12C-110 (4) 69 RICK DR BP-2017-1031
GIS4: COMMONWEALTH OF MASSACHUSETTS
Mao:Block: 12C- 110 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-2017-1031
Project# JS-2017-001775
Est.Cost: 51863.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JASM ENTERPRISES LLC 108517
Lot Size(so. 9.): 10497.96 Owner: SOTO HECTOR L&CARMELITA TORRES
Zoning: RU100)/URA(100)/WSP(100)/ Applicant: JASM ENTERPRISES LLC
AT: 69 RICK DR
Applicant Address: Phone: Insurance:
P O BOX 1276 (413) 427-5481 WC
CH ICOPEEMA01201 ISSUED ON:3/17/2017 0:00:00
TO PERFORM THE FOLLOWING WORK ATTIC FLOOR OPEN BLOW CELLULOSE
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 if 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 3/17/20170:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File R BP-2017-1031 —br4)
APPLICANT/CONTACT PERSON JASM ENTERPRISES LLC
ADDRESS/PHONE P O BOX 1276 CHICOPEE (413)427-5481
PROPERTY LOCATION 69 RICK DR
MAP 12C PARCEL 110 001 ZONE RI(100)/URA(100)/WSP(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid I'n/
Building Permit Filled out
Fee Paid
Typeof Construction: ATTIC FLOOR OPEN BLOW CELLULOSE
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
INFOKMATION PRESENTED:
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
ur Delay
Signature of Building 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:
Building Department Curb Cut/Driveway Pemit
212 Main Street Sewer/Septic Availability
Room 100 WaterNyell Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PIM/Site Plans
Omer Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address:
q - e k Dr I V.2 Map Lot Unit
(JtO (DZ. Zone Overlay District
Elm St.District DB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Cann-el i 4-a o{o CO RICK Dr. Fortnce SIR 010(07-
Name(Print) Current ailln Address'
SQ.e ar 0.ake aielliaan_W'IDn Form Telephone � 58CP-33(03
Signature
2.2 Authorized Agent: /
Sean SradshaL 70 SOX /276 dic01 in.
Name ure Current Mailing Address. 6/02/
5'/3 - 250-q74/16Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1 Building (-03 ��
(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 `^�
6. g(
Total iy�, qi Check Number dopy
This Section For Official Use Only
Building Permit Number. Date
Issued.
Signature.
Building Commissionedlnspecctor of Buildings Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
ms column lobe abed in by
Building Depanmcnt
Lot Size
Frontage _
Setbacks Ingot
Side l.: R L: R: ....
(tear
Building Height
Bldg.Square Footage
Open Space Footage %
(La area minus bldg&paved
parking)
4 of Parking Spaces
Fill: - —J
(volume&Locanon)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW g YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO eg DONT KNOW 0 YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 4 , Date Issued:
C. Do any signs exist on the property? YES O NO " 1
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. WII the conetniction activity disturb(clearing,gradirexcavation,or filling)over t acre or it part of a common plan
that will disturb over acre? YES O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 6-DESCRIPTION OF PROPOSED WORK tcheck all apt/kale)
New House D Addition ❑ Replacement Windows Alteration(s) l i Roofing El
Or Doors ❑
Accessory Sidg. ❑ Demolition ❑ New Signs t❑] Docks to Siding IC] Other IA
., tn�u.la.kift tl
Brief Description of Proposed
Work Mir Floor O�oe n Bio" (eU wlotc Co" I2 Cp3b.F.
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
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 stones?
f. Method of heating?_ Fireplaces or Wnodstoves 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 AUTHOR/ZAT10N-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING IPERR�MIT
I, See Av1-I2orIZQ, For as Owner of the subject
property �{'}'} aye c...+ 1 �+
hereby authorize J 43n £ { trp/7se l!C.-
to act on my behalf. in all matters relative to work authorized by this building permit application.
Whorl
Signature of Owner Date
Sean 'Bradshaw as OwnedAuth ,
Agent hereby declare that the statements and information on the Foregoing application are true and accurate,to the best oTmmyy knowledge
and belief
Signed under the pains and penalties of perjury.
Sean radshat3
Print Name
U9/2011
Signature • er tip Date
SECTION 8-CONSTRUCTION SERVICES
8-1 Licensed Construction Supervisor: /'j^1 /�////!(''nj1j.�r'' ii Not Applicablee 0 S
Name of License Holger ,$,eon £radI 'Igeti _cs /585/7
License Number
PO SOX 12 76 Cit ccgee inn omit /Z -/a - Vis'
Address Eaprznon Data
9/3 250 9796
Signal ---- Telephone
;t.Reoletered Home Improvement Cotractor: Not Applicable LI
Tin MI en 'erprises LLC /46 O }Y .^
Company Name Registration Number
Pet 804 0-7lo CAiite pee. ,OAR D/OZw 1/-2/-/8
Address Expiration Date
Telephone ///330/ 86/6
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG/.o.152,§25Ct6))
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 ,1!y No .
11. — Home Owner Exemption
The current exemption for`homeowners"was extended to include Ownn r-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 108.53.1.
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 accessary to such use and/or fano
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 bonding permit.
As acting Construction Supervisor your presence on thejob 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 fhr 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, Male and Local Zoning Laws and Stale 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: LOC) Ret trt\it Tiortnce MP CIO(oZ
The debris will be transported by: USA Oumpst1er
The debris will be received by: USP Dumps /er
Building permit number:
Name of Permit Applicant Sean 3rac/SAah✓
.3I1LpIzo1-7
Date Signa ure of Permit Applicant
•
Permit Authorization $'Cfl
mass save Form
Site ID: $00050276820 Customer: CARMELITA SOTO
CARMEUTA SOTO ,owner of the property located at:
(Owners Name,pruned}
69 Rick Dr FLORENCE
{Property Street Address) tory)
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: (9, at- aO,01/4.
Date: — 0 7 1 7
FOR CLEAResult OFFICE USE ONLY
CLEAResult has assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
JP1SM C o feypc eS 5M-V x¢.71-1
Participating Contractor Date
Er in
CLEAsesuk • 5owashington Street,Suite 3000 • Westborough,MA 01581 . 1800-4867472 b at!
For Office Use Only
Rev.202015 -__.-
•
' .a..t JASME-1 OP o:PM
A`Ot7 RCERTIFICATE OF LIABILITY INSURANCE °A1011E` �016Y'
Tits 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 MSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H te certificate holder Is an ADOmONAL INSURED.0m peney(It)must be endorsed K SUBROGATION IS WAIVED,subject to
the tames and conditions etuM policy.certain polities may requlre an endorsement A elatement on this certificate does not confer Hgbts to the
certificate holder M Seu of such endersemenl{s).
FsaouceRHAM
Raymald Lukas
Chase
8 Street P.O Clarke LB X9031a P 640601134854531 ._. 022102.4*4132144160
Springfield,MA 01102 ss:dukae@ChaselnSAOm
Reymond Lubin/ ---
INSURERS)AFFORDING COVERAGE CNC II
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PO Badshton8 aw wsmeec:ArWSa Profaouon ._... 41380
Chicopee,MA 01021 _Neursea:Torus Specialty _....
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER
THIS IS TO CERTIFY THAT TUE POLICES 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 POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITION$OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY'�P'yAgD�C�LpAaM�S.
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ALL X I SCHTOWIE° BODILY INJURY Mee/DEdeel I ._
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X UIrsRNSALNB OCCUR EACH OCCURRENCE Z000.000
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Damp-note GEOPEAATmus,AdN.Tmr I YFAN:LEe 0400rm1111.Ame..IR....L.ae.s...m.Y a.N.m.a xD......o.—omit
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OP THE ABOVE D6sORMEDPOLICIES aE cs.N m A EDaEFORE
ERE icalinATTON DARISE Engineering.a division A000ru NCE VOTED THE potcv pRNIEREOFoliaONt NoTiceYrl IN
of Thielsch Engineering
60 Shawmut Rd,Supe 2 AfrMWPZEaPFPM69ENTATNE
Canton,MA 0202i Raymond Lukas
0100&2014 AGGRO CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo ere registered marks at ACORD
AC RO ate CERTIFICATE OF LIABILITY INSURANCE w011
11.00NYY"
4/....P-- 10/2312016
CERTIFICATE 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 CERTIfiRATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUREINS), AUDtORU2ED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
U SUBROGATION IS WANED,subject to the terms and cm.ditions of the polity,MEEK policies may require an endorsement A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
000000S0
CHASE CH SOX 9031 CLARKE STEWART&FONTANA iu
SPRINGFIELD,MA 01102 —I I t N9 _
WEURFRB}AMMEc COW of Nike
MP410RA: Liledv Mutual Fire Insuranos 23035
MJASM ENTERPRISES LLC w84"E"' -----
PO BOX 1276 =mllnve"
CHICOPEE MA 01021 INSURER Y:
INSURERS: �. .......�-. _
INSURER is
COVERAGES CERTIFICATE NURSER: 32498764 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLUC4ES OF 41SURANEE LISTED semi HAVE BEEN ISSUED TO TRE INSURED NAMED ABOVE FOR 1HE POLICY PERIOD
INDICATED. NOTMTHSTANOmO ANY RCOUIREMENT.1GIM 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 CONOrTIONS OF SUCH POLICIES.LIMITS SHOWN MAY HA VE BEEN REDUCED BY PATO GAMSERSE
.
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WOKERS COMPENSATION INSURANCE COVER:CEAPPUES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA
This cedIflvate cancels and supemedes MI preaiUsly issued smtiorates.only as they relate to sostere ecernpensitifial toverage,
CERTIFICATE HOLDER CANCELtATION
NATIONAL GRID THE
ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
PO BOX 960 AACCCORRDDINNCE WITH THE POLICYMoo* DATE fROOVISIINS.ms. NOTICE was B` ae+'rvaEn m
NORTHBOROUGH MA 01532
AtilltORMAEFRVIENTAINE A 34404..t /}
1 Liberty Mutual Fife insurance C'I'd)k--4.
01984-2015 ACORD CORPORATION. MI rights reserved.
ACORD 25(2016/03) The ACORD Remo and logo are registered marks of ACORD
.x.Pe'RE I v .nam } .e-r,,R: I Lent SSE I mRLF2RE 472E,RR ER (POI I Emit I Ee I
__�\ The Commonwealth of Massachusetts
cut_
Ct Department of Industrial Accidents
run_
cel= 9 I Congress Street,Suite 100
''t1-3" Boston,MA 02114.2017
4" www.mass.govldia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(BusinessfOrganizationnndividual):JASM Enterprises, LLC.
Address: P.O. Box 1276
City/State/Zip: Chicopee, MA 01021 Phone#: 413-301-8010
Are you an employer?Cheek the appropriate box: Type of project(required):
tai I am a employer with 9 employees(run and/or Part time).• 7. ❑New construction
2.01am a sole proprietor or partnership and have no employees ID for me in g. Remodeling
any capacity.[No workers'comp.insurance required]
9. ❑Demolition3Dlam a homeowner doing all work myself.[No workers comp.insurance '
1amahomeowner and will be hien 10 Q Building addition
a
0 g contractors m conduct all work on my property.
ensure that all cono-actors either have workers compensation insurance or are tele 1 I.❑Electrical repairs or additions
proprietors with no employees.
12.Q Plumbing repairs or additions
sit lam a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs
These subcontractors have employees and have worker:comp.insurance?
6.0We are a corporation and its Officers have exercised their right of exemption per MGL c.
14.0Omer insulation
I52.plta).and we nave no employees.[No workers comp.insurance required]
*Any applicant that checks box fl must also fill eta the section below showing their watts'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.
tComntten Qat check this box must attached an additional sheer howing the name of the sub-contractors and state whether or not those entities have
employe B the aubcontractars have employees,they must provide their workers'camp.policy number.
I am an employer rhea is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Liberty Mutual 1
Policy ft or Self-ins.Lie,* pWC2-31St 372772-015 Expiration Date: d' Z) /7
I(.06/nn !
Sob Site Address: I �IC� 3r ve City/State/Zip: P-IOV2,nt-e N1fl 010(p2
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MOL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
r do hereby certify under the ins an emotes of perjury Mai the information provided above is true and correct. —
Siang-arc' Date: 3I I U/7-011
Phone#: 413-301-8010
Official use only. Do not write in this area,lobe completed try 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 t:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CST) CS 12
X08517 10/18
SEAN BRADSHAW License Number Expiration Date
Name of CSL Holder
P.O Box 1276 List CSFTape(see below) U
No.and Street "'— Type Description
Chicopee, MA 01021 a Unrestricted(Buildings up to 35,009 cu.H.)
City/Town,State,111" — R Restricted Mid Family Dwellin=
M Masonry
RC Rodin, Covering
WS Window and Sidin•
Sean@jasmenterprises.corn Solid Fuel Burning Appliances
413-301-8010
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC) 166074 4/21/18
JEFFEREY BRADSH,AW HIC Registration Number
HIC Company Name or HIC Registrant Name g Expiration Date
JASNI Enterprises,LLC JASM7954 rr.aol.com
No.and Street
Chicopee, MA 01021 413-301-8010 Email address
City/Town, State, ZIP Telephone
SECTION b:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.I52.§25C(6))
Workers Compensation Insurance affidavit roust be completed and submitted with this application. Failure to provide
this affidavit will result in the denial ofthe Issuance ofthe building permit.
Signed Affidavit Attached? Yes _._. RI No D
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize [ASM ENTERPRISES,LLC
to act on my be-halt;in all matters relative to Work authorized by this building pennit application.
Please see attached authorization form _ .. /I(y I'—(
Print Owner's Name(Electronic Signature) i Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATIONe.
By entering my name below. I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Pritrt Owner's or Authorized Agent's Name(Electronic Signature) /Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below,
Total floor area(sq.ft.) _ (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhalffbaths
Type of heating system _ Number of decks/porches
Type of cooling system Enclosed Open
3 "'Total Project Square Footage"may be substituted for''Total Project Cost'
\ • 1 Cnl �' ( 0J6 �7/ / 24Jr(6 ti)(11i
-�
13
Office of Consumer Allan and Business Regulation
/ 10 Park Plaza - Suite 5170
Boston, Massachusetts 021 16
I lame Improvement Contractor Registration
Regislcation: 166074
Type: LLC
Expiration. 4121/2018 Trp 119291
JASM ENTERPRISES LLC
JEFFEREY BRADSHAW
P.O. BOX 1276
CHICOPEE, MA 01201
Update Addreasand return card.Merl: reason for change.
Address lionessalEmployment Lost Card
:A, =o=wso.
'iG, Y,,,,,,,,,,,,,,,///y' /6:.,,,d.7..a. License or
.i.:1, Oahe of('onnemer Allah i<nxlnrkr
,w gwdation registration valid for individut use only
"1 -._��;,HOME IMPROVEMENT CONTRACTOR hefore the cspiration date. ff found return to:
r`i' /,Registration: 1E6074 Type: Office of Consumer Attain:end lhusinecs Regulation
t��,) Expiration: 4121/2018 LLC 10 Park PI -r Suite 5170
Roston, MA 02116
NSM ENTERPRISES LLC
"C
EFFEREY BRADSHAW -
`_ ') /I L f Li ..
)5 NEWdURY ST ( / ---."'
PRINGFIELD, MA 01101, 1'ndmxcrediT ;Nt valid without signawc
Unrestricted - Buildings of any, use group Schick
- - conlaln less than t-.000 Cubic lccl (nn I m')of
enclosed space
, : CS-108517
SEAN BRADSHAW IV
244 CONNECTICUT AVENUE
Springfield MA 01184
Failure to possess a current cull bon,of ihr M,nsnr husetts
92. --e - State Building Code or r ansa for rownr,rtron of thn license
12110/2018 In,DPS Lrnn my,nin notionvi.n w,v., . ,..u.r,v/ln^,