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(f1-0V- 504 1 ( ' ‘ t‘ \ rv4fit (.2i)4Y _04 ‘A 0,0 -ce 9 Oft mass save :...q. ttYOYa ..»tpYYM¢.ntV PERMIT AUTHORIZATION FORM 1, G -4'f v GO/ for/ , owner of the property located at: (Owner's Name, printed) G ootN FL c (Property Street Address) (City/Town) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a budding permit to perform insulation and /or weatherization work on my property. Owne s Signature ( t515 Date FOR CET OFFICE USE ONLY Center for EcoTechnology has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: � � . 4--13 - Participating Contractor Date Rev. 5/24/2012 -oo L. vo L- 0 C C I— 0 e. 4' a ..,4 ..... J. 0 . 0 .4*.d * 1 c. .,_ - E -a tx.■ r.... oLl 8 ,— —.1 •Lt. c C a o cte ''s a to. o '-- ' ° iii o = = = , . '''' t': ,,, 7 "0 .... '' T?: t &. o 0 , 4 . 4,../ .., x ,. ?.. C = trs .— La la . •4 c too 4- te", 3.,- Ci l try 0.) s.., ;..) It "f: te "S Lo •, --o ,4) C11 0 cl 1 AA ... 0 ...Y • ■ v) 01 w ;—■ ,..., „... r . z L. <,,, CV 0 % • Ei N Z N.. 1.... ., Z V,= 0. ....4 (...) - t 1 v .., 1 \ 0„. I) E •\,„ ...., re CI) l'-• ,e LLI c,) . Z LLJ X LU ' 0 ,'") ' E (t) 2 ..-- • cc ,:k 0 I IX Ili )- w ',-,-, ts 4 , , 7 ,14 0 0 1 ',, '',, ' • .... I-U u Lii (5 4 .....„ .....1 ii,,„ , C4 0 -,', 4.... LI; , ( 5 5 ,... 0 Unrestricted - Buildings of any use group which contain less than 35,000 cubic feet (991m of enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For DPS Licensing information visit: www.Mass.GovfDPS ( iin.tructiirn Supcn i.ru• • CS -094734 JEFFEREY A BRADSHAW r Ilk PO BOX 1276 CHICOPEE MA 01021 10/13/2013 • ACORD_ CERTIFICATE OF LIABILITY INSURANCE OP ID Jig DATE pIB10PYYYT, JASME -1 11/02/12 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Chase Clarke Stewart 6 Fontana HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 101 State Street, P.0 Box 9031 ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. Springfield AA 01102 Phone: 413 - 788 - 4531 Fax: 413 -731 -9234 INSURERS AFFORDING COVERAGE NAIC # t - - BaIIRED ! , INSURER A . Arbelia Mutual Insurance INSURER 8 Liberty Mutual JASM Enterprises LTd+ HS)1RERC Aa.,LA Sm_eaLY ia.u.aaa 10017 Jeff Bradshaw PO Box 1276 wsaaER D. Chicopee !A 01021 — P E COVERAGES THE POUCIES CO SBURANCE LOTH) DELON NAVE BEEN ISSUED TO THE INSURED KNEED ABOVE FOR THE POLICY PERIOD 8O CATED. HOT W8103TAR01R0 ANY REQUIREMENT , TERN on OOBITIOM CO ANY CONTRACT OR OTHER GOV./VENT WIN RESPECT TO WHICH THIS CERTIFIUTE NAY BE ISSUED OR MAY PERTAIN. THE IN2IMAHCE AFFORDED Sr THE ROUGES OESCR SED RERUN M S0BJECT TO ALL THE TE RNS. EXCIUSIOHS AHD DONOR EMS OF SUCH POLEOES. AOORE0ATE LRA S SHOMI NAY HAVE SEEN REDUCED WV PAID CLAYS !W AODL -- - _ POLICY EFFECTIVE POLICY EXPIRATION POLICY MEMBER DATE (1NRDOF)Y) DATE Y) LRET5 LTA IMRD TYFB OF INSURANCE ' ®tK LMBRStY EACNOCCURRENCE s1000000 DWA ETO RENTED f 100000 A % x c scALDERERALumun 8500040304 06/20/12 06/20/13 / A GET RENTED o, OASES MIX X mom NED EAR (Aw PIN meson) 16000 PERSCRAL S ADY INJURY 1 1000000 GENERAL AGGREGATE f 2000000 GEM.04*10ATE LIMIT ?PRIES PER PROOUCrs. COYPAT• AGO 3 2000000 _ AC — oc POLICY ACT ' ANTOMOINE WEENY ! CGYBINED WAX / LEAK s 1000000 C AMY AUTO 12726400004 10/05/12 10/05/13 " Au OWED AUTOS BOGEY *WRY f PM WANE % fpEp{AED AUTOS ! % *20AUf4 ECM T INJURY P (PM EoeHAIq X p YEMIDA4a PROPERTY DAMAGE 8 (PM KcCAID QUINN LIABNTY AUTO - EA ACCpENT f ANT NJTO I OTNERTHAR EA ACC S AUTO ONLY . E 400614PAISRELLA AAw„ EACH OCCURRENCE f 1000000 A I OOCW ( I CLAMS RADE 4600052470 09/01/12 09/01/13 AGGREGATE s s s DEDUCTIBLE 1 8 X W RHON 110000 I Nc 81*00 l OT F T ORY LINTS ER WGB{agOO1/(MATIOR MID '. Bsa1°'D""BIL7d WC1 - 31S - 372772 -012 05/02/12 05/02/13 E.L.voiACODERT s 1000000 B MC( POOPRIETORADITHERJEXICUTIVE EL a$EASE • EA EMPLOYEE f 1000000 OFFICENEEMSER EXCLUDED E x , 45 ,,," E -L DSEASE. PouDY LRNT 8 1000000 SPECIAL FR'ANPIDNB AINR _ } OTHER 4EBp1IPHON OFOPEPATEOM IL00A110E4I MIMES ( 5CLUSCMS ADDED BY 5OORSEAOiT ( SPECIAL PROVISOES CET, National Grid, The Berkshire Gas Company and their respective offices, agents and employees are included as additional insureds with respect to General Liability. Waiver of Subrogation applicable to CET in respect to general, to waive all rights of recovery against Center for EcoTechonology or any of its affiliates for any loss or damage covered by said policy. CERTIFICATE HOLDER CANCELLATION 8 ANY OF THE ABOVE DE8CRRIED POLICKS BE CANCELLED BEFORE TEE ESPSMTION DATE THEREOF, THE ISSUING RISURER YAL.L ENDEAVOR TO RAIL 10 o Ari WRETTBI 4400)08000)42 CEROF)CATE HOLDER NAMED TO THE LEFT. PIT FALURE TO 00 f0 SNAIL Center for gcoTechnOlogy, , Inc. , IMPOSE NO DBLIWTgN OR LIABNJTY OF ANY KIND UPON THE PURER. MA AGENTS OR 112 Sim Street REPRE$ENTATNES. Pittsfield MR 01201 AUTHORED REPRESENUTVE Paul P. Petell © ACORD CORPORATION 1988 ACORD 26 (2001A08) The Common wealth of Massachusetts if. =,..-: - Department of Industrial Accidents l i i _ " Office of Investigations __'_ ....• 1 Congress e, e 10 Boston, MA Stre 02114 -20tSuit17 0 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information _ '� ! Please Print L • . "b Name ( Business /Organization/Individual): ` )I " C v /� / g _5 L Z .. Address: / 1110 & - e - ' /c — 6 J a " r City /State /Zip: _ - . — 6- 0 • _' LL. Phone P hon e #: �'� S 7 7 Are yo n employer? Ch the appropriate box: Type of project (required): 1. am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working c a employees and have workers' g for me in any capacity. tY 9. ❑ Building addition [No workers' comp. insurance comp. insurance.: required.) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions h o fficers have exercised their 1 i. Plumbing repairs or additions 3. ❑ I am a homeowner doing all work ❑ g a p myself. [No workers' comp. right of exemption per MGL 12 R re insurance required.] t c. 152, §1(4), and we have no �, p employees. [No workers' 13 Other -Y 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. :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. lftlte sub - contractors have employees, they must provide their workers' comp. policy number. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. t L' ` ""j ^ i Insurance Company Name: `� . Policy # or Self -ins. Lic. #: W C / ' 3) �57�� %I. 1 I Expiration Date: OS O' - /3 Job Site Address: 6 &- / / / ��+ ' f Q---- City/State /Zip: Q / cl- 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 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 hereb ce • the p ' , • ' penalties of perjury that the information provided above is true and correct: Si" : ,,:a , AS Date frri ■r C � Phone #: / v/3 -.)-5 - V / 7 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supe r: Not Applicable ❑ jel I I �� S ) v. ,,.) 0 73 V Name of License Holder : �''��' License Number 1 k 1 ��c C Vc L (V 6131--V. (.-7c / J .. ) 3 + ►1 Address / Expiration Date It A„ I ll ? L � ) 7 •J / Si at a Telephone ,.. RealStoredrHbme Improvement Contra+rtor: Not Applicable ❑ TA sM EA,l rpri y s, LLC / 7: 0-7 V Company Name Regis tTe ion Number / - 0 ei_;._ ... /(/ Atldress / Expiration ate Telephone LN -9-' -° fe) - / may/ SECTION 10 O RKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affid it must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil ing permit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Lxem tion 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 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 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 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [01.► De ks [[] Sidi g [0] Other [J Brief Description of Proposed 1-2-01 c� � � ✓ ��<rZ �` f 4 Work: t� �L.`�i \ 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: 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 well City water Supply SECTION 7a -OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ,e519/149 e h Or l c t o J )") , as Owner of the subject property hereby authorize my behalf, to act on m behalf in all matters rel bye work authorized by this building permit application. Signature of Owner Date ‘119r6 -ee -Owri 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 t m nd penal 'e f perjury. Print Name Signatur of Own /Ag t 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 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 ver been issued for /on the site? NO 0 DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DON'T KNOW 0 YES IF YES: enter Book Page and /or Document B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNO*, YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Da 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 Q NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, a vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r F"... ECEVE— Department use only ity of Northampton St atus t�f P�rmit> = uilding Department CurbCut/ — 0 212 Main Street ewrer /SepticAvailability . w �` T 13 Room 100 Water/Weil Availability DEPT OF BUILDING INSPE T orthampton, MA 01060 Two Se ,of Structure' Puns NORTHAMPTON MA,,, 7 . 41 - 587 -1240 Fax 413-587-1272 L Flot/Site Plans .�' Other Specify. , A PPLICATION 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 Map Lot Unit ( or , 1 ( Pr Zone Overlay District 1 0 6' 11. Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: KATHLEEN OR WILLIAM GOLASKI 68 GOLDEN DR N me (Print) Current Mailing Address: SAME gnature Telephone I/ _ .2_ 1 / 2.2 Auth • - d; nt: f * a 1 / )it) . t i0 1 c)--(e, (l;Ce Df i N. • Print` Current Mailing Address: / eC,/ —;,' - L ip - 7 - 5 Vie/ S'• • • e 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 // l !� �( 6. Total= (1 +2 +3 +4 +5) ! v Check Number 16' This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0912 APPLICANT /CONTACT PERSON JEFFREY BRADSHAW ADDRESS/PHONE P 0 BOX 1276 CHICOPEE (413) 427 -5481 PROPERTY LOCATION 68 GOLDEN DR MAP 29 PARCEL 429 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /1/ J p b -� Fee Paid Tvpeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 094734 3 sets of Plans / Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 ,v," • ? , ,De1ay 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. 68 GOLDEN DR BP- 2013 -0912 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 429 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- 2013 -0912 Project # JS- 2013- 001557 Est. Cost: $1209.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEFFREY BRADSHAW 094734 Lot Size(sq. ft.): 11412.72 Owner: GOLASKI KATHLEEN L & WILLIAM J Zoning: Applicant: JEFFREY BRADSHAW AT: 68 GOLDEN DR Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427 -5481 WC CHICOPEEMA01201 ISSUED ON:4/10/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC 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 4/10/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner