35-217 (8) 18 LADYSLIPPER LN BP-2017-0419
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:35-217 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-2017-0419
Project# JS-2017-000693
Est.Cost: $1700.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouo: JASM ENTERPRISES LLC 108517
Lot size(sq.ft.): 43560.00 Owner: SWARTZ GREGG
Zonin : Applicant: JASM ENTERPRISES LLC
AT: 18 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
P O BOX 1276 (413) 427-5481 Liability
C H I C O P E E MA01201 ISSUED ON:9/28/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:ATTIC BLOWN IN CELLULOSE 1300 SQ FT
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:
FeeTync: Date Paid: Amount:
Building 9/28/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File e BP-2017-0419
APPLICANT/CONTACT PERSON JASM ENTERPRISES LLC
ADDRESS/PHONE P O BOX 1276 CHICOPEE (413)427-5481
PROPERTY LOCATION 18 LADYSLIPPER LN
MAP-d,5 PARCEL 217 001 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
T eo ,Ggnstruction: ATTIC BLOWN IN CELLULOSE 1304 SOFT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 108517
3 sets of Plans!Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFOIgMATION 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
L
De'-
' i► � 7
Signa- Buildin-, 0 (Zia Date
Note: Issuance of a ZoninF
g 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 MOL 40A. Contact Office of
Planning&Development for more information.
• R
f3epartmentusenNy
City of Northampton Stan of pemy-_14 ' ,.. --_ - -' -
Building Department Curb Cuupnv way Permit _
Ose_ t 212 Main Street iAr"—:Septta Avatlabdlty
aw
+'� o l 1 Room 100 Glfa(erM'ait(ivadabIhty
Northampton, MA 01060 Two-Sets of Structural Plans
D tcv t, I phone 413-587-1240 Fax 413-587-1272 Piot/Sae Plans
L, 1 ' ji- Other Specify
C APPLLCATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
t--rEtT701 SITE INFORMATION
1.1 Property Address- /0
p This section to be completed by office
/0 �aaysfip �� i� Map Lot Unit
rio rt/)Ct / inn 0/0p2 Zone Overlay District
x/735
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIPtAUTHORIZED AGENT
2.1 Owner of Record:
( Adi .S 12-- ,Sa/n�
Name(Print) 64 Current Maiifng Address:
/�
9/7 S64' 394.6"
Set?. A- - NI( ,$(!r n/-N- Telephone
Signature /.-'rat/`r.a'
2.2 Authorized Agent: /
_ 3,200. a3r ze/3AahJ 22/e GGnnec+rcu4- sv, s cid nine/log
Name(Pratt) Current Meiling Address,
2 _ti/3 25'o y �/�
Signature Telephone
SECTION 3-ESTIMATEDSTCONSTRUQTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /�j1„�p„r. / 7/1,'J (a)Building Permit Fee
2. Electrical I
Cil._) (b)Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) /�/��
5. Fire Protection $ y'//
6. Total=(1 +2+3+4+5) /7-60 a c Check Number 3e 7 V
This Section For Official Use Only
Building Permit Number Date
Issued'
Signature:
Building Commissioner/Inspector of Buildings Date
Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column:n be filled in by
Sinking Depanmeni
Lot Size _ _..._______ i__. _ ___ I ____ ____
Frontage I- — __ _ _
Setbacks Front ' - - ...._
Side L RI _ L:I RI
—_:
Rear -_, ._.
. ..
Building Height I_
Bldg.Square Footage — o p --I - -__—_
Open Space Footage % _._
(Lot mea minus bldg&Paved —_ _._.__
.ail
_ 1 I —1 —
#of Parking Spaces 'L_____.i
Fill: -�
(volume&Location) —
A. Has a Spe at Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES d
IF YES, date issued::
i
IF YES: W s e permit recorded at the Registry of Deeds?
NO DONT KNOW O YES 0
IF YES: enter Book ; Page; and/or Document#(
B, Does the site contain a brook, body of water or wetlands? NO DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Con ervation Commission?
Needs to be obtained Obtained Date Issued: ,, ,
C. Do any signs exist on the property? YES 0 NO 157
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO it
IF YES, describe size, type and location; 1
E. Will the construction activity disturb (clearing, gradin xcavation, or filling)over 1 acre oris it part of a common plan
that will disturb over 1 acre? YES C> NO
IF YES,then a Northampton Storm Waier Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing
Or Doors O
Accessory Bldg. n Demolition n New Signs (ENDecks ID Siding ED) Othe ". Tit>r+tt" ON
Brief Description of Proposed,"r Fj t tl c o inn, h tom 11 a u Itit /OS3OCs . 97'
Work: T/
Alteration of existing bedroom Yes X No Adding new bedroom_ _Yes X No
Attached Narrative Renovating unfinished basement Yes X 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. !s there a garage attached? ,,,,_
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
1. 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
i C/ (�Y7{ li -' }C,aor/Z ,as Owner of the subject
properly R,.
hereby authorize Sear s/cU _
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner / Date
I Sa4 T3ccxr /o ,as Own /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best o edge
and belief.
Signed under the pains and penalties of perju &Qh 8ra 1SL
Print Name x.4`
2<3 Sc/ 26
Signature o •caner.•gent Date
SECTION 8•CONSTRUCTION SERVICES
$1-Licensed Construction Supervisor -nn_ —• /—/'/� —. {— —, 1_ ._ _ .__. Not Applicable O_ _
Name of UcenSe Holder _- „ Sech 6radjhaW es-fogs/7
License Number
2WWCv cony chcu4 /tue-, c91 mB01169 1z. —/Cs -Ieye
Address Expiration Date
v13 Z56 5' t/
Sign Telephone
!Cm;:PO
S. Registered Home Improvement Contractor. Not Applicable 0
SASm en /erpreces CLC /(2(,, 0 ?4
Company Name Registration Number
P4 Sox /Z7 6/e en inn o/o2r ti- 27- -24/ &
Address Expiration Date
Telephone `W3 2SD 4
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 buil '-g permit.
Sipped Affidavit Attached Yes
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) 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, duringand upon
completion of the work for which this permit is issued.
Also he 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 personis)
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: 18 1aCrys/r orcr �h
The debris will be transported by: _ 0Sfl Dumpsfc(
The debris will be received by: (Lb Oc,ny95)zr
Building permit number:
Name of Permit Applicant Scan /3v- / aJ
28 SzpfZG/G
Date Sig . ure .:teta'.plicant
• Permit Authorization
1fl I
S SAVE Form
s a.w.0 w.nad..r
"n.
Site ID: $00050216349 Customer GREGG SCHWARTZ
•
GREGG SCHWARTZ ,owner of the property located at:
Raan4 name pia tee
18 Ladyslipper In - FLORENCE
property Senn Address) Icxrl
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain building per t to perform insulation and/or weatherizatlon
work on my property.
Chwier's • Al lA.
• Date: IMF
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
--51(45m 5cs LLC
Participating Contractor Date
MELI
-Eat.
for Mk*usaoah
Lmunatba Sbios Gen4R • 50WnM. n Sven.Suite 30O • WdQotei *LM e1585 ♦ 2800-4 80-7471
-
Rev.062015 •
The Commonwealth of Massachusetts
Department of Indttstrial Accidents
t—_ : bf}ice ojlnJestigatians
I 1 Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gow/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization:ndividual):
Address:
1
City/State/Zip: _
Are you an employer?Check the appropriate box: / t):
I.❑ I am a employer with 4. Q I am a get / ,.r, f
employees(full and/or part-time).* have fired OlY
2.ill am a sole proprietor or partner- fisted on a //d
ship and have no employees These sub-
working for me in any capacity. employees
[No workers' comp.insurance comp.t sur
required.] 5. fl We are a cot 'ditions
3.0 l am a homeowner doing all work officers have ditions
myself. [No workers' compright of exert
insurance required.)t c. 152, §1(4),
employees. [# .—
comp.insuran
*Any applicant that checks box ill must also fill out the section below showing Pith .o on policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then/lire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of die sub-contractors and state whether or not those entities have
employees. if the subemu-x:4pr have employees,they must provide thew workers'comp_policy number.
7 am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: 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
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under the pains and penalties of perjury that the information provided above fc true and correct.
Signature: Date:
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 Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: