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15B-025 (2) z�'° , mass save PERMIT AUTHORIZATION FORM y owner of the property located at: (Owner's Name, printed) (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 building permit to perform insulation and/or weatherization work on my property. 13, Owner's Signature /0 Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project. 0 41 Participa TgOo nt ractor Date Rev. 12132011 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 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): JASM ENTERPRISES, LLC Address:P.O. BOX 1276, City/State/Zip: CHICOPEE, MA 010121 Phone #:413-427-5481 Are you an employer? Check the appropriate box: Type of project(required): 1.FE-1 1 am a employer with 5 4. [J 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 g. F� Demolition working for me in any capacity. employees and have workers' 9. Building dition [No workers' comp. insurance comp. insurance..* g� required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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 13.❑ Other INSULATION employees. [No workers' comp. insurance required.] 'Arty applicant that checks box#I must also 511 out the section belo'A 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. 1 am an employer fit at is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: LIBERTY MUTUAL Policy#or Self-ins. Lic. #:WC2-31S-3727720913 Expiration Date:51211 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. 1 do hereby certify under the pains a enaldes of pe jti}y that the information provided above is true and correct. Si nature: Date: Phone-#, 413-427-548 Official use only. Do not write in this area,to be completed by cin,or town official. City or Town: Permit/License # Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. Citv/Town Clerk 4. Electrical lnsnector G Phrmhina rnenam- SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: rr Not Applicable ❑ Name of License Holder: Q License Number PG (3 OX 12 7(�, C�,,(Upu- InIf ( o-ZI 16 - 13 Address Expiration Date Sign a Telephone 9.Reaist6red Home Ilan 'rovement Contractor: Not Applicable ❑ / &6G �/ Comoanv Name Registration Number Address Expiration Date (� +JC,�( % �4 ��Ca�I�� Telephone ZI13 260 q7 �2 2 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 A, SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) 7 New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[[3] Other[[Zl Brief Description of Proposed Work: ATTIC OPEN BLOW CELLULOSE 8"ACROSS 1072 SQUARE FEET.R VALUE TO ADDED R-30 Alteration of existing bedroom Yes NO No Adding new bedroom Yes NO No Attached Narrative Renovating unfinished basement Yes NO No Plans Attached Roll -Sheet sa.`if-New"It tiuserand or'addi#ion to @XiStihQ housirig, COrnolkt Ahe 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 I, '55�. I'1(J ©� 1 Z Q �7(5 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 as Own r/�uth en ereby declare that the statements and information on the foregoing application are true and accurate,to the best o ge and belief. Signed under the pains and enalties of perjury. IT C444- � Print Name )�z Signature of Owner gent 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 Rear Building Height Open Space Footage % (Lot area minus bIdg&paved ...... of Parking Spaces (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? �� NO v�� DON'T KNOW �_� YES U IF YES, date issued: ) IF YES: Was the permit recorded nt the Registry ofDeeds? NO �� `_,K l DDNTKNOYY YES IF YES: enter Book Pagel and/or Document# ��/�� �� B. Does the site contain a brook' body of water or wetlands? NO «�� DON'T KNKNOW YES x_� IF YES, has a permit been or need to be obtained from the Conservation Commission? _ Needs tobeobtadned �~� Obtaned »-� Date | | �_/ ' ' C. Do any signs exist on the property? YES u^~� NO 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 |F YES, describe size, type and location: | | L---__..... ___ _---------------------------'---' E. Will the construction activity disturb(clearing,gradingexcavation, or filling)over 1 acre oriadpart ofo common plan that will disturb over 1acre? YESK��� NO K�� �� |F YES,then o Northampton Storm Water Management Permit from the DPW iarequired. ��,6 0 n P "fitLAd I r° j City of Northampton " I Building Department I 212 Main Street L I; APR � � ;,l Room 100 LNorthampton, MA 01060 - - hgne 13-587-1240 Fax 413-587-1272 p } f APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Properly Address: / 117- ( I es ie r l ! e l d Map Lot Unit A'lt.S , !w/1' ll Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: J Caren Weiner and Robert Schrader 112 Chesterfield Rd �QidS (y) H (310 ,53 Name(Print) J m Current Mailing Address: 413-687-1806 <S(2-e /4 tU / {'t U r 1 z {v r T" Telephone Signature 2.2 Authorized Ascent: 413-427-5481 413-427-5481 Name(Print) Current Mailing Address: 413-427-5481 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 1,563 (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=0 +2+3+4+5) 1,563 Check Number p� This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1053 APPLICANT/CONTACT PERSON JEFFREY BRADSHAW ADDRESS/PHONE P O BOX 1276 CHICOPEE (413)427-5481 PROPERTY LOCATION 112 CHESTERFIELD RD MAP 15B PARCEL 025 001 ZONE URA(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 T3Teof 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOIjDIATION 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 Demolition Delay Signa re of Buildmg 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. 112 CHESTERFIELD RD BP-2014-1053 GIs#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 15B-025 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-2014-1053 Project# JS-2014-001808 Est. Cost: $1563.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO Const.Class: Contractor: License: Use Group: JEFFREY BRADSHAW 094734 Lot Size(sq. ft.): 46609.20 Owner: SCHRADER ROBERT W&CAREN M WEINER zoning:URA(100)/ Applicant: JEFFREY BRADSHAW AT. 112 CHESTERFIELD RD Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427-5481 WC CHICOPEEMA01201 ISSUED ON.411512014 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: FeeTyne: Date Paid: Amount: Building 4/15/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner