29-151 (3) 107 SPRUCE HILL AVE BP-2016-1198
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 151 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-2016-1198
Project# JS-2016-002060
Est. Cost: $5900.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOHN MICHONSKI 49376
Lot Size(sq. ft.): 66646.80 Owner: FUNGAROLI DONNA M
Zoning: Applicant: JOHN MICHONSKI
AT. 107 SPRUCE HILL AVE
Applicant Address: Phone: Insurance:
66 CONWAY ST (413) 834-7725 WC
SHELBURNE FALLSMA01370ISSUED ON.•4/13/2016 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 Occupancy Signature:
FeeType• Date Paid: Amount:
Building 4/13/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2016-1198
APPLICANT/CONTACT PERSON JOHN MICHONSKI
ADDRESS/PHONE 66 CONWAY ST SHELBURNE FALLS01370(413)834-7725
PROPERTY LOCATION 107 SPRUCE HILL AVE
MAP 29 PARCEL 151 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyneof Construction:_INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 49376
3 sets of Plans/Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
De itio D y
Signa of Building 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
City of Northampton Status of Permit
APR 13 2016
Building Department Curb Cut/Dnveway Permit
I L t Ht
212 Main Street Sewe�lSepUc:Avatlability
Room 100 mterNMI Availabillty�
DEFT.Gr E J =GnoriS
rac�.raa.wsir�+.rvaaoioso N rthampton, MA 01060 Two Sets of Structural Plarts f
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans ,` 3 . r.� _l,r
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
10"7 W-4,e'. Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2,-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record-
Z')or �t
Name Print + Current Mailing Address:
y r,_
/
h/t co 0 (21-10-- Telephone
Signature
2.2 Authorized Agent: tt
_ S �tNowsk.� C - v►
Name(Print} Current Mailing Addr .
3
` Yi -Ta v-MT a,
i ature Telephone
SECTION 3z= STIMATED CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed b 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) lyc/c 1. 00 1 Check Number
Me 6-
This Section For Official Use Only
Date
Building Permit Number: issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
yr a4 (�i ��'of 0 rt�tt TTt I tI71T
{� t 44ttssar4usrtts
DEPARTMENT OF BUILDING. INSPECTIONS
212 Main Street a Municipal Building
Northampton, MA 01060
LOUIS HASBROOUCK BUILDING PERMIT FEES Phone: (413)587-1240
BUILDING COMMISSIONER Effective July 21,2008 Fax: (413)587-1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING—Residential
$200.00 PRINCIPAL BUILDING-Commercial
*NEW CONSTRUCTION $ .50 per square foot for 15�floor
.30 a u u u 2nd floor
.20 " '/2 floors,attic,basement,garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of$55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty(120)square feet and over
$ .20 per square foot with a minimum fee of$25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty(120)square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in-ground
*SIGNS&AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING&ROOFING
Residential $35.00 per structure
Commercial $55.00 min.per structure OR$6/K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMiT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1(1)INSPECTION WILL BE A MINIMUM OF$25.00;ALL OTHERS WILL
HAVE A$50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED,WITH THE COMPLETED PERMIT APPLICATION,TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH -CHECKS OR MONEY ORDERS ONLY !!
`Filing deadline is 12:00 pm(noon)on Wednesday.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Q Siding[p] Other bilit
Brief Desc�_iPption of Proposed
Work: %Mike 1c.a]Jo1est_ 6A %$ice la*Ag wuw4-
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.
1. 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, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized_
Agent hereby declare 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.
Print Name '�/�
/i! —
g ture of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: r John's Home Repair Service 9 4 376 76
66 Conway St. License Number
Shelbume Falls, AAL C i 370 6 - _o1p 1b
Address Expiration Date
[0 Y13- 73 - �2a.s
Agrni-afur-e Telephone
9.Realstered Home Improvement Contractor: Not Applicable ❑
Company Name John s Home Kepall serAce Registration Number
John Michonski
<S-r- aolb
Address -i Shelburne Falls,MA f.,1370 Expiration Date
Telephone y/3-8'3Y-7? T
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....... P,, 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
The Cr nwwnweafth of Massachusetts
Departnwnt of Industrial Accidents
0iiceOfInvesd9ations
600 Washington Street
Boston.Mass. 02111
ivww.mas&gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetziciansj?lumbers
App]llcant Information Please Print Ltgibly
HOME REPAIR SERVICE
Address- 66 Cbnway Street
0-ty/StateMp: Shelbume Falls Ma. 01370 Phone#: 413-834-7725
i
Are you an employer?Check the appropriate box: Type of project(required):
1,(j)I=an employer-with 4.0-1—a general coa.-actor and 1 6-UNTm f,-onstruction
employees(J`hU and/or part dine) have hired the s7dbcontractors
empi 7
rl Remodeling
10 I,:arn a sole proprietor or parer- Listed on the attached sh----
Thesesqg>-con�— rs ha-ve
oliti
ship and have no employees ODem on
working for me-in any capaci-ty. employees and have workers'
9.ri Building addition
[,-No worKm,comp.insurance comp.MSc.requhred] 5.0we a're,a comomdon and.it, 10.M Electrical repairs or additions
13.0 T am a homeowmer doing all work affic--rs have t-mercised iheir
11-0 Plumbing repaLrs or additions
Myielf J-No woflc=s,comp ri of exemption permINIOL
i�4.U foo?repairs
invuran,ce required] c. 151 �'41 and we have no
emPl1:N;,m-Ino workerse 13 M OfnerWeatherization
.
comp.ins= =ice requal-ex-li
-AAY applicant that docks bol#1029 915D BE OW*e section below show*#At-worteW Wmpftsada PO&Y W*nUatiOn.
Homeowners who s8bM*Ods a0ftft bbS=ftg tb---am doing*I work asd tires bhv osWide counadors mug submit a new aRW:n*hsdkatbag sacL
*C*aUctors that cbeck this box mot attach an 2"tional shed showbS Se name of the sub-c*s#rad ors and state wheaw or not those eatWm bsve employees. if
ft&-nb.cQaxrat�ars haft empkyeesthw must ymyldethewworkmW mwtber
.1 am¢n envicTer that is proves workers,conpenmffonhnu?wzc--I
j or mp anpMyee&Aekw is&epo&-y andjob sage
informz1am rd Ins. Co.)
Guard Insurance Group (Nor qua.
Insurance Company\alne: (�
Poli,Y:4 or S-elf-ins,Lie.'"JOWC Exp on Date: al"i
job Site Address- lo'? W%4 A,-jo— yy%, . a
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration(date).
Failure to secuxee coverage as rewired trader Section 25a of MIGL 152 can lead to date imposition of criminal panalies of a fine
up to$1,500.00 andior one year imprisonment-as well as ci-vU malties in the form of a STOP'WORK ORDER and a'flne of
$250.00 a day agaLrist violator.Be a&ised that-a cop-,,-of this;s-tatement maybe fmzwwded to the Office of In-vestimtions ofthle
DIA for covE2Le ve-m6celion.
I do herby certz)$under the pains and pence ofpey*ry MX the information provided above is true and correct
Signavure: -0. U,- Date. -1- 7. a 01-t.
Print; , .John Michonski 411 3-334-77253-334-7725
Official use onty Do not write in this area to be completed by, c4 or town ofi7cial
City or ToNva: PermMicense
Issuing Authority(circle one):
1.Board of Heath 2. Building Department 3.City./Town Clerk 4,ElectriW Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone i
City of Northampton
Massachusetts
4 DEPAR22WNT OF SUXLDZNG ZNSPECTIQNS
212 Main street • Municipal Building
Northampton, MA 01060
Property Address: 15 7 Zt&hrz tgo E4 i Fav-P
Contractor
Name: john's Horne Repair:se c:
y johrt Michonski
Address: 66 Conway Si.
City, State:
Phone: (A 13- IKSY --276ts
Property Owner
Address: 10? SMy W- 4'11 1-4'r-
City,
-4'City, State: 3 ��, w,.�►. nl o b a
1, L ' )Yll c.�n�+tiaK; _ (contractor) attest and affirm that the building I intend to
i ulate does not have any open air (knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature
Date
7.62016
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: iti? 6ervice %4;►<
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
7�a ol-
Date Signature of Permit Applicant