17A-303 _ The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
U9 600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
to"A C1 t'
Name(Business/Organization/Individual): _ 641 J
Address: JSCAZ�JN VO&A
City/State/Zip: n b!'__),0 Phone#: —&P�T 3130
Are you an employer?Check the propriate box: Type of project(required):
1.Q I am an employer with 4.01 am a general contractor and I 6.0 New construction
omMoyees(full and/or part time).* have hired the sub-contractors 7.0 Remodeling
2. I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8.0 Demolition
working for me in any capacity. employees and have workers'
[No workers'comp.insurance comp.insurance.$ 9.0 Building addition
required] 5.0We are a corporation and its 10.0 Electrical repairs or additions
3.01 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 12.0 Roof repairs
employees.[no workers' 13.0 Other
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 most 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: ) G
Policy#or Self-ins.Liic.#h: I�G, � 0a I rA-Fti Expiration Date: 1"" 2.o 15
Job Site Address: ' }V" 1 �l�cn—& Z)n U' , City/StateJZip: F(W t P _m A b( 6b '2_
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 nder the p ins and penalties of perjury that the information provided above is true and correct.
d
Si ature: Q Date: ( Z l
Print Nam 12M 1 A'I,)C1 Phone#:
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#:
N1 as sar,
Board Of C
�,!e ns
BWimna a
gulari
(j �")'Iaarcis
M as saic-
c
_:cerise. CSSL-103443 Board o F Building
speciolti
JAY R BOLAND _,tense CSSL-101880
12 PISGAH RID mat
HUNTINGTON
MA 01030 - JAY R BOLAND
12 PISGAH RD
HUNTINGTON MA 01050
12/27/2014
12/27/2014
Jay Boland
ID#2011-554
P
mass save
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5 170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 164603
Type: DBA
Expiration: 10/26/2015 Tr# 244106
HOME ENERGY SOLUTIONS
JAY BOLAND
12 PISGAH RD.
HUNTINGTON, MA 01050
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
SGA 1 in 20M-05/1 I
-%FXC tr(Iffi J11011111("(11111.1r, License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation before the expiration date. If found return to:
IOME IMPROVEMENT CONTRACTOR
Type: Office of Consumer Affairs and Business Regulation
e Istration: 164603
9 10 Park Plaza-Suite 5170
Expiration:
10/2612015 DBA
Boston,MA 02116
HOME ENERGY SOLUTIONS
JAY BOLAND
12 PISGAH RD.
HUNTINGTON,MA 01050 Undersecreiar" Not ah itsignature
yv vv. s.vr-. rr•�.- i`iJJVGGYpV L{.NVfIL,LLY
PAW 81!03
OWNER AUTHORIZATION FORM
Terrence Donnelly
(owners Name)
owner of the pmpertjr located at
107 Hillcrest Drive
(PmPwty Address)
Florence, MA 01062
(Properly Address)
hereby authorize q--D � R
(sub=contractor)
an authorized subwr&o for for RISE EngUumft,to act on my behay to obtain a building
Permit and to perform work on my property.
s ftnsWre,
D
E EDVlE
OCT - 3 2014
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction�S/u1p.,e visor: I " 1 Not Applicable 0
Name of License Holder: '0 ( c v W
License Num r
I ') 1��-7 11 `-(
Address Expiration Date
Signature •. Telephone
a Q.
9.Realstered Home Im r v m nt Co t r: Not Applicable,❑
�Jbff)a tt (,t L(CLO
Company Name Registration N ber
2 a_h �� f �✓��-l� �j S
A ress `/ Expiration Date
14 -i\�n � l>>L7 Telephone l I
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....... ,z"', 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) NZ. Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [Cl] Decks [[] Siding[o] Other[a
Brief Description of Pro ----, ``
Work: MCI Lsk i c '�4i z)(1 r1. 23)
Alteration of existing bedroom Yes '--No Adding new bedroom Yes N
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 FORE BUILDING PERMIT
l r fl nG � �n tl_I`L, as Owner of the subject
property
hereby authorize � ' -�
to act on my behalf, in—all ma ers r alive to work authorized by this building permit application.
Signature of Owner ;; Date Z
I, d o'A- as Owner/Authorized
Agent hereby d clare 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.
go i as
Print Name
Signature of er/ 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
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 ® DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DON'T KNOW i 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 0° YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O 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 O Nll�—o
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 O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
-~ I Department use only
City of Northampton Status of Permit:
j Building Department Curb Cut/Driveway Permit
NOV 1 4 lI� �� J 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
- -�
Northampton, MA 01060 Two Sets of Structural Plans
Eli ctric, Piumbing&Gas Inspections p
Northa npton,k1lA oio ho 413-587-1240 Fax 413-587-1272 PloVSite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pros)er Add This section to be completed by office
i ID 9 f-►l I(w 4 0 r, Map Lot Unit
al U Zone Overlay District
Cv�-
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: . L
b'1 ..i�rl Use , �. nice
Name(Print) Current'Mailing Address:
�L Telephone u `� / -
Signature � 1.� .J j
2.2 Authorized Agent:
Name(Print)I Current x(Mailin Tess:
4LAp%
- Lo Qvd.,�'
pmqa 13-. A 0V7 -3( 2) 0
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building S ` D� (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) UQ (7 Check Number d �j
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0567
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 107 HILLCREST DR
MAP 17A PARCEL 303 001 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
Typeof Construction: INSTALL ATTIC INSULATION&AIR SEAL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 101880
3 sets of Plans/Plot Plan
THE LOWING 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
D lit'
Sig e of Building ficial 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.
107 HILLCREST DR BP-2015-0567
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 17A-303 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-2015-0567
Project# JS-2015-001081
Est. Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 21823.56 Owner: DONNELLY TERRENCE P&GAIL K
Zoning:URA(100)// Applicant: JAY BOLAND
AT. 107 HILLCREST DR
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON.11/17/2014 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ATTIC INSULATION & AIR SEAL
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 11/17/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner