36-186 (6) 878 HURTS PIT RD BP-2017-0425
GIS 8: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 186 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-2017-0425
Project# JS-2017-000704
Est,Cost: $1500.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Coast.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq.ft.): 31232.52 Owner: OHOTNICKY JULIANNE D&JOHN R
Zoninv: Applicant: JAY BOLAND
AT: 878 BURTS PIT RD
Applicant Address: Phone: Insurance:
12 PISGAH RD (4131214-2414 Liability
H U NTINGTON MA01050 ISSUED ON:9129/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:8" ATTIC FLOOR CELLULOSE, AIR SEALING,
INSULATE HATCH &VENT BATH FAN TO ROOF FLAPPER
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.V.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame
Gas: Fire Department FireplaceiChimney:
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 9/29/2016 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0425
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)214-2414
PROPERTY LOCATION 878 HURTS PIT RD
MAP 36 PARCEL 186 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED O
Fee Paid j/ 7
Building Permit Filled out u
Fee Paid
Tvpeof Construction: 8"ATTIC FLOOR CELLULOSE AIR SEALING,INSULATE HATCH&VENT BATH
FAN TO ROOF FLAPPER
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
Demiry 9 /J
Signatu e of Buildmg Official 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:
+'� '' :vb Building Department Curb Cut/Driveway Permit
!� ✓ �(b�' ,,Q, 212 Main Street Sewer/Septic Availability
_<Q `5:2 Room 100 Water/Well Availability
�j✓ �: 'ic-
es Northampton, MA 01060 Two Sets of Structural Plans
0i , phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
la Other Specify
PLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Atldress:/ n D - This section to be completed by office
911CI hart-S rt+ WMap Lot Unit
1 O I Kms' I LQ 1� A P6(11-
/ L O /_ Zone Overlay District
U Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: (y�(/ //� D \1 rv1�
J U 1 -- r,(\9 l na�--n 1Lk1 D I D �J6 <, _pt� PA More alit
Name(Print) Current ai' AAA Adddrreess e /�
lis i JI' Telephone -- D y c - �� 3{V
Signature
23�tuthorized ent:
J � (3o A id- 9i3 -h ,P2 }{u lfin on, incl- OK°
Name,(P nt) Current Mailing Ad ss:ii
r J
413-(i .7- 3i36
Signal ......• 44114et Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 11 -0
l-/(� !�V 0 (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 l p�7y9/
6. Total=(1 +2+3+4+5) (5U(,1 • (_)(] Check Number , &c5—
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Permit Authorization .,"� t
,,,;
mass save Form ao
CONTRACTOR
Site ID: 500050218041 Customer: JULIANNE OHOTNICKY
I, JULIANNE OHOTNICKV ,owner of the property located at:
(Owner's Name,printed)
878 Burts Pit Rd 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.
Owner's Signature: `o i U tL,{3i-(ti(,C
Date: ':... q j l I kr
FOR CSG OFFICE USE ONLY
Conservation Services Group has assigned the following Mass Save Home Energy Services Participating
Contractor to the above referenced project:
•
Participating Contractor Date
Mcal
For Office Use Drily
Conservation Services Group • 50 Washington Street,Suite 3000 • Westborough,MA 01581 • I00-480.7412
Rev.062015
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)ja Roofing Q
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs I[0] Decks [p Siding[0] Other(p]
Brief D-s npti•no Proposed / c T r wO( CtiIW Os-( 40 r S-tR(h • I nS.AJa e
Work: _ J _ ,. — V I. • _ et - • t► • a n ill- • '�i
Alteration of existing bedroom Yes �c.N //��o Adding new bedroom Yes 7.,No
Attached Narrative / Renovating unfinished basement Yes nfyo
Plans Attached Roll -Sheet —7—
6a.If New house and or additioyclexisting 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
C1R r1 D+ n ) c__ -1
I• \ 1f1.� .as Owner of the subject
property ( (nom 1/ '�,
hereby authorize -( y-�3`��f
to act on my behalf,in all matte relative to work authorized by this building permit application.
Signature of Owner Date , I
I iflt1 ` / IA ' �—„ ,as Owner/Authorized
Agent ereby dBBBBdare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
elief.
Sign under the pains and pees of perjury.
n \ bol uessa fat 04/41411 /
il
Sign of er/
Print Nall Agent Date --/ni
/ It
-?L, -7/)(
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/diever been issued for/on the site?
NO 0 DONT KNOW 9 YES 0
IF YES, date issued: T
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW C1 YES O
IF YES: enter Book `� Page and/or Documenten #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW t7/ YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO 1CJ
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 (a
IF YES, describe size, type and location: •r
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO p)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTIONS-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Appllii�clab+le{'�0
Name of Urntpe Heider'. ���a Alb ; I 1 V { b d 0
>.
License Num er
, -p 1 r, d... -h al 4k 11 • �aS a 1
A •na ss _SPILI _f' ! Expiration Date
ft Telephone
yl3-60 -313a
:.r iuur Tor_ -r:u.amuT • tsl r t--. Not Applicable 0
II e "efiI , b MJI� n5 _ I(,fyCeQ3
Company me J / Registrati n Numbe
Lid A. �� 1QS� � � � (1 1
l+1f o
Redress ) M 147 -C-T3
j /�D Expiration Date
Te ep one I
SECTION 18-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 Nit No ❑
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;.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 faun
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 he 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: 2v) ? aV r-Kl ea
roe -nat-iget
The debris will be transported by: irrm'
The debris will be received by: % ULY, td /r QiQ tyle
Building permit number: 0
Name of Permit Applicant •--40 Dane. third- 414/
dieci
Date Signature of Permit Applicant
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RCS PLANVIEW DIAGRAM [�
Customer Q tj<�-n;t/Ya )) Home Phony: ( 1 ). R o7p{
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Address: g..78 Pians fa- Rs! Work Phone: t
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Town: Pr ore trete Cell Phone: ( r
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Bushes Ladder Neighbor Proximfy Pocket Doors insert Radiators Fence(S)
Eating Conditions X=Access 0a Vents Note Inside Square R=ROOF S=Soffit G=Gable
RV=Ridge Vent CS=Continuous Soffit CDE=Continuous Drip Edge T=Triangle
Install O=New Access Note In Circle C=Ceiling w=Wall S=Sheathing Temp Unless Noted Otherwise
A.Vents Note in Mangle P=URoof S=Soffit G=
Gable M c R'Mvshropur For Access
2200-10-in5
ftp ve CERTIFICATE OF LIABILITY INSURANCE W2(" TTY"
12/4/2015
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 POUGMES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: I the certificate holder is an ADDITIONAL INSURED,the policy(es)must be endorsed, If SUBROGATION IS WANED,subject to
Bre terms and conditions of the posey,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in Neu of such endorsement(s).
PROWLER COMAti Barbara Van Hourik
NNIS: I
Finck 6 Mertes Insurance Agency Inc. jeicafrFm: (413)527-5520 tie+c NA;µ11352a-6470
6 Campus Lane 640 e"e;byanmourik9Einckandperras.can
RWJREFga)AFFORDING COVERAGE _._._.-_.. MAIC/
Easthampton MA 01027 MEURERAMain Street America Assr Co _ 29999
=._.. .._. .._
INSURED wsmsJl BOOM insurance Company 14788708
Jay Boland dba INSURER c PorGUARD Insurance Company 31470
Borne Energy Solutions INSURER o;
12 Pisgah Road INSURER E:
Runtington lilt 01050-9769 INSURER F: .—..—._
'.OVERAGES CERTIFICATE NUMBER:CL15113001946 REVISION NUMBER:
THIS IS TO CERTIFY THAI THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED MOVE 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 IttHAIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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4 CLAIMS MflE I R]OCCUR S ISPs 1 $
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ART7922T 11/1/2015 11/1/2016 MD PSP(Any ono Ray,) $ 10,000
PERSLNAL&ABU INJURY S 1,000,000
LOU AGGRE�GATAT7E WR APPLIES REE I GENERAL.AGGREGATE $ 2,000,000
'C HBI( j LOC ( PRODUCTS-COMROP AO $ 2,000,000
OMR EAU 5 10,000
AUTOMOINLE DULA ICY CONIINE/SINGLE DMR s 1,000,000
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ANY AUTO lne0457R 1/4/2016 1/4/2017 BODILY WURY(Pap) S
AALLOOSWNEED x SCREDULE0 141a0457R 1/4/2014 1/4/2016 BODILY IMAM CIAr».b%aj S
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EILCEST1 IRS LM{A� CLAIMS-MADE AGGRrGAi2 5 1,000 000
0E0 EIEMIONS CUT79251 11/1/2015 11/1/2016 S
WORKERS COIPENSAIWN A
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ANY RKWPoETOMPARna3LEXECURVE EL EACH AMBFNY S 500,000
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ON�anadsmry MO) GAK675477 11/1/2016 11/1/2016 EL.04SE u-EA EmpLoyEE 5 500,000
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.TIFICATE HOLDER CANCELLATION
3)561-1272
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANrRI I FO BEFORE
City of Northampton THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
212 Main Street ACCORDANCE WITH THE POLICY PROVtSiONS.
Northampton, MA 01060
AU NESENTATNE
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@ 195&2014 ACORD CORPORATION. All rights reserved.
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