Loading...
31B-145 (21) 112-114 KING ST BP-2017-1199 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:31 B- 145 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-2017-1199 Project# JS-2017-002031 Est.Cost: $5240.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const Class: Contractor: License: Use Group: JASM ENTERPRISES LLC 108517 Lot Size(so. ft.): 8058.60 Owner: YENNER WILLIAM Zoning:GB(100)/ Applicant: JASM ENTERPRISES LLC AT: 112 -114 KING ST Applicant Address: Phone: Insurance: P O BOX 1276 (413) 427-5481 WC CHICOPEEMA01201 ISSUED ON:4/25/20170:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL R-32 OVER 2200 SQ FT OF OPEN ATTIC AREA 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 4!252017 0:00:00 $65.00 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner File#BP-2017-1199 APPLICANT/CONTACT PERSON JASM ENTERPRISES LLC ADDRESS/PHONE P O BOX 1276 CHICOPEE (413)427-5481 PROPERTY LOCATION 112-114 KING ST MAP 31B PARCEL 145 001 ZONE GB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST i D REQUIRED DATE ZONING FORM FILLED OUT Fee Paid /IDS Building Permit Filled out / Fee Paid lll/// Typeof Construction: INSTALL R-32 OVER 2200 '• F - •F OPEN ATTIC AREA 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 7 D ION PRESENTED: LL// 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 De It a .40811. Signature of Bw ding Official Date 7 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 euro CuUOdvaway Parmar 31r�' ry 212 Main Street Sewer/Septic Avadabliity APR 4 Room 100 WaterrwenAvailability Northampton, MA 01060 Two Sets of Structural Plans _.__._..phone al&567-1240 Fax 413-587-1272 PlagSife Plans Other 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/. .y /2� r I� 9Z'(l`'i t-.l/1 Vii' Map :?/J tot / y,J Umt SVu( kWillq ✓1 Mia C «(cq Zone . _Overlay District Elm St District Ca f)bUigt SECTION 2-PROPERTY OWNERSHIP(AUTHORIZED AGENT 2.1 Owner of Record: u�l _V'n r VCi T XkPPLV�i�1 Ro PIs'( CP -1R-C +oco2 Name flab p Car nt Maair,g Address: PI r:a 6 l74 : .0 _Cll 1.__ Tete. one Signature 2,2 Authorized Agent: ! Sean eradskaw /0 86X /2.6oCAk ee /nr Name{Mina ,, Current Mailing Address: ayoxy 5/3 — 256-Q? Sgnatere -t Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars}to be Oficial Use Onty completed by permit applicant t Building 7. , 1 O (a)Building Permit Fee 2. Electrical Li �`C,,,,,,1 _ (b)Estimated Total Cost of Construction from(5) a Plumbing Building Permit Foe 4 Mechanical(HVAC) 5.Fire Protection ,� r S. Total=(1 .243.4.5) ht�L1o. 00 Cheek Number 3 /53 CC This Section For Official Use Only Building Permit Number: Date --` ._ ISSued: Signature. building Commissionerflnspector of Buildings Date Section 4. ZONING AU 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 o Open Space Footage o0 (Lot area minus bldg&paved parking) k of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES o IF YES, date issued: IF YES: Was the permit recorded at the Registry 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 Si DONT KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES O NO �( 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 X IF YES, describe size, type and location: E. Will the construction activity disturb(clearing.gradin excavation,or filling)over I 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 Management Permit from the DPW is required. SECTION 6-DESCRIPTION OF PROPOSED WORK(check all applicable) New House Q Addition Q Replacement Windows Alteration(s) I I Roofing ❑ Or Doors in Accessory Bldg. ❑ Demolition fl New Signs (al Decks (O Siding tC) Other/en'1 C'V it,it O Brief Description of Prdllosed n Work. 1 rnS\ctAt $Z t'%BY Zv\�.-�CiCr ',ft?F O-c n Fr 1t1 act l t CX. P. Alteration of existing bedroom Yes N No -YJ Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes N No Plans Attached Roil -Sheet 6a. 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 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 Ta-OWNER AUTHORIZATION-TO SE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT See Punic rat ,as Owner of the subject property ,,[{, hereby authorize Y�-12#f( �/ t/Pn`ses ezt to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Q I Osie 1, Sean 6radshLt4 , as OwnedAutn Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best o my nowledge and belief. Signed under the pains and penalties of perjury. Qh f`aradsIT4& Print Name �ii ,1472 /7,01-1 Signature Cate SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Sopervisoc: Not Apphoable 0 Name of Wens.Holder: Sean Sradshaa CS /615/7' License Number Pp 80X. 1276 C,4icopee mn OtOz ! /2 -/CS- 25` Address Expiration Date e„ 9/3 250 vfl' Signal '- OP Telephone p.Registered Home Improvement Cop tractor: Not Applicable C TASm en'IZerpr)ses LCL /6,6 0 ?W Company Name Registration Number p0 sox ta7 Chita,te. am oiort Y-2/-4$ Address Expiration Date ....._ Telephone 419330/ 34/6 N/fCns fin in c f @j Om antra , CUM 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. Signed Affidavit Attached Yes X 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 tinder 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 fin 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,Slate 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: 117- ' ISL k \yle cSsS . The debris will be transported by: _ USA Ovmps/er The debris will be received by: USA °um/s ler Building permit number: Name of Permit Applicant Eta'? Jraols at✓ ZI Zt11 11NO- 410.1 Date Signa ure of Permit Applicant AIR SEALING/INSULATION Work Order FACILITY:KING STREET APARTMENTS ADDRESS: 112-114 KING ST,NORTHAMPTON, MA 01060 NUMBER OF UNITS IN FACILITY: 7 CONTACT: WILLIAM YENNER, 119 TURKEY HILL RD,FLORENCE,MA 01062 413-727-3390 WILLIAMYENNER@GMAIL.COM AUDITOR NAME: ANTONIO PELLETIER AUDITOR CELL PHONE: 401-301-2793 SITE DESCRIPTION: King Street Apartments are located at 112-114 King St,Northampton,Massachusetts.This evaluation is based on two (2) of seven (7) apartments. The complex was constructed in 1910 and features asphalt shingled roofs, double pane windows in fair condition, with a vinyl sided exterior. Heating system is a forced hot water boiler, and domestic hot water is provided by a freestanding gas water heater,both systems are combustion vented. Attic areas feature 2x6 16 o.c.joist,conventional constmction. There presently is 6"fiberglass roll batt insulation and fiberglass installed. Access is available in unit second floor closet areas. Boards in attic will be blown over. SITE IMAGE: If a +1 tom_ y —:. SCOPE OF WORK COMBUSTION SAFETY TEST: Perform combustion safety tests for gas-fired space heating /domestic hot water devices. Work below will not be performed for any units where system(s) fail, until corrections are arranged by owner and system(s)pass. AIR SEALING Seal attic and basement(if applicable) electrical and plumbing penetrations, scuttles,ducts, bypasses, transitions and other leakage points to reduce heat loss through air infiltration. ESTIMATED AIR SEALING HOURS—40 hrs ra $65.011 per=$2600.00 ESTIMATED AIR SEALING SQUARE FOOTAGE—2200 8 HOURS TEST 32 HOURS SEAL ATTIC ATTIC INSULATION Furnish and install blown cellulose insulation, including ventilation chutes, wind-wash baffles and damming as necessary. Insulation measuring sticks must be installed. An accurate bag count must be recorded and reported. Install R-32 over 2200 sqftof open attic area. 2200 SQ. FT(y $I.20 PER— 5264200 CO-PAY$825.00 Note: Any additional work performed and/or materials used beyond the scope set forth in this work order will be the responsibility of the installing contractor without an approved change order by the installation manager and/or energy specialist. 4 --. m• • s it "ft 011:k; 4 , r 1,erii 1 ; fr4 ; 7 44 ' / r*:t a'A"t JASME-1 OP ID:PM ACCORD, CERTIFICATE OF LIABILITY INSURANCE °Aia1'ea e' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS HO 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. If Ow certtfieate holder Ran ADDITIONAL INSURED,the NatWest must be endorsed If SUBROGATION IS WAIVED,subject to Na terms and conditions of the policy,certain policies may require an endowment. A statement on this certificate dose not confer*pHs to the certificate holder in lieu of such endo semeO(s). Nmw0ER "ce Ra a Luka Chase Clarke Stewart&Fontana I Pm 101 State Street,P.O Box 8031 Fx1413-780+7531 ajm. dt -21441 Springfield, 01102 is Nuk94@chasmns.com Lukel RS*RERIS)AFFOmJMG CwvuGE awes NAMED ASPS Enterprises LLC ---+-01awNORhiend Insurance Companies Jeff Bradshaw MBREea: P6 Bax 1276 INSURER c:Arbelta Protection 41360 Chicopee,MA 01021 MMRERI:IOMS Specialty POURER E: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POUOES OF INSURANCE USTED mow HAVE BEEN CSSND TO THE IRSUREO NAMED ABOVE FOR THE POUCV 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 PERTAN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ML THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITSSHOWN MAY HAVE BEEN REDDU�CEDIBY PAID CLAWS. BR PwFOF WGPwIGP. AWL Maar MIWER OiDOl1'1'Y1 Ir%C Y0Yn.— _ LISTS A X WRITEROML GENERAL tAAaR1'!Y EACH OCCURRENCE $ 1,906,090 I C.AwSAMOE 1 X I OCCUR X WS281416 062012015 0612012017 ppEM.sEs Dy,�);— 100,009 MED EXP(Ms NS Anal) s 5,000 PERSONAL a MN Mwrsr $ 1,000,000 GENT nO[We6+TE UMnAFasS PER OFNFRALAVFaEGarE s 2,000,000 T xn uJEW :_,{LOC FRDauOTs-ccartln+AGO S _.... 12600,000 OTHER- s I AUIoloet6 L$8lUTY t ID DOWNED SINGLE UNIT $e modem) 1,000,000 C ANY ALTO 1020008523 1010511010 10/0512017 BOORS AWRY In penal) $ ■At T.OWNED 1 sOUJI1EO PIrt09 X AV10a ROOST M.NRiT(Pp anent) s ... X AIRED AUTOS X i AUTOS G eHDRAPP Y S _ i 14 © LWAREtLA U.S o DR EACH OCCURRENCE s _ 2,000.000 0 121 Etna MAR ^ CI„cws`.uwe T6451I/02AL1 08/294015 06202017 AoGREGATE $ 2,000,000 I DFD -jrrtTENTION$ _,,, S ARO EfictOTIORA Winn JTY InVATAKERSCOMPRISATION �� STATUTE EC. ANY AROPRTIMPARTMERRXRCUTNEEL EACH ACCIDENT S acnCFAa.P.MRER ExCLpO? nNIA t YY rmataY M NIIEl°RFJSE-EAEMPLOYES 1 0.�SCRIPII QFOPEPATIX19R+MM 4 El 0$EASE-POLICY LIN! $ 1 Ass Annan oc CRFMMRF IAPCATWS I YAA0LAA ATAARD 101rA0..0.10,.A-A.nwbM,Avy M,NeLeJ H Ass.4.M,4Mwn CERTIFICATE HOLDER CANCELLATION MOULD ANY Of THE ABOVE DESCMDED POUGES SE CANCEIYED SORE RISE En6lrTeednO,i division THE EXPIRATION DATE THEREOF. NOTICE Wal BE De],NERE6 IN RS gln e.ing,enD AccowARGEARn inc POLICY PROVISIONS ch SO Shewmut Rd,Suite 2 AUTHORIZEDREPMa9DAA2 Canton,MA 02021 Raymond Lukas ea 1940.2014 ACORO CORPORATION. All rights reserved. ACORN)25(2014/01) The ACORD name and logo are registered marks of ACORD A DB CERTIFICATE OF LIABILITY INSURANCE DAIViW2 16 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. H the certificate holder Is an ADDITIONAL INSURED,the poiky(les)must have ADOTONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED,subject to the terms and conditions of the polky,Certain POONA may require en endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endersement(s), "Ma" CHASE CLARKE S I LWART&FONTANA CONTACT SPRNGFIELD,MA 01102 .... —....... I .11D4 -. -- flogoaalM}o ZNecowmAcm woe* nauran: Liberty Mutual Fire lusts 22306 INSURERNJASM ENTERPRISES LLC w41mEI9: .... PO BOX 1276 INSAMERC:. —... ... CHICOPEE MA 01021 MAURER0: � tltMOROIE: COVERAGES CERTIFICATE NUMBER: 52498764 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERkQD 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, sig AND CONDITIONS OF SUCH POLICIES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAIDCIABAS. Lm onOF n8WWICE aNSCESSY POLICY MAMMA 10MWpry TY1 C? 1 UNITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1�Ma O i 4 OCCUR -1546 �s ETEr. PREMLNEaAgg FBEI(MN Onn�l I HER PERSONAL&ADE AMURY .....—_ SEM hNAGGREGATE TIMnKGIESPER. GENERA ACGREOATE CY I.•-1Ira I J LOC PRODUCTS-COMROP A00' i.. ._ IDIRER ANnMOSILEHAAILEN I COMBINED sweat LIMB 1 Na AUTO I EGDRY NJURY tn«Erma) -.._ LYNXEO '---T SCHEDULED I eCDILYIRXBRB BA+SEAN AUTOS ONLY ALROS _ HIRED RONONED PROPST DANE ONLY OM" AUTOS ONLY Per eMNmp - UNSRELANAB OCCUR EACH OCCURRENCE EXCES�SLU{E CWM&MADE AGGREGATE t DEO (RETENEONS •—•_ __�. s A WORKERS�INSAATION WC24318-614507-010 10120/2016 10/2012019 AND J f $RTVT€ EPN YIN �RO IETONPARTNENT}T RIVE ( nwEL EACH/comets 2 1000000 E OfncONIEREN.YioEW I V NiA ..._ RA)NYN��Nvy In NN) EL.DISEASE-EA INFLOYEE S 1000000OEraRIPiION GpOPERAT NWS WEE El.MELEE.POLICY LIMIT t 10LU"DDS 1 OSEPUPFWN OF-OPERATIONS)LOCATIONS evEsoes tACCAD III.AMWw:Y Re116104Wm*"mry be sllxM thwart yy(+M rp4ITOp WOKEHS COMPENSATION INSURANCE COVERAGE APPLIE3 ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA, This turnouts cancels and supersedes eB previously issued certAcalss,only as they relate to workers compensation coverage. CERTLFICATE HOLDER CANCELLATION NATIONAL GRID SHOULD ANY OF THE ABOVE DESCRIBED POL.CIES?ECANCELLED BEFORE ACCEWTEPTHEREOF. HYPONOTICE WEL NE DBLM6f£D ix PO BOX 960 ACCORDANCE WITH THE OCVISIONS. NORTHBOROUGH MA 01532 MT(tANrzUMd+ FSATNE /T to /T I Liberty Mutual Fire Insurance C'ITd'-W- C198S2615 ACORD CORPORATION. All rights reserved. ACORD 25(2616103) The ACORD name and logo ma registered marks of ACORD 33.4,0764 i 1.47.45V1 1 IT-L3 WC I va3W3 e t 14Annnd E.:P:P6 PA (TETI 1 Ease i of The Commonwealth of Massachusetts t�=Eig El Department of Industrial Accidents P =" 1= a 1 Congress Street,Suite 100 EPo + :1 Boston,MA 02114.2017 •' �,�c' www.mass.gov(dia Walkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO RE FILED WITH THE PERMUTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organizationnndividuap:.)ASM Enterprises, LLC. Address: P.O.Box 1276 City/State/Zip: Chicopee, MA 01021 phone#: 413-301-8010 Are you au employer?Cheek the appropriate box: Type of project(required): Q! I am a employer with 9 employees(mat and/or paranme)• 7. ❑New construction 2 t fain a sole proprietor or pumership and have no employ«s working for me In 8. ❑Remodeling any capacity.INo workers'comp.Inaumnce moulted.] IDl am a homeowner doing all work myself.(No worker.comp.insurance d. 9. ❑Demohtloa a❑I am a homeowner and wilt be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.0l am a general contractor and I have hired the subcontractors listed on the attached sheet 13.❑ROOf repairs These sub-contractors have employees and have worker:comp.insurance? b.❑We area corpomdon and its Officers have exercised their right ofexemption per MOL c. [4,[pother insulation isz,4:(oy and we have no employees.[No workers'comp.Insurance required.) "Any applicant NN checks box#1 must also fill out the section below showing their woken'compensation policy information. ]Homeowners who submit this affidavit indicating they am doing all work and than hire outside contractors must submit a new affidavit indicating such. ;Contactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have emit eat Utile subwntacton have employees.they must provide their workers comp.policy number. 1 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 Setf-ins.Lic.$: WC2-318-372772-015 Expiration Date: 6- e27 /7 Job Site Address: ) )2 ' SF Ciry/Statetzip: (''(1✓1G,Lvl l'1 `- `ft onod Attach a copy of the workers'compensatio policy declaration page(showing the policy number and expiratio 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 co rcragc verification. I do hereby certify under the ins an enatties of perjury that the information provided above is true l /and �correct. Signature: Dare: "1/z_ /TYI1 Phone 4: 413-301-8010 Official use only. Do not write in this area,to be completed by city or/own official. City or Town: Permit/License# lasting Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone is SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) eS-108517 12!10/18 SEAN BRADSHAW License Number Expiration Date Name of CSL Holder �pp .P.0 Box 1276 List CSL Type(see below) V No.and Street Typo Description Chicopee, MA 01021 a Unrestricted(Buildings up to 35,000crr e.) e R City?Town,Sate,ZlP `RdMasonry &2 Family Dwelling R Restricted i RC: Roofing Covering WS Window and Siding 41.3-301-8010 Sean®jasmenterprises.eom SF Solid Fuel Burning Appliances �7... Insulation Tse hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) I66074 4/21/18 JEFFEREY BRADSHAW HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name JASM Enterprises,LLC JASM7454@aol.com Na.and Street Email address Chicopee, MA 01021 413-301-8010 City/Town, State, ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(4.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 ofthe Issuance ofthe building penult. Signed Affidavit Attached? Yes 0 No ❑ 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 JASM ENTERPRISES, LLC to ac on my behalf, in ail matters relative to work authorized by this building permit application. Please see attached authorization form / Print Owner's Name{,Electronic Signature) Date SECTION 7b: OWNER'ORAUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all ofthe information contained in this application is true and accurate to the best of my knowledge and understanding. ��n . edAC6<aName(� u/Z+ 'D Print Owner's or Authorized Agenf's Name(Electronic Signature) ate NOTES: I. An Owner who obtains a building permit to do histher 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 M ww.mass.eov/oca Information on the Construction Supervisor License can be found at www_mass.gov/tips 2. When substantial work is pia nned,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 of half/baths 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" '��c aJ1/I1ionroec</7/ r/C 67.,;A,5cecAti e//i Office of Consume Affairs and Business Regulation 110 Park Plaza Suite 5170 Boston, Massachusetts 02116 l Ionic Improvement Contractor Registration Reyislrahon: 1688074 TYPe LLC ExPratian: 4/21(2018 Trt$ 41929.. JASM ENTERPRISES LLC JEFFEREY BRADSHAW P.O. BOX 1276 CHICOPEE, MA 01201 Ilpdalc Address and return card.Mark re:aen for change. Address Itene•wti Employment Lost Card -r,4, x. , „,.0A dei- 7G.:,,/,,,..u. 110. ontre o(('onsantcr. radii S Runners Rrnnlatiun Choose or registration valid for individol use only t :;.HOME IMPROVEMENT CONTRACTOR before the espn Wtndate. If found return la: { Re istratio¢ Office 01(.onsi nc Affairs and Business 9 1660]4 TYPe: Regulation �se/ Expiration: 4/21/2018 LLC 10 P.n$Pi e'1-Snit¢5170 Boston,MA 02116 _ SSM ENTERPRISES LLC 2FFEREY BRADSHAW 1.f 'a )5 NF.WBURY ST _ `\` J / I_; �� PRINGFIELD, MA 01104 t nderse C renv,' N t valid without signature > - Unrestricted - Buildings of at use group which . , . contain less thin t5,000 cubic leen pl(>Inl'I of ' •, :..,, `'-' enclosed space CS-108517 SEAN BRADSHAW VI 246('ONNECTIC.UT AVENUE Springfield MA 01104 Failure to possess a current 41111u-on of Ihw hbrssat huu•tts 9Z- .21..-44Y-.. State Building Coder.t aim,for rvvor dtion nt thy;!i ease 12!10/2018 Inr OPS I irommg"I:,t roar,",vi.n Wow to„-.t,r.vlfa^, City of Northampton Ott on ; 1Massachusetts �,fADEPARTMENT OP BUILDING INSPECTIONS�'�.. 212 Main Street • Municipal Building \,74.2-,"°!5. vNorthampton, MN 01060 ��h ppvm's' Property Address: 11 / - lit-1 kl�,� r. K& Ork�l(�AN1�JtDY`\) -AR Contractor Name: 3OSM L1'geirlOrl e..SM Li C . Address: PO SVA IZ-7(D City, State: Chts co 7,°,t, H f C; 02-I Phone: 011.3) .301 -8010 Property Owner Name: IA9IIIlel YV) YP.(1t7tr Address: IIZ-1�)" 77,�4 kin St AA City, State: tv(JrZPaefrit't}»)j Mg CIO400 I, SY Un(l E rad STh/)e ) (contractor)attest and affirm that the building I intend to insulate does 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 >9 Date to /2-i ZLI1