting Construct' • u • ervisor your presence on the job site will be required fr . 's time to time, during and upon
completion of • work for which this permit is issued.
Also be .: • ised that with reference to Chapter 152 (Workers' Compensation) and Chapter (Liability of Employers to
E • . yees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, vo • av be liable for person(s)
ou hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Buildin ode, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5 - DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacemenndows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [O] Other c6
Work: fDescription of Proposed t j J atIftrt WO of i•®4 to
Alteration of existing bedroom Yes , No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa ft> " it t . a iki tifiit Efi WifitliTifra Ilia; rr E n e ii oll w' `h :
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? F • r aces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetl. • • s? Yes _ _ No. Is construction within.100 yr. floodplain Yes No
'e
j. Depth of basement or cell oor below finished grade
k. Will building confo to the Building and Zoning regulations? Yes No .
I. Septic Ta City Sewer Private well City water Supply \
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN ,
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, jp�C it- O r\ / (,D Jf t r tL , as Owner of the subject
property 1T /
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
gent hereby ecl t the statemen and information ot5 the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under a pains and penalties of perjury.
Print Name /
Signature of Owner`'. en - 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 be filled in by
Building Department
Lot Siz ?
Frontage (I
Setbacks ront i 1 1 '
Si..
L: R: 1 L:' I R:' 1
Rear = 1-1 f / 1
Building Height
Bldg. Square Footage i l f 1% I l j i
Open Space Footage
(Lot area minus bldg & paved 1 I d ( 1 /
parking) l
S
# of Parking Spaces i \
Fill:
(volume & Location) E I
A. Has a Special Permit /Variance /Findin ever been is _ ed for /on the site?
NO Q DONT KNOW YES
IF YES, date issued:; !
IF YES: Was the permit recorded a the Registry of Deeds? \
NO 0 DONT OW 0 YES 0 \
IF YES: enter Book i 1 Pager ? a d /or Document tt ,
B. Does the site contain a broo , body of water or wetlands? NO Q DON KNOW Q YES 0
IF YES, has a permit b- n or need to be obtained from the Conservation Comm' lion?
Needs to be obtaine• ® Obtained Q , Date Issued
C. Do any signs exist o the property? YES Q NO Q
IF YES, describe ize, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 0 Q
IF YES, describe size, type and location: i
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
+ ^ s
City of Northampton
Building Department -, `r
212 Main Street l • _ l _ � .
Room 100 r ay _ 4
Northampton, MA 01060 �� � `
phone 413 - 587 -1240 Fax 413-587-1272 ,i ' '
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 7 w � � �� Ma Lot, Un
Zone Overlay District
Elm St;Distrlct . CB District
SECTION 2 - .PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
x %� / ,6 x0 ; j4 dr //7 - ,,ems.
Na a (P n Address:
Current Mailing Ad
PE K C /\TTR p �-�� �� 1>
i Telephone
Signature
2.2 Authorized Anent: m. C n > s f., � o / 4 w � G f e'"r° 1 ' cn
Name (Print) Current Mailing r ess: 27Zr 20,440/
.� " g/./ 11 - - / 4:1 2 Y
Signature Telephone
SECTIO 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) 1 + 2 + 3 + 4 + 5 S 00 Check Number
l ( )
This Section For Official Use Only
Date
Building Permit Number:_ Issued:
5/
Signature:rr J� 1 0
Building Commissioner/Inspector of Buildings Date
WF'R3 k BP- 2010 -0905
GIS #: COMMONWEALTH OF MASSACHUSETTS
fl 35.084 . ' 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- 2010 -0905
Project # JS- 2010- 001340
Est. Cost: $6500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 20386.08 Owner: BOU ANGEL L & CARMEN L MONTES
Zoning: SR(100) //WSP II Applicant: JAY BOLAND
AT: 1237 BURTS PIT RD
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214 -2414 WC
HUNTI NGTONMAO1050 ISSUED ON:4/14/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS &
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 4/14/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo