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Bardwell Woodworking&Remodeling Highlighted Contractors working on this job
49 Main ST.
Hatfield Ma.01038 413-247-0226
CONTRACTORS INSURANCE POLICIES:
Company Name: Phone# Insurance Company Policy# Exp.Date
Bardwell Woodworking&Remodeling
Jonathan Bardwell 413-247-0226 Farm Family Casuality Ins Comp
49 Main St 2008x0043 3/13/14
Hatfield Ma 01038
Korpita Masonry 413-256-8541 Blair,Cutting& WC59747007
P.O.Box 263 Smith Inc.
Deerfield Ma.01342
Mistarka Home Improvement 413-575-1271 Amherst Ins.Agenry.lnc.
P.O.Box 205 20 Gatehouse Rd.Box 48
Northampton Ma.02061 Amherst,Ma.01002
AM/PM P&Heating Inc. 413-256-8541 Blair,Cutting& CCP9863020 6/4/08
P.O.Box 527 Smith Inc.
Hatfield Ma.01038
Thomas G.Sullivan Dream Tile 413-863-9994 A.H.Rist Insurance Agency,INC.
13 H St Box 391
Turners falls,Ma 01376 Turners Falls Ma.01376 SCP 35693283
Harris&Gray 413-781-0416 IRM Insurai Bresnahan WC7488266
P.O.Box 300 Insurance Agency
Ashfield Ma.01330
Dion&Son Floor Contractor 413-538-7862 Webber&Grinnell CBP1156366 7/8/11
74 Russell St. Insurance Agency
Hadley Ma.01035
James Crowell Carpenter 413-247-5467 Whalen Ins Agency ART0360451
84 Elm ST.
Hatfield Ma.01038
M&S Electric Inc. 413-247-5330 Phillips Ins.Agency s1841019 10/7/08
119 Elm Street Inc.Chicopee Ma.
Hatfield Ma.01038
All Seasons Heating&Air 413-247-9842 Webber&Grinnell MPP45108
Elm Street Insurance Agency
Hatfield Ma.01038
David Michalowski Plumbing 413-665-8384 Cray-Dowd Ins.Agency.INC.CBP 5808744 4/7/14
&Heating
17 Graves Street
South Deerfield,MA.01004
Urban&Sons Insulation Co.Inc. 413-783-0701 McClure Insurance CPA018807911 8/1/08
385 Liberty St. Agency,Inc
Springfield Ma.01104
Right Way Drywall 413-586-2412 A.H.Rist Insurance CCX0396682 5/15/08
C/O Brian Johnson Agency Inc.
206 Coles Meadow Rd.
Northampton Ma.01060
Foster Electric 413-296-0219 Webber&Grinnell MBI95049 4/25/14
C/O David Foster Insurance Agency
24 Stage Road
Williamsburg,Ma 01096
Justin Jaquay-Wilison Tile 413-625-8501 A.H.Rist Insurance CBP8650804 4/18/12
DBA Justin Jaquay Wilison Agency Inc.
PO Box 7
Guckland Ma.01338
Turomsha f Painting 413-296-4578 Finck&Perras Ins. MPO8901T 3/12/12
Peter Turomsha Agency Inc.
182 Old Chesterfield Road
Williamsburg Ma.01096
., The Commonwealth of Massachusetts Print Form
= Department of Industrial Accidents
is r.`"±`.r---
--i Office of Investigations
?
N,g1 Congress Street,Suite 100
sz»•
r,' Boston,MA 02114-2017
°" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �J\\01J'fRT1 'h0 - lMk' U t.4)jL-L-_
Address: (A S V\tr.M S-C-4zt el""'
City/State/Zip: k-kfirkSZIAD OM. Ol b 5 $ Phone#: c-I 13 L'-i 1 02-2-0
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.RI I am a sole proprietor or partner- listed on the attached sheet. 7. cgi Remodeling
ship and have no employees These dub-contractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
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. 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: —
Policy#or Self-ins.Lic.#: Expiration Date:
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.
certify under the pains and penalties of perju at the information provided above is true and correct.
I do hereb p /
Signature: 'iv"-11 . _ _ - f l ��
— Date
Phone#: 4//3 2-'f 7 —0 Z. Z &,
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 Supervisor: Not Applicable ❑
Name of License Holder ,.10►J+1k r*A 1J r! E,l-L C J -0 5"5 cj i 0
,_i License Number
Aotok-
Address Expiration ate
C `�
3 -2-4 -d 2-z.,b
Sig ture Telephone
9.Registered Home Improvement Contractor: Not Applicable El
*Q�ititr kok—W'p ,KY0etK3rlG E r Ms►'7F:LSr�� tat °I S 2--
Company Name Registration Number
4% rah Vet S- "" t\tErPs. b 1 o + ''(
Address Expiration Date
Telephone `f(3 Z�-}-02L4
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 l 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 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 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 ever been issued for/on the site?
NO 0 DONT KNOW ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW €1)1 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q 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 41
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 will disturb over 1 acre? YES 0 NO e
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) IN Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [EJ Siding[lam] Other[CO
Brief Description of Proposed r
Work: -Mks M-Y4u u442,!` VNit' r R Qlat_ t N'v-c.'c ck c
Alteration of existing bedroom Yes 1.7No Adding new bedroom Yes (� No
Attached Narrative _ unfinished basement Yes i.l No
Plans Attached Roll She
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
' F 0 S l?�t" 5 V--9 ,as Owner of the subject
prope
hereby uthorize ON1kTi 't1 BIZ-.96.)E1..f--
to act o my bej�If,jB aII matters relative to work authorized by this building ermit application.
t/cJ [vl <
� ,...... 15 /:
Signatu f Owner ate
I v0/VA-T- f/r/V 'ft-tz._Dkzi�L L ,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.
AoN vtk c7\EzL--
Print►-_I e �I
i V�G+ull► k. ` .,i/ /3
Signature• Owner/A,ent Da
Department use only
RECEIVED City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
tAAI 1 6 2013 Room 100 Water/Well Availability
N rthampton, MA 01060 Two Sets of Structural Plans
DEPT.OFg1ILDINGINSP.��t_„$ -587-1240 Fax 413-587-1272 Plot/Site Plans
NORTHANIPTGN,tiIA
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
/ Si rn, a' - iZ 2 oC E. JZoko Map Lot Unit
PLO F2r7/e a X101--. Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
rR+MLS 050 3Ki-/ /S/ MA Pi-6- 2rD6e ROAD
Nart (Print) Current Mailing Address:
a`rigi. Telephone
Sig a ure /—
2.2 .uthorized Agent:
' 014 rt#"ht4 �w23:0-,ELL 4i Iv•cuM -t—' 'kik-Tirti ikit
Name(Print) Current Mailing Address:
i: 1* s-
Signature 1111 Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building Gr42-6. e� (a)Building Permit Fee
2. Electrical 0 per_ (b)Estimated Total Cost of
Construction from(6)
3. Plumbing 2 1 0 Q i e'e-_ Building Permit Fee
4. Mechanical(HVAC) e�
5.Fire Protection
6. Total=(1 +2+3+4+5) /372-S ,0O Check Number 3og� Sg
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2013-1100
APPLICANT/CONTACT PERSON JONATHAN BARDWELL
ADDRESS/PHONE 49 MAIN ST HATFIELD (413)247-0226
PROPERTY LOCATION 151 MAPLE RIDGE RD
MAP 36 PARCEL 260 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out ���
Fee Paid
Typeof Construction: INSTALL SHOWER UNIT&REPLACE INTERIOR DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 055910
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
ela
APP1400111111F1 /9"
■10.".■d°. - 77-
Signature of B ' din: If cial 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.
151 MAPLE RIDGE RD BP-2013-1100
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-260 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2013-1100
Project# JS-2013-001820
Est. Cost:
Fee: $82.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JONATHAN BARDWELL 055910
Lot Size(sq. ft.): 51400.80 Owner: OSOFSKY JAMES R
Zoning: Applicant: JONATHAN BARDWELL
AT: 151 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
49 MAIN ST (413) 247-0226
HATFIELDMAO1038 ISSUED ON:5/20/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SHOWER UNIT & REPLACE INTERIOR
DOOR
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 5/20/2013 0:00:00 $82.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner