43-153 mass save ��
�t �, -....�-
PERMIT AUTHORIZATION FORM
I, Mark Jankowske ,owner of the property located at:
(Owner's Name,printed)
17 Hawthorne Ter Florence
(Property Street Address) (City)
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.
X
(Owner's Signature
r
Date
FOR CSG OFFICE USE ONLY
Conservations Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
Participating Contractor Date
Dfr�
Di
For Office Use Only
Rev.12132011- --_------- -- --- -------- - -- - -- - -
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston,MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADDlicant Information Please Print Leeibly
Name(Business/Organization/Individual):�5
Address: v
City/State/Zip: r'1 Phone t ,3 V "
Are you an employer?Check th ppropriate box: Type of project(required):
1.❑ I am a employer with 4. [j I am a general contractor and I
employees(full and/or port-time).
• have hired the sub-contractors 6. C]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, [3 Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers'comp.insurance comp.insurance?
required.] 5. ❑ We are a corporation and its 10.El 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.❑goof repairs
insurance required.)t c. 152,§1(4),and we have no
employees.[No workers' 13.❑Other
comp.insurance required.]
'Any applicant that chocks box#1 must also fill out the section below showing their workers'compeirsation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContraetors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. if the subcontractors 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:_ Q I " ! V-
Policy#or Self-ins.Lic.#: - I L' Expiration Date:
Job Site Address- rn�- (� 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
I vesti ations of the Dj&for'gMRgce coverage verification.
I do hereby certify u r the pads d ury that the information provided above is true'and�rprrect
Signature: at 1 Phone -
#:
Official use only. Do not write In this area,to be completed by city or town ofjiciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 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 ❑
Name of License Holder: License Number
�- a � bla
Address _ , Expiration Date
6)
SignaWe Telephone
9.Re istered Home Improvement Contractor: . Not Applicable ❑
ci 5
Co pane Name Registration Number
Address Expiration Date f
Telephone�f������' 1'�(�� � ��,
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) E5a Roofing ❑
Or Doors 17-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[[3] Other[[:1]
Brief Descriytio of Prop ,sed
Work: (c U Fp��1 �I pw�' 'f,j ktC I Uwe_ io
Alteration of existing bedroom Yes `�No Adding new bedroom Yes '-' No J
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
' ( ia� e.. as Owner of the subject
property
hereby authorize J `
to act on my behalf, in all ruafters relative to work authorized by this building permit aljp4tion.
Signature of Owner Date
as Owner/ oriz
A ereby clare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signedu der the pains and penalties of perjury.
Pku
Print Name
M1
Signature oWwne0gent 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 a er been issued for/on the site?
NO ® DONT KNOW YES
IF YES, date issued:
IF YES: WFthermit recorded at the Registry of Deeds?
NO DON'T KNOW ® YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW 'YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES ® NO a
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 C)
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading,tyAlVation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ® NO V
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
rElec _ Department use only
ity of Northampton Status of Permit:wilding Department Curb Cut/Driveway Permit
FEB 7 �' 5 212 Main Street Sewer/Septic AvailabilityRoom 100 Water/Well Availability
as Irspecli hampton, MA 01060 Two Sets of Structural Plans
orthampton. R,9A01U60
e -587-1240 Fax 413-587-1272 Plot/Site Plans
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
' � ��� , Map Lot Unit
`�7�D(-,e.nce- f R o I C�-- Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
l .z.fc �-��n� e
Name(Print) Current Mailing Address:
. 4
( jl--�0 Telephone 6 L¢C) ` 9 311—'-1 It.,
(�
Signature b
2.2 Authorized Agent:
_r I, I P' 1 -h 1�� m�
Name(Printj Current Mailing Adq re s:
Y ,
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building t��--1 x)o (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) s 67-8 Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
i
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-0798
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON01050(413)214-2414
PROPERTY LOCATION 17 HAWTHORNE TER
MAP 43 PARCEL 153 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
in i
-Is
Signature of Buil ing fi ial 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.
17 HAWTHORNE TER BP-2015-0798
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 43 - 153 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-2015-0798
Project# JS-2015-001553
Est.Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 43995.60 Owner: JANKOWSKE MARK
Zoning: Applicant. JAY BOLAND
AT. 17 HAWTHORNE TER
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON:211812015 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 Occupant Signature:
FeeType: Date Paid: Amount:
Building 2/18/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner