30A-004 JOHN MICHONSKI
JOHN'S HOME REPAIR SERVICE
66 CONWAY STREET
SHELBURNE FALL, MA. 01370
413-834-7725
Building Inspector Town of Northampton Ma. July 1, 2013
Reference permit for 292 Florence Road
Sir,
Enclosed is a permit application and a check for$55.00 for weatherization work at this
address. If possible could you mail the permit to my address or I can pick it up on the day
we start work. Please call if you need any more information or have any questions.
Thanks for your assistance with this matter.
. c hn Michonski
(WI I Lt _
ohn's Home Repair Service
1 iilassacPiiseLts - of ic Sa
s
Board of Building Reguiaiiiorls and Standards
Construction Supers isor
CS-094376
JOHN P MICHONSKI
66 CONWAY ST
SHELBURNE FALLS MA 91370
06/11/2014
.c-C-17;ie"Ccmnionevea/ otattwarlirriel7s
Office of Consumer Affairs&Business Regulation
*ME IMPROVEMENT CONTRACTOR
r ;egistration: 142709 Type:
xpiration: 5/1/2014 DEA
JOHN'S HOME REPAIR
JOHN MICHONSKI
66 CONWAY STREET
SHELBOURNE FALLS,MA 01370 Undersecretary
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/individual):JOHN'S HOME REPAIR SERVICE
Address: 66 Conway Street
City/State/Zip: Shelburne Falls Ma. 01370 Phone#: 413-834-7725
Are you an employer?Check the appropriate box: Type of project(required):
1.0I am an employer with 3 4.0 I am a general contractor and I 6.❑New construction
employees(full and/or part time).* have hired the sub-contractors ❑Remodeling
7.2.01 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8.❑Demolition
working for me in any capacity. employees and have workers' 9.❑Building addition
[No workers'comp.insurance comp.insurance.$
required] 5.0We are a corporation and its 10.❑Electrical repairs or additions
3.0I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers'comp. right of exemption perm MGL
insurance required] t c. 152,§ 1(4),and we have no 12.❑Roof repairs
employees. [no workers' 13. Other Weatherization
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contactors that check this box must attach 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:Guard Insurance Group (Norguard Ins. Co.)
Policy#or Self-ins.Lic.#:JOWC 226642 Expiration Date: S- g4)144
Job Site Address: a q2 F)oct,,, City/State/Zip: c.1pS�„�{ Q Y v�o, OI b 6X
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 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
$250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: 11/1/1 Date: ( - al ..
a D 1 3
Print Name: ohn Michonski Phone#: 413-834-7725
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 Heath 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 ❑ I
Name of License Holder: 0 q 3 9 7-6
License Number
John's Home Repair Service
John Miehonslri 6 -// - 3 01s1
Address I__I 111_—_I 66 Conway Si Expiration Date
Shelburne Falls,MA 01370
Sign ur Telephone
— 44/4,v ,�,,-� / 3 3 Y- 720,\3--
.Registered Home Improvement Contractor Not Applicable ❑
3oNnu: S !—�aw�• . ea:s 14
Company Name Registration Number
_ John's Home Repair Service `S -/-el o/y
Address John Michonski Expiration Date
l_ =1:11_ 4 66 Conway Si Telephone �i 3'�3 y-7
Shelburne Falls,MA 01370
—
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 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 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[p]
Brief Description of Proposed
Work: Install approx.1000 sq.ft cellulose insulation R-19 in attic.Air seal basement&attic.
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
l , 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
1, 3CAn.. W1►(Aft(' ,&K.. , 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.
Pr t N me
1/1/1/ .. . 6 - a ,- a.o13
nature of Owner/Agent Date
( it of Nnrt1 am{rtnn
1 rsr `,, Ai_
'_ � Sthisseu tusrtts 1 * i x,
' DEPARTMENT OF BUILDING INSPECTIONS ''3, �
w °
212 Main Street • Municipal Building syiv geDO,
Northampton, MA 01060
T HSBRULOUS AOCK BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMMISSIONER Effective July 21, 2008 Fax (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercial
*NEW CONSTRUCTION $ .50 per square foot for 1st floor
.30 " " " 2nd floor
.20 " " '%floors,attic,basement,garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of$55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over
$ .20 per square foot with a minimum fee of$25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in-ground
*SIGNS&AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$6/K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1 (1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH -CHECKS OR MONEY ORDERS ONLY !!
*Filing deadline is 12:00 pm(noon)on Wednesday.
CVe-° , 20 066"
REGE� fF a 'n I
Department use only
....°"_. City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
Z0i3 I 212 Main Street Sewer/SepticAvallability
Room 100 Water/Well Availability
DEPT.OF BUILDING INSPECTIONS Northampton, MA 01060 Two Sets of Structural Plans
NORTHAMPTON,MA mot; one 13-587-1240 Fax 413-587-1272 Plot/Site Flans_
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
a eloee�.ce- Map Lot Unit
o AMA. Zone Overlay District
Ibba EIm'St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
\be.:da aq F\oCevt RA. Flom. es., mor
Name(Print) c� Current Mailing Address: O�Obe1
3, y� 3 — S�7- 9366
i Telephone
Srgnature
2.2 Authorized Aqent: 6 6 C eh�,,. 34
Sa1n.� X114 51,•••■h v e- cu.ktg vv\A- 01 3,t,
Name 'dirt) n Current Mailing Address:
S'r ure Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 300 (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) DO OD Check Number
This Section For Official Use Only
Building Permit Number: !J' P !Li - 000 o I Date
9 Issued: 7/9/I
c./1 7��c� ___
Signature: - ! JL
Building Commissioner/Inspector of Buildings Date
292 FLORENCE RD BP-2014-0001
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30A-004 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: INSULATION BUILDING PERMIT
Permit# BP-2014-0001
Project# JS-2014-000029
Est. Cost: $1000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Conti-actor:1 it t�ioC:
Use Group: JOHN MICHONSKI
Lot Size(sq. ft.): 14984.64 Owner: PLACIDO HENRIQUE S& DEBORAH J
Zoning: URA(100)/WSP(100)/ Applicant: JOHN MICHONSKI
AT: 292 FLORENCE RD
Applicant Address: Phone: Insurance:
66 CONWAY ST (413) 834-7725
SHELBURNE FALLSMA01370ISSUED ON:7/9/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:Attic insulation and air sealing
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 7/9/2013 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck- Building Commissioner