23A-030 Construction Super isor
_ -s a. CS4MM376
.TORN P MICHONw ,K. .:.
66 CONWAY ST : ��`
SHELOURNE FAI.LS14)
_
0sflII2014
CJlre�os�ma�uamltlr p�'c�fG.�xdtusetts
,Q, Offim of Coasumer Affairs&Business Regul ation
MpRpVEMENT CONTRACTOR -
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JOHPI'S HOME IREP IR
.10HN MICHONSKI
66 COMMAY STREET
SHELBOURNE FALLS.MA 01370 Undersecretary
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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 Cbnway Street
City/State/Zip: Shelburne Falls Ma. 01370 phone#• 413-834-7725
.Are you an employer?Check the appropriate bog: Type of project(required):
1.(E)I am an employer with 3 4.O I am a general contractor and 1 6.❑New construction
2.®employees(full and/or part time).* have hired the sub-contractors 7.❑Remodeling
I 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'
(No workers'comp.insurance comp.insurance.$ 9.❑Building addition
required] 5.0We are a corporation and its 10.❑Electrical repairs or additions
3.01 a homeowner doing all work officers have exercised their 11.❑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.p other Weatherizaboh
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: ,5 -a1- �Q-,/N
Job Site Address: �� (= City/State/Zip, u�� , �,AA ��6
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 fy under the pains and penalties of perjury that the information provided above is true and correct
Si ature: Date: iq s� c . oZ
Print Name:John 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):
i.Board of Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#-
CERTIFICATE OF LIABILITY INSURANCE 05/07/2013 DATE(MWDDNYYY)
A`dR0`
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Paychex Insurance Agency Inc
PAYCHEX INSURANCE AGENCY,INC. PHONE FAX
150 SAWGRASS DRIVE • 877-266-6850 • 585 389-7426
ROCHESTER,NY 14620 E-MAIL Certs @paychex.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: NorGUARD Insurance Company 31470
JOHN MICHONSKI INSURER B:
64 CONWAY ST
SHELBURNE FALLS,MA 01370 INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
TRR INSR D (MMIDD/YYYY) (MMIDD/YYYY)
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
PRE
Ea
occurrence) _
CLAIMS-MADE�OCCUR MED EXP(Any one person) $
PERSONAL 8 ADV INJURY $
GENERAL AGGREGATE $
EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $
POLICY =PROJECT=LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident) _
ANY AUTO BODILY INJURY
ALL OWNED SCHEDULED (Per person) $
AUTOS A�I�ND.OSS WNEO BODILY
HIRED AUTOS AUTOS (Per accident)
$
PROPERTY DAMAGE $
(Per accident)
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LU1B CLAIMS-MADE AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION AND X I WC STATU- OTH-
EMPLOYERS'LIABILITY JOWC336079 05/28/2012 05/28/2013
E.L.EACH ACCIDENT $ 500,000.00
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000.00
(Mandatory in NH) FY N/A E.L.DISEASE-POLICY LIMIT $ 500,000.00
H yes,describe under
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
CERTIFICATE HOLDER CANCELLATION
JOHN MICHONSKI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
JOHN'S HOME REPAIR DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY
64 CONWAY ST PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
SHELBURNE FALLS,MA 01370 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2010/05) @1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
John's Horne Repair Service 1?q 3?(0
Name of License Holder
awaul
66 Conway St License Number
Shelbume Falls,MA 01370 E, - P -C .-o l y
dre s Expiration Date
_R
igna ure Telephone
8.Reaistered Home Improvement Contractor: Not Applicable ❑
) `f a 70cf
Company Name John Michonski Registration Number
66 Conway SL s- /-3- 61 Y
Address Shelbume Falls,MA 01370 Expiration Date
Telephone
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....... t 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 buildine 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 ED
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[p] Other[�]
Brief Description of Proposed ---. f
Work: V)1& St.j4A %Iki+` V41,C
Alteration of existing bedroom Yes J 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 �L—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
I, 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
I, sOk c�kc 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.
P' t Na e �l
q
r
nature of Owner/Agent 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 tilled 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 Q DONT KNOW 0 YES 0
IF YES, date issued:''.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 0
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
�� City of Northampton status of Peiml;
k g 2a�a ;gull ing Department Curb Cut/Dnveway Permit
;l. ew
?j Main Street Ser/SepticAvadability y '
°�10 oom 100 Water/Well`Avallabllity
E\ectr;c.F ,clt_ _y ' orthampton, MA 01060 Two�efsof Struiiral Plans r
phone 413-587-1240 Fax 413-587-1272 t 1pypjte�Pjans£
Other Speafy a t j
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 �0 e,K S+ Map Lot Unit
�IOTQhC Q lQ� Zone Overlay District
Elm St.District CB District
SECTION`2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
t�Mti4�r��h v r+a�,c� i� ��r ks� �c� ',�•.e� �n�tA
Name(Print) Current Mailing Address:
9 1 A-- �5` i '-4 Ll sv
Telephone
4gn re
2.2 Authorized Agent:rr j\
e(Print) Current Mailing Addres : L 13,
LL (// :z , '3Y -)->as
ignature Telephone
SECTION 3—ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building I ,c c (a)Building Permit Fee
2. Electrical �j (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) 19 a C)o` Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0787
APPLICANT/CONTACT PERSON JOHN MICHONSKI
ADDRESSTHONE 66 CONWAY ST SHELBURNE FALLS (413)834-7725
PROPERTY LOCATION 63 PARK ST
MAP 23A PARCEL 030 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: INSULATE ATTICE&WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 49376
3 sets of Plans/Plot Plan
THE F.OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below)
IV
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
mo a
Signature of Building O ficial D4e ?
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.
63 PARK ST BP-2014-0787
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23A-030 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-2014-0787
Project# JS-2014-001343
Est. Cost: $6200.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN MICHONSKI 49376
Lot Size(sq. 1): 7579.44 Owner: SEVERANCE MARILYN
Zoning:URB(100)/ Applicant: JOHN MICHONSKI
AT. 63 PARK ST
Applicant Address: Phone: Insurance:
66 CONWAY ST (413) 834-7725 WC
SHELBURNE FALLSMA01370ISSUED ON:111012014 0:00:00
TO PERFORM THE FOLLOWING WORK:I N S U LAT E ATTICd & WALLS
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 1/10/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner