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10-002 (2) 401 KENNEDY RD BP-2017-0969 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 10-002 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-2017-0969 Project JS-2017-001672 Est.Cost: $2000.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sa. ft.): 83199.60 Owner: PALCHES JAKE Zoning: RR(100)/WSP(l00)/ Applicant: JAY BOLAND AT: 401 KENNEDY RD Applicant Address: Phone: Insurance: 12 PISGAH RD (413)203-2454 0 WC HUNTINGTONMA01050 ISSUED ON:2/24/2017 0:00:00 TO PERFORM THE FOLLOWING WORK:INSULATE WOOD SHINGLE WALLS 4" DENSE PACK 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 2124/2017 0:00:00 $65.00 212 Main Street, Phone(413)587-1240, Fax:(413)587-1272 Louis Hasbrouck—Building Commissioner File A BP-2017-0969 APPLICANT/CONTACT PERSON JAY BOLAND ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)203-2454 0 PROPERTY LOCATION 401 KENNEDY RD MAP 10 PARCEL 002 001 ZONE RR(100)/WSP(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building.Permit Filled out Fee Paid Typeof Construction: INSULATE WOOD SHINGLE WALLS 4" DENSE PACK New Construction Non Structural interior renovations / Addition to Existing 46) J 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 INFOR ION 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 `•• olif n D- eo lui•oftcial 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 Building Department Curb Cut/Driveway Permit 2`,j La1 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans 1/ Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING �� SECTION 1 -SITE INFORMATION �O 1.1 Pro a Address: \ y(� This section to be completed by office �D I n2.0tA1 7� Map Lot Unit 1--R-&d 3 , (_ 1(h o1 O J3 Zoon Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: fcbb P2 eek s LI-0I '4,�nefi Ro2c Name/(Pririntt))+�--���ry Current M ing(A ss: /jam' (1°C1 0 /`moo S W it/E-tri 0 Telephone ��N �'L� ^ lX w Signature l.2 ( 1 2.2 A rized Agent: 1(10 Name)Print, al of / . Cmit li Address. EN v n p, 0tog-3 Signatu Telephone 1-fj 3- 205^ a4-SL( SECTI�-ES 'lt ED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 9-0(r ,aD (a)Building Permit Fee l 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection c� �j 6. Total=(1 +2+3+4+5) D-O OD - VV . Check Number X0/7 o,6 This Section For Official Use Only Building Permit Number: Date Issued: Signature:Signature: Building Commissioner/Inspector of Buildings Date Section 4. ZONING AR 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 r been issued for/on the site? NO ® DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Regi of Deeds? NO O DONT KNOW YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW OYES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained ® , Date Issued: C. Do any signs exist on the property? YES O NO V 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,ex ation,or filling)over 1 acre oris it part of a common plan that will disturb over 1 acre? YES ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. • • IsiiiiPermit Authorization �'°�i0 mass save Form Site ID: 50197853 Customer: Jakob Patches I, Jakob Patches ,owner of the property located at: (Owners name,printed) 401 Kennedy Rd Leeds (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 y on property. is�yyI2. . Owner's Signature: i///j/tz Date: OIM 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 - - - - - o' o - f. Fex0Mce US*Only - Conservation Services Group • 50 Washington Street Ude 30D0 • Westborough,MA 01181 • 1900-480-7471 Rev.062015 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [C] Decks [0 Siding[J] Other[CJ] /� (/ Brief: crf p6an of PfoposejI � / waits 1 t I < r (t t /� „ _ , /1�C1` Work: 1 ( c,�uictr� �amd Shy„ Lc,. WCits ,l ZJ,Y/I-'LC/ Alteration of existing bedroom Yes t/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: . Ise of building: i -• amity Two Family Other b. Number of rooms in each fa ' unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construc ••. Dimensions e. Number of stories? f. Method of heating? A - • .ces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck z-•• Compliance form attached? h. Type of construction i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. goo•• 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 ev- I, t7b --9,„ s ,as Owner of the subject property hereby authorize J(�']wor l \ my to act on my behalf,in all m ers r ative R work authorized by this building permit application. Signal of Owner Date4.. (O _ • I, a ,as Owner/Authorized gent by bebldre th�s Cements and information on the foregoing application are true and accurate,to the best of my knowledge e ief. Signed unc7 the pains a penalties of perjury. <lintp Print Name p 2- e '_ I 1m..2--o i'1 Signa r o r A t Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor://� I n Not Applicable) 0 Name of License Holder: 6 (- t- ,/2r 4 l o ` g C v /aJ� //� ` 1 License Number r� ,� a5 CD1l.��. s� I4r-)� 1 G-t/ 1 S' Adrkesss Expiration Date UU\\�r / (Y) A- o l D'13 Lure Telephone 1 q13 -203 ^2L(SL( e • Home Improvement Contrar Not Applicable 0 lo?,�� i s 1 It Lkt03 Co ripen Nam Registra' n Num er sees U -. ai ace_res /n�^^ /� ((jj Expiration Date / IY`P. 0 ,013 TelephonJ13•2d3-24c4 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 buildinguildpermit. Signed Affidavit Attached Yes Lyi Na 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 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: `1 D 1k pA A/Cf,n <Or I u-c, The debris will be transported by: 1 \ £r\ L SDI ti ld✓t,S The debris will be received by: \ ( 'LKG4LEtC LYYIR-� Building permit number: Name of Permit Applicant SA K?Db I" 4Ju Date Signature of Permit Applicant S To II C m •te or 0M N LI . 0n A M 2r X41 2 w" 13 19 n m c Q - - E ae O z= CO a m m a 1 A _ co _ ma oo` a --Z`m N Cm U3 RC2 .vIll E Ma vN -ix i- 11 0 CO .1".;,m - § to a` o:ttoof T -I ¢w. m ti �v.z TI ® U (21 4 ( 1e ! - i l r r/y #44 0 I 'II e /r? Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 18460$ s Type: DBA Flq)irafon: 10r1872017 Tra 270968 HOME ENERGY SOLUTIONS JAY BOLAND 12 PISGAH RD. HUNTINGTON, MA 01050 -_ — Update Address and return card.Mark reason for change- SCA I hange.srns a pumsr -- LI Address [] Renewal ❑ Employment ❑ Lost Card ..�.._�-- 5/-'Y.•r:Wan nireetl.c(.TA.;adttedb License orregistration valid for individol ase . :a, Office of Consumer Affairs&Business Regulationonly 'NOME IMPROVEMENT CONTRACTOR before The agitation date. If found reran.to: Registration 164603 Type: (Mkt of Consumer Affairs and Business Regablku Expiration:_ 10128(2017 ORA tO Park Plaa-Sade5170 Boston,MA 02716 HOME ENERGY SOLUTIONS<7:. JAY BOLAND 0 12 PISGAH RD. HUNTINGTON,MA 01051),':'..: Undersecretary Not valid without signature The Commonwealth of Massachusetts �,_ Department of Industrial Accidents �ii _ = l Office of Investigations �1= I Congress Street, Suite 100 hL � Er Boston,MA 02114-2017 www.mass.govidia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information e I Please Print Legibly r ' Name (Business/Organization/Individual): ,DI�O� Et1.Q,l'�(L CD(] .l.(- Df�s I C._,Address: 622 Russell .) , II^(P i�ooA. J City/State/Zip: ') NA,A-r 1 1 n )L t o Phone#: On r— Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These subcontractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp.insurance comp. insurance.t required.] 5. [A We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their ILO Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]? c. 152,§1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors 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-contractors 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. (1,M 0,,11.Al2: _` , /�� Insurance Company Name: fl ' 1 ie I ke W . Policy#or Self-ins. Lic. #: SS /y 0 6lQ' Ot� Expiration Date: 1- ,)-. .D t Job Site Address: it DlnnLd 14 „ City/State/Zip: ) _Li J 1 , MA PI 0s3 Attach a copy of the workers' compens on 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. I do hereby certify uncle t pains and penalties o lig that the information provided aboverlis true and correct�l Signature: `_4 Date:( rXl 0 I (• I Phone#: 43"a°3-- 46-4 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Perwit/License# I 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 It: ACCWEI‘EICERTIFICATE OF LIABILITY INSURANCE DArSMJDo;" 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(ies)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). PRODUCER CONTACT Elizabeth Carballo Finck a Perna InsuranceAgencyInc. PHONE . (413 527-5520 FAX i WC.XI:(413)527-5910 6 Carpus Lane Ap- REy bcarba110@finckandperras.com INSURER(S)AFFORDING COVERAGE ) NAILS Easthampton MA 01027 INSURER A ArbelXa Insurance Group 17000 INSURED INSURER a AmGOARD Insurance Company _ 42390 Home Energy Solution Inc INSURER : 68 Russellville Rd INSURER D: INSURER E: Southampton MA 01073IMS__.__._.._....-�_ _.. . UREB F' COVERAGES CERTIFICATE NUMBERCL16123002677 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. •DOL SUER' POLICY EFF POLICY EXP - - - IITSF TYPE OF INSURANCELIMITS IIXBD WYD� POLICY NUMBER ryWDOIYYYYI'IMYNWYYYYI X II COMMERCIAL GENERAL LIABILITY I DM4 OCCURRENCE g 1,000,000 A CLAIMS-MADEX OCCUR DAMAGE TO RENTED ----- 50,000 PREMISES LEA occurrence) 5 • li 8500066829 1/2/2017 11 1/2/2018 MED BW(Any one gveon) $ 10,000 . 1 PERSONAL a ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER. 1 GENERAL AGGREGATE $ 2,000,000 •X 'POLICY',_)jECT __ LOC I PRODUCTS-COMP/OP AGG $ 2,0, 00,000 OTHER. EmPloree Benefits 5 • AUTOMOBILE LIABILITY CCM RSINGLE LIMIT AS 1,000,000 1E AINED EAJJ A I ANY AUTO 1 BODILY INJURY(Perr accident)! $ 1 ALL OWNED SCHEDULED NUTOV Ef BODILY INJURY(Per amdeM) f X AUTOS AUTOS HIRED AUTOS : AUTOS :Per accident)DAMAGE )S - --- X 1 151 1 ll 1 1 RTY I (Per accident) X UMBRELLA UAB • OCCUR EACH OCCURRENCE f 2,(100,000- ---- AteEXCESS UAB CLAIMS-MADE I 'AGGREGATE f 2000,00_ _ DED 1 RETENTIONS 10,000 16600066831 1/2/2017 1/2/2018 $ WORKERS 1PERNEH- AND EMPLOYERS'WAeILnRY VIN i 5TPER _, ANY FFCER/MEIMBER EXCLUDEIE%ECUTVE EL EACH ACCIDENT $ $00000 ,CEFILEWMEMDE0.FXLWDED? NIA' - R :Mandatory In NH) `J, 1 NONCB<1192 1/4/2017 11/4/2018 IEL DISEASE-EA EMPLOYE'$ 500,000 IF yes,describe Geer I DESCRIPTTION ON CF OPERATIONS below I E L DISEASE•POLICY LIMIT $ 500,000, II I • • DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD IDI,Additional Remarks Schedule,may be attached If mare apace a require) Proof of Coverage CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Leeds THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1040 Park Drive ACCORDANCE WITH THE POLICY PROVISIONS. Leeds, MA 35094 AUTHORIZED REPRESENTATIVE E Carbal to/BETH Ci v< G.—...-...i@ ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSO25 nfunn