24D-087 (7) 50 NORTH ST BP-2017-0967
GIS(4: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-087 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit q BP-2017-0967
Project# JS-2017-001668
Est.Cost: $800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 7927.92 Owner: STABILE JOHN T&PAMELA C C/O BRIGITTE M PAROT
zoning_URC(lOU/ Applicant: JAY BOLAND
AT: 50 NORTH ST
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 203-2454 0 WC
H UNTI NGTONMA01050 ISSUED ON:2/24/2017 0:00:00
TO PERFORM THE FOLLOWING WORK AIR SEALING, ATTIC ACCESS, CRAWL SPACE
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 ti 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 2/24/2017 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File# BP-2017-0967
APPLICANT/CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413)203-24540
PROPERTY LOCATION 50 NORTI 1 ST
MAP 24D PARCEL 087 001 ZONE URC(IOI)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out {Pp
Fee Paid
Typeof Construction: AIR SEALIN , TIC ACCESS,CRAWL SPACE
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
INFO¢MATION PRESENTED:
1/Approved 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
pslirtnDela
do
Si: are of BuilCng Offi ml 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 40k Contact Office of
Planning&Development for more information.
g ). �� Department use only
�ekr- \ \\ City of Northampton Status of Permit:
0� Building Department Curb Cut/Driveway Permit
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
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pro a Ad ress'��� ttt��� This section to be completed by office
1/45-0 ) bre 1 S�i t i Map Lot Unit
�b r 11
\\�•A A /\ m h b (a LQ b Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 ner of Resor (�
Q,1�1 2s Tare S) T4v�t (ii— \
C ll
e(Print) "Tont dd
i'n As r
( ° )t 1 D 10
ma I i / &. Telephone
'.nature L1\ ''' 51Aa D3` 8
2.2 Author'zed A.ent: f� @DAP as 1.O\- r ' l/0DAP — A (
Name(Phnt) rrent ging Address:
a-01 m3" INCri
Signaturei Telephone i_I 15
rd. .• cj`?, - , (_t G ( I
SECTI.-ES (MATED CONSTRUCTION COSTS ( 1
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building DO D7 (a)Building Permit Fee
2. Electrical VV (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) q OD. Check Number /96/CifY
This Section For Official Use Only (�
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) d Roofing D
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [IU Siding[0] Other[01
Brief DesqGG'plion of o@,used ,�{- C
Work: (LI r _ vii D1l�� 1 "Inc
In �r ��.
Alteration of existing bedroom 'Yes Na Adding new bedroom Yes /o
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Ba. If New house and or addition to existing housing. complete the following:
a. Use of building:One Family Two Family Other
b. Nu • • looms in each family unit: Number of Bathrooms
Ci
c. Is there a garage attaches.
d. Proposed Square footage of new •• truction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. i.sscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is constm •- 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. (2)49--3/4 aciONQ 'ParD 1 .as Owner of the subject
Properly cJ1r., '�v, +1
hereby authorize , 1 Yb t�r,-c-r
to a n my behalf, in all m ers elative to work authorized by this building permit application.
150i0 ther
ignature of OwnerDate _ - 1 e-
ar •c [ ,as Owner/Authorized
/eel the the statements and information on the foregoing application are true and accurate,to the best of my knowledge
Signed urfirtaritie pains and penalties o perjury.
i:A lc
Pd?ii,T ��✓� a i iii 1
SigyipnAgent Date
RISE60 Shawmut Road, Unit 2 I Canton,MA 02021 I 339-502-6335
ENGINEERING www.RlSEengineering.com
OWNER AUTHORIZATION FORM
I, f3 ✓Lic-idi. P4 Co% ,
(Owner's Name)
owner of the properly located at:
(Property Address) , •
(Property Address) a _ . . •
Css r
hereby authorize tYu? ( T\a/ybt� Sr)\ L/ 1/"�(1S,� e\ r
(Subcontractor) `J
an authorized subcontractor far 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.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowners
responsibility to close out this permit by contacting their municipality at the completion of this work.
Owners i nature /�
1 / 17 A—
Date
6.2016
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: Lja l e)tl\ar) l 0 I °o
2
License Number
. 3 fm\\gao �kCAMLf. 1 M 31 \aD )9i
dress �yyr� �1 Expiration Dat
340 nl f rlf\ (Apt N (3-) 3.-2-SIS I
Signature Telephone
,. R. .' t -d Home Imovement Cont dor: Not Applicable ❑
Q. nitChIj4i c 1124 tpb
omoan Name Registrati n Num r
?,3 (�O10 �nu.)a�l I0 -le� aoi -7
?rens J U r Expiration ate
-,-7) c it On FI r)Itri� Telephnee a45
1
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6f
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 buildingilpermit.
Signed Affidavit Attached Yes `ti1V No 0
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 budding 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 I53 (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 Commonwealth of Massachusetts
ES= Department of Industrial Accidents
Office of Investigations
--a - =) I Congress Street,Suite 100
.n
N Boston,MA 02114-2017www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organiratioo/lndividual) t��+�^\ikj )Q ( (�s ��(-1
aA
Address: fin,►bey nr'��jj,, , aa
City/State/Zip: SOU' \\:An. f-Na e if 3 Phone it: "Ilr�"r
Are you air employer?Check tll a appropriate box: Type of project(required):
L❑ 1 am a employer with 4. 9 I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
listed on the attached sheet 7. 9 Remodeling
2.❑ I am a sole proprietor or partner-
ship and have no employees These sub-contractors have g. ❑Demolition
workingfor me in anycapacity. employees and have workers'
a tY. 9. o Building addition
[No workers' comp. insurance comp, insurance.:
required.] 5. Et We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.9 Roof repairs
insurance required.] t c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box 41 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.
1Contractors 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. �
Insurance Company Name:4(��U, f\\, s c�'n� 1L CID rncon,
Policy#or Self-ins. Lie. #: kAbk3•CW. .1 Q p—' � '( Expiration Date: � - 1) ��
Job Site Address: -] (C* -1
1 City/State/Zip: 0 to lj(r,� COIf y L[alb
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.
I do hereby cerci der the psis• ,ora :., of perjury that the information provided above is true and correct
Signature: IC4flt. /y/ Date: �a] (
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#:
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Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston,Massachusetts 02116
Home Improvement Contractor Registration
Registration: 164603 0
GAM: DBA
Expiration: 1012517017 Tth 270869
HOME ENERGY SOLUTIONS
JAY BOLAND
12 PISGAH RD.
HUNTINGTON, MA 01050 —
Update Address and return card.Mark reason for change.
-- ❑ Address Li Renewal Q Employment ❑ Lost Card
scat o 291.401+
'L-re ne in<.,...rand e iinsateAtea✓n
Office or..oasnmer Attain&Business Regulative License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before tie expiratkm date_ If found return to:
Registration 164603 Type: Moe of Commune Affairs and Rosiness Regulation
Ext ore:- 10116/2017 OBA 10 Park Ph1-Suite 5170
RoshLMA02I16
HOME ENERGY 5O1.J ONS
JAY BOLAND --_-='-i '
12 PISGA11 RD. `G
HNii1NGTON,MA tuosa - Uadasaretary Not valid without signature —......
4.1t,„ City of Northampton
(--,
µ Massachusetts .
i�nxsaEer of BUILDING rasp;crroazs .
212 Main Street • edwicipal Building
.%� �-^^,, N,�,-�NNory'thampton, ha 01060 f
Property Address: ,011 U omit s ( reC {
contractor ( Golan L
Name: � }#-�f /'� 4 t � `` `` ` /
Address: )2'53 ....C',6 2 -im C ki,c) LC`
City, State: , 1)) k' 1n"Z ImA� Il0io`13 —
Phone: 4 t 5 t "z03- fit( --
Property Owner tt
Name: re- 19 tT k Q_ aro i
Address: C.-o Nor-R\ s_C(".u-1
City, State: 140 ` aM C\ r1 Pr 0 ( 0400
I, (An G (contractor)attest and affirm that the building I intend to
insulate d 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 !
IAa i
Date ( 3iayj01)11