31A-024 (9) 42 FRANKLIN ST BP-2016-1031
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 A-024 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-2016-1031
Project# JS-2016-001741
Est. Cost: $2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 17903.16 Owner: BRENNEIS SARA
Zoning: URB(100) Applicant: JAY BOLAND
AT. 42 FRANKLIN ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214-2414 WC
HUNTINGTONMA01050 ISSUED ON:2/19/2016 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC & KNEEWALL 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:
FeeType: Date Paid: Amount:
Building 2/19/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1031
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON01050(413)214-2414
PROPERTY LOCATION 42 FRANKLIN ST
MAP 31A PARCEL 024 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid l C
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC&KNEEWALL 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
INF05MATION 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 D
Si ure of Buil ingficial 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.
Department use only
ity of Northampton Status of Permit:
-- uilding Department Curb Cut/Driveway Permit
FEB 816 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
N rthampton, MA 01060 Two Sets of Structural Plans
LIDEPTOFr"N INS Dm►�41 -587-1240 Fax 413-587-1272 Plot/Site Plans
NORTHAMPTON,M 01060
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
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone I)0 c-7
nature
2.2 Authorized Anent:
Name(Print) Current Mailing A ss:
4w Ll 3-CCU ":�>I3C:)
SignatuAFOrTelephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building ` r o 1 (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
This Section For Official Use Only
BuildingPermit Number: Date
Issued:
Signature:
Building Commissioner/inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks Siding[o] Other{C]
Brief De rition f Pro u , t
Work: pti p sed :� ( Il 10 q q4 U SPE>e ee
5►a�e.
Alteration of existing bedroom) Yes .l No Adding new bedroom Yes 'No °Yt_:^c�e:�
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
1, � 1. c ' -a ---� a � as Owner of the subject
prope
hereby authorize
to act on my behalf, in all mafteA relative to work authorized by this building permit application.
(tea-�`-
ignature of Owner —� Date
I as Owner/Authorized
g t Ijereby de la that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
elief.
Signed under,the pains and penalties of perjury.
r-3017
Print Name
Signatur Agent Dat
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: \—i� Not Applicable ❑ Q
Name of License Holder:��LA 4 10 � G D
License Numb
\2 Q s t r CN C)
Address Expiration Date
Signature Telephone
9.Re istered Home Improvement Contractor: Not Applicable ❑
1 �a4 (a 03
Com an Name Registration Number
2 2 to 2z)1 --7Address 2 3 3D Expiration ate
Telephone J' �
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.x.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
The Commonwealth of Massachusetts
Department ofIndushWAc cidents
O ke of Invesfigadons
1 Congress Street,Suite 100
Boston,MA 02114-2017
' wwwntus gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electriciandp mnbers
AAmU a ut Information Please Print!Azibiv
Name(Business organizationandividusl): L TMJ LA ICCNj
Address: O
City/Stat, Zi : b Phone#: '4 1 3" ( P77- '3130
Are you an employer?Check tbhappropriatc box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
„_-ymployees(full and/or part-time)-* have hired the sub-contractors 6. Q New construction
2. I am a sole proprietor or partner- listed on the attached sheet. ?. Q Remodeling
ship and have no employees These sub-caonumtors have g- Q DerrioBBan
working for me in any capacity. employes and have workers' 9. Q Building addition
[No workers' comp-insurance comp.insurance.
required.] S. Q We are a corporation and its 10.0 Electrical repairs or additions
3. I atm a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself[No workers' compright of exemption per MGL 12.Q Roof repairs
required.]t c.152,§1(4),and we have no
employees. [No worlow 13-❑Other
comp-insurance required..]
•11rry apPhicaru than ducks box ll l must also fill out the section below showing their workers'comPensation Policy Wimination.
t xomeowrras who submit this affidavit indicating they are doing all work nut that hire outside contractors must submit a new affidavit indicating such.
TCConttadors the check this box must attached an additiooai street showing the name ofthe sub-contractors and state wherflier or not those entities have
eanpkroc s. N the sub-contacDors have employees,they most provide their workers'camp,policy number_
Ion an ennph9w thud is providing workers'connpensadon hitsa entce for my mployeaL Biu+'ds the pry►amdf,fob Me
innfornsadonn. - /i
Insurance Company Name [.�I.tJZ ,44 X71._�( S G ( rtNWWl�A�____�
Policy#or Self-ins.Lam_#:_ t WA)iV Iv, f►-1 Expiration Date: - " 2b 1 (p
Job Site Address: 4z t—<-Pk�h s d1 (--Lk� ( L
-� CitYlState!ZiP~��1�_,�_T���� ..�
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 imprisomnent,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 anhJy under Mepains andpenaltier ofperjruy tt►W the mfornurton provdded above is true anndconte
Date: t S 2 C)
Phone# I---2.)'.-
al
DhIciuse only. Do not write int this area,to he caaarkred by city or town oQ'icrat
City or Town: Permit/License#
Issaing Authority(circle urate):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5,Plumbing Inspector
6.Other
Contact Person: Phone M
i
OWNER AUTHORIZATION F09M
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City of Northampton
Massachusetts
"' xY DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street a Municipal Building }mss lea
Northampton, MA 01060
Property Address: VA',n ��(i(>
Contractor
Name: .9A�j ,.�DIx UEi1�LA f r3!�j S�I� hLwl S
Address: I Z- 1 t).�'
City, State: n M A 0 1 1)
Phone:
Property Owner �
Name: �jF1 ►J re. r\Y-\ 21
Address: 1.f Z C- rA no o Sir e e-
City, State: No D 1 w). `M A L) 1 Dto0
i, (A r a� , nc� (contractor)attest and affirm that the building 1 intend to
insulate doesinot have any open air (knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner ;U copy,of this affidavit..
Contractor signaturetar
'
p.
Date