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17A-136 (5) 237 CHESTNUT ST BP-2016-1047 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 136 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate-,ory: INSULATION BUILDING PERMIT Permit# BP-2016-1047 Project# JS-2016-001777 Est. Cost: $1500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN MICHONSKI 49376 Lot Size(sq. ft.): 23478.84 Owner: ROSTEN JULIE Zoning: URA(100) Applicant. JOHN MICHONSKI AT. 237 CHESTNUT ST Applicant Address: Phone: Insurance: 66 CONWAY ST (413) 834-7725 WC SHELBURNE FALLSMA01370ISSUED ON.•3/1/2016 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 3/1/2016 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2016-1047 APPLICANT/CONTACT PERSON JOHN MICHONSKI ADDRESS/PHONE 66 CONWAY ST SHELBURNE FALLS01370(413) 834-7725 PROPERTY LOCATION 237 CHESTNUT ST MAP 17A PARCEL 136 001 ZONE URA(100) THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCL SED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid BUildinp,, Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC/KNEEWALL INSULATION New Construction Non Structural interior renovations Addition to Existin Accessory Structure Building Plans Included: Owner/Statement or License 49376 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF aIQATION 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 DemQliitiQn D10ay Signatu u g fficial 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" . CER! City of Northampton Status of Permit Building Department Curb GutlDrtveway Permit 212 Main Street Sewer%Septic`AvailablGty 'z { FEB6 �u ei i Room 100 WaterlWl A Yailabilityf - x Northampton, MA 01060 Two Sets of Structural Plans , OF BUILDING INSPECTIAR one 413-587-1240 Fax 413-587-1272 Plot/Sife l?lans.� `?t ' NpRTHMAPT N MA 01060 $a3 < ' •., 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/AUTHORIZEDAGENT 2.1 Owner of Record: J 01," �o��w.. _a3 c, , �-h, 1+ .5 0 be-wt cto- Name(Print) Current Mailing Address: Yi 2 - S7 16617 Telephone 11019'Eature 2.2 Authorized Agent: rLI Name(Pri Current Mailing Addressj- yi3 779�cr Signature Telephone SECTION 3.w.ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit 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=(1 +2+3+4+5) -IS-60. Check Number - This Section For Official Use only Building Permit Number. Date Issued: Signature: Building Commissionedinspector of Buildings Date SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition F� Replacement Windows Alteratlon(s) ® Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [Q Siding[p] Other[[A Brief Description of Proposed .,r se-+1%'_ 'n Work: �'..G �1�� yg4ie- 444C II"lh&e - C'Q.�aP (Q 1�-..rL ..yelLl�ur insu�q��Cti Alteration of existing bedroom Yes No Adding new bedroom Yes No 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 X I, J u1 ��`t� as Owner of the subject property hereby authorize � �� to act on my behalf, in all matters relative to Work-authorized by this building permit applicatio . L-... o?- /b- �ol� Signature bl Owner Date I, bjnr� ic�t n,..t�C as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my know edge and belief. Signed under the,� ( pains and penalties of perjury. P Name 5 nature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: Cl y 3 76 License Number - ,1, 6 C t7v� 3 R� �� I G)376 n 0/6 IAdress Expiration Date '-/ 3- 3 5 ignature Telephone 9. Reaistered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number John's Home Repair Service Address 66 Conway St Expiration Date - Shelburne Falls,MA Np70 rione Yl3 -Sr3 y-�7as 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....... L!1— 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 homg 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 buildine 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 City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: .3 7 C; ,Y-(- S4- The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant _bx.,., k,c C%c-� � �L R -/6 ate Signature of Permit Applicant 4�-1 3 0 Y John's Horne Repair Service John Michonskl 66 Conway SL Shelbume Falls,MA 01370 Pie Comwnwealth of.41assachuseas Departnwnt of IndustrWAccidma Offwz ofInvaoigadons 600 Washing-ton Street Boston,,,Vass. 0-1111 w-ww.mamgov1zUa Workers' Compensation Insurance Affidavit: Bu-Hders/ContractorslElectricians/Plumbers Applicant Information Please Print LegcdplK -Name JOHN'S HOME REPAIR SERVICE Address: 66 Conway Street city/statelzip: Shelburne'Falls Ma. 01370 Phone#: 413-834-7725 Are you an employer?Check the appropriate box: i T),W of project(required)- 1,(Sil am an employer With 0 1 am a general C*=zctor and-1 6.oNew Construction employees(;'uU an&or part time).* have hired the sub-contt=-tors 1 7.rl ReModeting 2.01 am a sole proprietor or partner- Listed on the atwhed sheet ship and have no employees T1 hese sub-contzztors have 8.M Dmolition workhg for me-in any capae�• emplc °ees and hxve workers' 9.0 Bixilding addition r-No-woe-kers,comp.insurance COMM.iD-�� reg?i* 5.0we a':e a omponnition and its 10.rl Electrical repairs or additions 3. 1 am a homeo�mer doing all work officers have exercised their H.0 PlmnbiT�g repairs or add ons nryselff I-No workers'comp rpt of exemption permNIOL 14' and we have no 2.ri R-oorepairs ---nployees.[no workeW Mother Weatherizatiori comp.iasLzrancee required.I *Any applicant dw checks box 41r, 11 aw in oat&e section beiow sbuwft aeir workere c p satioa poricy wsort�sation. *Hot nem**o sabatit this affid"it indicating the=am doing*2 wark and thm bim outside coutzactors roast sabn?h a sew affdavit m4katft sock;. *Contactors that deck this box mug aftweb an gdditlouW sheet showft tke—we of&a sab-contractors and AM weer or not tbaft entities have etuployees. if Me- have empkw-w%they most provide tbw workers,atow wlicy zmmber. I am an mrL*er that Is prowift workvs'conpensadon h=rww--jbr im, enVioyam Below is Me po&-y and jots site lmumce Compairy Name:Guard Insurance Group (Norguard Ins. Co.) Folia?=0 or SeLf-ins.Lic. JOWC C,c'1 -7 Expiration Dater. .5-4'*- ol 0 1(a Job Site?Address: 3 7 (-)Lzs�-4 -S+ Cry 5 Ztp. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration(date). Failure t o se cuxe coverage as reqtiiseci tm df�-; Sermon 25a o f MC-L 152 can le ad-to the Lznpositi on of crim inn Ll Wires of a fine up to 51,500.00 ane-ior one year ftnprisonment as well as civ-H]penalties in the form of a STOP WORK ORDER and a fine of $250.00 a day againsti,violator.Be advised tbr, a copy of this sem-menT maybe forwarded to iffie Office of Investigations of the DIA for cov!me ve ification. I do herby cert z thepaths )�-under and pence of perjury that the tnformadon provided above is true and correct Signwure G-Y t,-C-hpl A ,.,,,_,�John MichonskiPhow=. 41 3-8:�-7725 Offxialuse onh- Do not write in this area to he completed byy c4 or town oyf7cial pity-or Town: Perinitilicense Issuing Authority(circle one): 1i I.Board of Beath 2. Building Department 3.Ctty,/Town Clerk 4.Electritid Inspector S Plumbing Inspector 6.Other I Contact person: Phone fi A CERTIFICATE OF LIABILITY INSURANCE 06/512015°""''�' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the Policy(les)must be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Paychex Insurance Agency Inc PAYCHEX INSURANCE AGENCY,INC. PH E: F 150 SAWGRASS DRIVE • 877-266-6850 585-389-7426 ROCHESTER,NY 14620 E- Ao%k Certs@paychex.com INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: NorGUARD Insurance Company 31470 JOHN MICHONSKI INSURER B: 64 CONWAY ST SHELBURNE FALLS,MA 01370 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDLXBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR NSR MRD MM/D GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED $ CLAIMS-MAD PCCUR I MED EXP(Any one person) $ PERSONAL&ADV INJURY S EML R GENERAL AGGREGATE $ AGGREGATE LIMIT APPLIES PER, POLICY 17PROJECT=LCC PRODUCTS-COMPIOP AGG $ S AUTOMOBILE LIABILITY COMBINED SINGLE uMrr j ANY AUTO (Ea aocklent) S ALL D OS �oOsS (PerDULED perILY on')URY $ HIRED AUTOS AAL%10 IED BODILY INJURY S --, (Per accident) (-- PROPERTY DAMAGE $ (Per accident) $ UMBRELLA UAS (_J OCCUR EACH OCCURRENCE $ EXCESS uAe C CIAU&MADE AGGREGATE s DED j RETENTIONS ; $ WOMCERS COMPENSATION AND X V{C STATU• OTH- EMPLOYERS•LIABILRY JOWC669917 05/28/2015 05/28/2016 E.L.EACH ACCIDENT $ 500,000.00 ANY PROPRIETOR/PARTNER(EXECUTNE � OFFKERMEMSER EXCLUDED? fyj E.L.DISEASE•EA EMPLOYEE $ 500,000.00 (Menwmn In w , Y_� N/A E.L.DISEASE-POLICY LIMIT $ 500,000.00 H yes.desa be uWw i � I I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional RwMM Schedule,H mora space Is required) CERTIFICATE HOLDER CANCELLATION JOHN MICHONSKI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION JOHN'S HOME REPAIR DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY 64 CONWAY ST PROVISIONS,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR SHELBURNE FALLS,MA 01370 LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2010105) 01988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD JOHN MICHONSKI JOHN'S HOME REPAIR SERVICE 66 CONWAY STREET SHELBURNE FALL, MA. 01370 413-834-7725 For your records my license information. Massachusetts - Department of Public Safety Board of Building Regulations and Standards License: CS494376 JOHN P MICHONS)a 66 CONWAY ST-f IT SHELBURNE Er Expiration Cornmission(tr 06/11/2016 -�C—\ Office of Consumer Atrairs&Busifiess Regulation ME IMPROVEMENT CONTRACTOR egistration: 142709 Type: 4 xpiration: 5/1/2016 DBA JOHN HOME REPAIR JOHN MICHONSKI 66 CONWAY STREET SHELBOURNE FALLS,MA 01370 Undersecretary Jong.,140ME REPAIR SERVICE General Contractor Weotherization Specialist Infr(?,red Technology 66 Conway Street Shelburne Foils,Mo.01370 Cell 413.834-7725 Fo-413-625-2824 CS At 94376 HIC#142749