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24A-188 (3) 41 JACKSON ST BP-2017-0542 GIS#: COMMONWEALTH OF MASSACHUSETTS Mao:Block:24A . 188 CITY OF NORTHAMPTON tot:-00 i PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit 4 BP-2017-0542 Project# JS-2017-000879 Est, Cost: $1522.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Grotto: JASM ENTERPRISES LLC 108517 Lot Size(sq. ft.): 10802.88 Owner: BELUR BELAJI Zoning:URB(999ZJ Applicant: JASM ENTERPRISES LLC AT: 41 JACKSON ST Applicant Address: Phone: Insurance: P 0 BOX 1276 (413) 427-5481 WC CH(COPE EMA01201 ISSUED ON:I0/19/2016 0:00:00 TO PERFORM THE FOLLOWING WORK:ATTIC INSULATION OPEN BLOW CELLULOSE 9" 600 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: FeeTvpe: Date Paid: Amount: Building 10/19/2016 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner Department use only `—L' City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 141 i 9 20t6 212 Main Street SewertSeptic Availability Room 100 WaterIWell Availability DEPT or eua.rNo lNs=rcnoNs orthampton, MA 01060 Two Sels of Structural Plans mM NOYION.WA fq r4 4 3-587.1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION t This section to be completed by office 1.1 property Address: 4', 'Sac R,r'dh sIt , / Map ..,.,T Lot Unit /orf amPfan, /h/1 U/Cee Zone Overlay District Elm St District,,,,,,, CB District ...... SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT L1 Owner of Record: (`fie/ajt & or- 'i/ Jacksol. sf Name(Print) ,/ Current Mailing Address: • Sec /9G, Mdrize form Telephone n- 982 9282 Signature 2.2 Authorized Agent: _ / &on Brac/s/ia J /4'0 66K /276 C/t(copet- /h/7 Name(Print) Current Mag Address: O/02 f 9/i3 2so 4/7Vb Signatures Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building $ 522 °0 J)t'- L2�l O 0 (a)Building Permit Fee 2. Electrical (b)Estimated Total silt of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Are Protection 1 //, r 6. Total=(1 +2+3+4+5) F /5ZZ oe Check Number 30 ?+,;P( U} This Section For Official Use Only DatBuilding Permit Number: Issued: �/ ed: ..- ssuq Signature: AlICS> ...-----n /5 -/! �- / Building Commissioner/Inspector of Buildings Oats Section 4. ZONING alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This mtunm to be filled in by Building Depemuent Lot Size Frontage _ Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage % (Lot arca minus bldg&paved parking) H of Parking Spaces Fill: (volume&Locatioto A. Has 5 tial Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF YES,date issued: IF YES: Was a permit recorded at the Registry of Deeds? NO DONT KNOW O YES O IF YES: enter Book Page " f, and/or Document# B. Does the site contain a brook, body of water or wetlands? NO „�U DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the ConservationYCommission? Needs to be obtained O Obtained ,,DDaate Issued: C. Do any signs exist on the property? YES O NO ,,(1) IF YES, describe size, type and location: �' '4 ,,y/ D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO p(p IF YES, describe size,type and location: ��,�"'���s E. Will the construction activity disturb(clearing,gradin ation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Manage ent Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing n Or Doors Cl Accessory Bldg, ❑ Demolition ❑ New Signs [pl Decks (Cl Siding[❑i Other ' Brief Description of Proposed /� H T / (r /+� j j � Work: l7 f l /� L/1 sV IC1TtC.7l'� peen blot,...) I(1S L'. rp Alteration of existing bedroom Yes No Adding new bedroom Yes No vLJ cD ` s, El Attached Nanative Renovating unfinished basement Yes _No lL! V Plans Attached Roll -Sheet sa.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 ,as Owner of the subject property hereby authorize e_. 1t,u Ale rice Imo'''-m to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner"` �7 _/ Date I. Sea�J e.gra t 141 ,as Owner uthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of m ge and belief. Signed under the pains and penalties of perjury. -rd t•SraCISACNci Pant Na -_ Sign.. :of aj,^ '9en Oat SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: II� Not Applicable 0 Name of License Holder: SQGA CZ 11Gw CS- /Oa5/7 License Number 2W (OnneCA/CO! Ave SpF/c/ /174 CV/by /2 -it/$ Address - Expiration Date ii/S- 250 - 47Y6 Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ T �a trim Celt ler priszs LLC /(6(9074/ Company Name Registration Number P6 60X12 Chictecz !hA ti Ozz-/z-/-2/-at -2/- Address Expiration Date Telephone Y/'3 361 36 j O 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.il Signed Affidavit Attached Yes `� No 0 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 10 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: y> Sc+c /csan S-{ The debris will be transported by: USA Qu nwsft The debris will be received by: USR IDu 'nosfer Building permit number: / // Name of Permit Applicant £.ean Brat-Shc✓ Date Signature of Permit Applicant RISE60 Shawmut Road,Unit 2 I Canton,MA 02021 1339-502fi33s ENGINEERING' www.RISEengineering.com OWNER AUTHORIZATION FOR ) r © F p s H I. BFLM,j � 6._Zuc au IJ (Owner's Name) owner of the property located at: y� S l�.so,j (Property Address) Nos)-7T r— � AkT Mn d I OC2 • (Property Acddd ) hereby authorize ./.}✓ J I II14 lC'(9f"�IPSC- (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property.This form is only valid with a signed contract. Ther Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's responsibility to dose out this permit by contacting their municipality at the completion of this work. Owners Signature I9-SEP-2016 Date 0.2018 The Commonwealth of Massachusetts 'e=;M,_•1=!t Department of Industrial Accidents l?n_ 1 Congress Street,Suite 100 c'il1= Boston,MA 02114-2017 www.mass.govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant lnformadon Please Print Legibly Name(Business/organiration kdividua0:JASM Enterprises, LLC. Address: P.O. Box 1276 City(State/Zip: Chicopee, MA 01021 Phone#: 413-301-8010 Are yea an employer?Cheek the appropriate boa: Type of project(required): rat l amm a employer with 9 employees(full and/or parttime)` 7. ❑New construction 20 I am a sole proprietor or partnership and have noemployees waking for me in arty capacity.[No workers'comp.imance tryoised7 8. ❑Remodeling CI am a homeowner doing all work myself.(No workers'comp.insurance bei 9. Demolition❑ requ c It 4.0lam a homeowner and will he hiringcontractors to conduct all work on myIU❑Building addition ProPoM1YIwill ensure that ll contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions s❑lama general contractor and I have hired the sub-contractors listed on me attached sheet. 13.0ROM repairs These subcontnctors have employees and have workers'comp.insurance. b.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.['Other insulation 152,31(4),and we have no employees.[No workers comp.Insurance required.] *Any applicant that checks box et must also fill out the section below showing their workers'compensation policy information. *Homeowners who submit this affidavic indicating they ere doing all work and then hire outside contractors must submit a new affidavit indicating Moll 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub.00ntractrs have employees,they must provide their workers comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Liberty Mutual Policy#or Self-ins.Lic.#:: WC2-31S-3727r+ r„)72-0,r1/5 Expiration Date: 5-- 1 - /7 [ Job Site Address: � ✓r/(kSo'y c City/State/Zip: v r7O440 Wit'/ Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152.§25A is a criminal violation punishable by a fine up to$150000 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. _. _.. . . I do hereby certify under the ins an naaies of perjury that the information provided above is Prue and correct. Signature. Date: x�— ca— & O r o Phone to 413301-8010 c Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk a.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i".., JASME-1 OP ID:JT 4C-ORO CERTIFICATE OF LIABILITY INSURANCE OATEIMM 4.----- CERTIFICATE 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 WAIVED,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). 'ROOUCER CONTACT DAME Raymond Lukas lhase Clarke Stewart&Fontana PHONE 413.788,0531 ' FAS bt3214-6t60 01 State Street:P.O Box 9031 4f�xss.rl:_ ,� IAtcsn t -__ ..... $pring0eld,MA 01102 E-MAIL rlukas chasein5.com taymond Lukas AgoRFss _ INSURERFa AFFORDING COVERAGE NAIL Y INSURER A.Northland insurance Companies INSURED JASM Enterprises LLC INSURER B'.Liberty Mutual Assig Rick Jett Bradshaw c A ._ —.......—_ __ P INSURER rbella Protection 41360 O Box 1276 Chicopee,MA 01021 NM,REP 0•Torus Specialty_ INSURERF INSURER P'. r 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 8E 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 SEEN REDUCED BY PAID CLAIMS. jr A.I OLBOLI MOOT Or• POU y EXP LTR TYPE OF INSURANCE IINSD''I MD POLICY NUMBER I IMMIDOFYYY) IM /00MYYYI LIMITS A I X I COMMERCIAL GENERAL amour/ I -EACH OCCURRENCE $ 1000,00*• j CLAIMSMADE I X OCCUR I X ' W5281416 . 0812012016 06/201201] DAMAGE TO'TaENTED "'-"" '.�PRBMats lEa occurrence) S 100,000 _ _ tt®ESP/Anyone Person) S SOON PERSONALS ADV INJURY I S 1,000,000 I CEN'L AGGREGATE LIMIT APPLIES PER 1 , GENERAL AGGREGATE $ 2,100,000 I POLICYdE9f Lac PRODUCTS a 2,000,001' -cnMPlDenor I OTHER S 'AUTOMOBILE UASAHS - COMBINED SUCRE LIMIT .S 1,000,00/ aapsident) -t C I ANY AUTO I 1020008523 1010512015' 10/0512016, BOOST INJURY[Per person) I $ no OwNEP :SCHEDULED AUTOS X AUTOS BODILY INURY(PeepeeoU $S X HIRED AUTOS I I NON OWNED �PROPERTY DAMAGE S -. - - 'AVTOS ,(Per tlept . S X UMBRELLA LIAR OCCUR I EACH OCCURRENCE $ 2,600,000 —. D X EXCESS LIAO cLams-MADe' 76851K162ALI 08120/2016 06/20/2017 AGGREGATE s 2,000,001 I DED I RETENTIONS WORKERS COMPENSATION PCR OYH, I AND EMPLOYERS'LIABILITY 1 ; 6IDi0TE _ ER B ANYFROPRIETORPARTNERIEXECUTbE 1—", WC231S-372772-016 05/02/2016 05!02/2017 _EL EACHACCIUENT $ __ 11000,00" OFFICER/MEMBEREXCLUDFDI ' NIA: - - - (uanealorylnNH) EL.DISEASE-EA EMPLOYEE $ 1,000,001 !If ymdewteunder DESCRIPTIONOF,PERATIONS below ' e E.L DISEASE-POLICY LIMIT S 1,000,00F • • ' I _ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES IACORD 101,Additional Remarks Schedule,may be atiacMd it more space Is required) Action Inc.and National Grid USA its direct and indirect parents subsidiaries and affiliates are listed as Additional Insured in respect to General Liability Jeffrey Bradshaw is excluded under the workmans comp policy CERTIFICATE HOLDER CANCELLATION SHOULD ANY OE THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE NaBox Grld THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Na iona 960 ACCORDANCE WITH THE POLICY PROVISIONS. Northborough,MA 01532 AUTHORIZED REPRESENTATNE Raymond Lukas ©1988.2014 ACORD CORPORATION, All rights reserved. ACORD 25{2614:011 The ACORD name and logo are registered marks of ACORES Unrestricted - Buildings at any use group which contain less than 1 ;0X) cubic feet (t/91m') of enclosed space Cs-108517 SEAN BRADSHAW 246 CONNECTICUT AVENUE Springfield MA 011(9 Failure to possess a current eddum nl iho M.ru.0 hucetta State Building Code is rause tor tonne atm el of Thr. licence_ 12/10/2018 For opt) en,ong viol War. na,“.'. t� q; fir o- Jrmict wea/IX o/0-1 ,,macA✓i.teii Ec�a y k Office of Consumer Affairs and Business Regulation a 10 Park Plaza - Suite 5170 X41 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 166074 Type: LW Expiration: 4/2172018 Tisi 419291 JASM ENTERPRISES LLC JEFFEREY BRADSHAW P.O. BOX 1276 CHICOPEE, MA 01201 Update Address and return card. Mark reason for change. Address Renewal Employment Lost Card SCA I D 2OM@5111 .c� Office of Coocioner Affairs ail !utas:Itegrlau:u License or registration valid for individul use only ITTCTiTiiiHOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: "I Registration 156074 Type: Office of Consumer Affairs and l3 usine s Regulation :,k'Expiration: 412 112 0 41211218 LLC 10 Park Plaza-Suite 5170 Roston,MA 02116 JASM ENTERPRISES LLC JEFFEREY BRAOSHAW C L ')"^C 805 845 NEWBURY ST SPRINGFIELD,MA 01164 Undrrscrretam N i valid without signature