18C-159 two
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mass save
PERMIT AUTHORIZATION FORM
f–\ t>t= L A I n ('—' F/tQ , owner of the property located at:
(owners Name, printed)
O .
(Property Street Address) V I (CityfTown}
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.
Owners Signature
Date
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services
project:
Participating-C-ontractor to t refereed
Participating Contractor Date
50–S
Rev. 12132011
The Commonwealth of Massachusetts
fn Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
d 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):
I.Q I 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 g, ❑ Demolition
working or me in an capacity, employees and have Nvorkers'
g Y P n' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.+
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 12.7 Roof repairs
insurance required.] ' c. 152, §1(4),and we have no INSULATION
employees. [No workers' 13.Q 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 short 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 that is providing workers'compensation insurance for my employees. Below is lite policy and job site
information.
Insurance Company Name:LIBERTY MUTUAL _
Policy#or Self-ins. Lic. »:WC2-31S-3727720913 Expiration Date:5/2/1
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.
I do hereby certify under the pains a naldes of perj that the information provided above is true and correct.
�,
Si ature: Date:
Phone-#, 413-427-5481
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License #
Iccnina Authority(nirrin nnnl•
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supery isor: / Not Applicable ❑
Name of License Holder:
J License Number
Address Expiration Date
21 5'/&/
Signature Telephone
9.Realstered Home Improvement Contractor: Not Applicable ❑nSM �A�,ct
Company Name / Registration Number
�C3 Q0X /2 IG Cklcoaee 'l' 21-16
Address
`V13 Expiration Date
�3 361 9016 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....... No...... ❑
11:M-°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 apalicable)
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [0 Siding[0] Other Uffil
Brief Description of Proposed �} J / / t
Work: / 7f_ (()t?�1/2 Y��c LJ (� l{)�� o vC.r l� 2
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
" If New house and or addition to exiist ng housing, complete the`following
a. Use of building : One Family x 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, n I Q Q Cat") as Owner of the subject
property
hereby authorize ►`+U A�C I Zr o '0 t��'
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Own /Authorize
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my nowledge
and belief.
Signed under the pains a penaltt s ury.
Print Name
Signature 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 filled in by
Building Department
Lot Size
Frontage a
Setbacks Front
IF
Side L R.. ..e .. 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 DON'T KNOW 0 YES 0
IF YES, date issued:t'
L_.,. e_ _ --
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES 0
IF YES: enter Book Page` and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
�....w.
Needs to be obtained 0 Obtained , Date Issued
C. Do any signs exist on the property? YES 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 avation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO AA
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
uilding Department ?
212 Main Street
Room 100
17
2014 Northam ton MA 01060 "
.._ N
_� phon 41
e3-587-1240 Fax 413-587-1272
Electric Plumh�r:_ p, OtheTtip .� � '
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
L
-� [va r o T o n f/l l Map Lot Unit
/k 0106
� Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A e, Toode Coin 51 bA49r ur ��
Name(Print) 1 Current Mailing Address-
3, 81 y
6 i /?L /?J Telephone
Signature
2.2 Authorized Agent:
re
61-aoil-lako /�?fl oks/
Name(Print) Current Mailing Address:
qi3 412 '
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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
6. Total=0 +2+3+4+5) Check Number &63710
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-1086
APPLICANT/CONTACT PERSON JEFFREY BRADSHAW
ADDRESS/PHONE P O BOX 1276 CHICOPEE (413)427-5481
PROPERTY LOCATION 37 WARBURTON WAY
MAP 18C PARCEL 159 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid rA
Building Permit Filled out
Fee Paid
Typeof Construction:_INSTALL ATTIC INSULATION
New Construction Al ev
Non Structural interior renovations /off I
Addition to Existin
Accessoa Structure L-f AM
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
INFOR ION PRESENTED:
pproved 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
olition ela
Si gN Wr ffr—e of Buildi 1<'O tfi 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.
37 WARBURTON WAY BP-2014-1086
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 18C- 159 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-2014-1086
Project# JS-2014-001862
Est. Cost: $902.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BRADSHAW 094734
Lot Size(sq. ft.): 0.00 Owner: CAIN ADELAIDE
Zoning URB(100)/ Applicant: JEFFREY BRADSHAW
AT. 37 WARBURTON WAY
Applicant Address: Phone: Insurance:
P O BOX 1276 (413) 427-5481 WC
CHICOPEEMA01201 ISSUED ON:412312014 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION -final inspection
required
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 4/23/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner