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35 City of Northampton Massachusetts 'G nWAFj2fMT OF BU=XW SDrBPB=X0KS "° x 212 Rain Street • ftmi.aipal Building DiorthwWton, DIB 01050 AFFIDAVIT Home haprovemest Contractor Law Supplement to Permit Application The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcontractors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a contractor must be registered as a Home improvement Contractor("HIC"). M.G.L.Chapter 142A requires that the"recons on.at< nWon,renovation,rami',modemizaWn,cawarsion, improveomwt rerrmva t,dere AWon,or consbucatfon of an addition to any pre-exis&9 owner-occupied buloft contakft at least one but not mare than fora'dmft uruts....or to sWxft w w Bch are acpcent to such residence or b~be done by reddered cosotractors. Nate:If the homeowner Inas contraaed with a corporation or LLC,#hat entity mom be registered Type of Work:' 1&6 n Est.cost. - w � �<- Address of Work: 1L �" '(aj} bY�' Q,d Date of Permit Application. I hereby certify that: Registration is not required for the following reason(s): Work excluded by law(explain): _Job under$1,000.00 Owner obtaining own permit(explain): Building not owner-occupied Other(specify): OWNERS OBTAINING TmM OWN PERMIT OR ENTERING INTO CONTRACTS WITS UNREGISTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABI E HOME IMPROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK PERFORhIW UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION. Signed under the penalties of perjury: I hereby apply for a building permit as the agent of the owner. hOWA �lj I � Date Contractor Name HiC Registration No. OR: Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northampton i, Massachusetts DWAR2N=T OF SaIT. nFG nZW=zOWS \ 212 Main SUGOt •MMdeipal Bni.ldiag ivy .a Northuwton• MIL 01060 4 �j1gC Debris Disposal Affidavit In accordance of the provisions of MGL c 44, 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 150,4- The 5pAThe debris from construction work being performed at: 0�- W '�-Rd (Please print house number and street name) Is to be disposed of at: �KhSLr (Please phnt npjhe and location of Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address) 44. 4�1114- � Signature of Permit Applicant or Owner Date If,for any reason, the debris will not be disposed of as indicated,the Applicant or Owner shall notify the Building Department as to the location where the debris will be disposed. � Onn:oo/ u\xsW// en 10 Peek P Suits 5 170 Boston, 10 saifts 02116 Horne { Regifetradon: 186794 Home Energy Solutions Ino 68 Fluesellville rd Southampton, MA 01073 ? ---------------- ---'—'--_-_'--_ Update Addm*wand mnpmv^"tMark Yawn for ohe'g* O Addrovm ORvnw*o) !I F(nploymwm DL*m| Cord Office of 40(ililimof ANjOre HOMj IMPA,6V11MINT COWAACTOA n omy y c. IV 1- G rn ! C 0 Jay Bola' "d u ;rile A 0 C�4 1"p ^ SS "oelpf, t" O cn ' Maissachusotts Department of Ptibliu Saf M PJoerd of Suliding Regulations and Stanch Liuenee: CS3t_•101880 JAY A BOLAND P Oji i}• ''! 12 PISGAH RD MUNTINOTON MA 01080 tz �.rC�il ' :J;;-trt�...• Cxpirati Commissioner 12/27/2[ i � I n ✓fir.., ..., vvrrsrrsyssiYGi un t/f lnassachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington,Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AD plicaut Information Please Print `bl Name Businewor ization/Individuat : t q4 inc t � ) Address: 40huew City/State/Zip: QiG43 Phone#: L11-3 Are you an employer?Check the appropriate box: Type of project(required): l 1� 1 am a employer with %9- 4_ ❑ 1 am a general contractor and 1 6. Q New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ 7. Q Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. workers'comp.insurance. g. Q Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required-] officers have exercised their 10-E]Electrical repairs or additions 3.n I am a homeowner doing all work right of exemption per MGL I Ln Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.Q Roof repairs insurance required.]t employees.[No workers' 13 U Other �)DLO a 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 arc doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of thesub-eoatractors and their workers'comp,policy infixmatiom lam an employer that is providing workers'compensation insurance dor my emnlim—c R.,r,....;V>F0.0 PUZ '.Y.aur fun sue information 0mce)(xv)Insurance Company Name: �lag rata om. G M F't Policy#or Self-ins.Lic.#: ��}V�C- 3� Expiration Date: 1 ;X / I Job Site Address_ rQ V M,3 �. City/StatelZiplj ►04 w T,6 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 A up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tnvestigations of the DIA for insurance coverage verification. t do hereby certify pains and urry that the information provided above is a and t? rrec •�'/ Da �i hire: 'hone# 0 offWal rise only. Do not write in this area,to be completed by city or town of f kiat City or Town: rermwlkem# fee"""s 4-06dvi*y(Oi-1011 On0i, 1.Board of Health 2.Building Department 3.Citty/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r SiteiD;;3566565 Custorrior',IpHN OMASTA i /I) !n owner o th'e}aroperty located atlt 165 W Farms Rd Northampton, MA 01062 (Property Strut Rdrl� } `�Glril Fere y auti 67ek tt a INasSSade HomE n r y Services Program assigrted`R tt c pacing orttrackor i�sted below td acf on rny.bet alf an i obtain a building per'mi t6pt'form—Ansutatiori'and/or weatiierzation ;w_ork ort my property r i lltO OFElCE.;USE ONLY' INe"have assigned the<follavuing Mass Save Home.Energy ServEces ParttciPat�hg Corltra�tOrto'tt:e aboue refer:,enc�d�pro}ecti � i Parktcrpat rtg 0 tractor' Date` i E r i r Name: CLEAResult Phone: 800-480-7472 Email: F�±r Cf�c�Ris�F3ts1�_ Rev.1Q2D15 - SECTION 8-CONSTRUCTION SERVICES 8.1 Li ed Consfrudlcn Su nrisor: Not Applicable ❑ Nam of License klottier: Q I8 Ucense Number a37� u whk ,Wrss Epiratim Mite S' TeteQt�te 9Not Applicable ❑ Registration Number 99MRM HMO n 113119 Address Expiration Date SECTION 10.WORKERS'COMPENSAT"INSURANCE AFFIDAVIT(M.ML..G 152,§25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit will result in the der"of the issuance of the building permit Signed Affidavit Attached Yes....... No...... ❑ SECTION 5-DESCRlPTiON OF PROPOSED WM( dr all anutk;abiel New House ❑ Addition ❑ Repk�cemertt Windows Alteration(sj ❑ Roofing ❑ Or Doors ❑ Accessory Skig. ❑ Demolition ❑ New Signs M Decks iC Skllng= Other � Brief of Proposed , Alteration of egg bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet iia._!#Nein iKRM and Or adCOMID exisdin 1 i oushm taomplehi.#w foga itom#: 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. n Yes No j. Depth of basement or cellar tam below finished grade k. Will building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHOWATM-TO SE COMPLETED WHEN OV01ERS1AGENT'OR CON'MACTOR APPLIES FOR BURJ)WG PERMIT 1, J Q ,a �i�j" �{L as Owner of the subject party hereby authorize 3VWA to act on my in aU rr tens relative fo work authorized by this building permit M,'�$ l 1� sig ubim of 0WW t» 1, c _v 1� i as OwnedAuthorizr.ed Agent hereby declare that the staternents and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties`of "ury. Shaw � Print NarrieJ s of � 1 06'Itr(CA-) Departmentuse ordy City of Northampton Status Of Permit: Building Department CurbCutlDdveway Permit M2.. 212 Main Street SewerLSepc I�vaiiabilty 1 . Roam 100 water/hell Avail",K Northampton, MA 01060 0 E phone 413-587-1240 Fax 413-58 -12 odw Spec#y. APPLICATION TO COW'T§ GT,ALTER,REPAY, TE ON OR FAMILY©WEWW SECTION 1-SITE INFORMATKlt�l )', OF BUILDING INSPECTIONS N 1.1 pro oeriv Addross by office Map Lot va 7/ Unit Zone Y District F.�St.District fa District SECTION 2-PROPERTY O VNERSIWIAUTNOM ZM AGENT 1 N �/ cunwit�� Telephone 2.2 Authorized Agerit Name(Print) fCupent Maft Address:goo � �J Y sigrift" fTelephone SECTION 3-EXIMATED CONSMUCTION COSTS Item Estimated Cost(Dollars)to be 0111dai Use Only cwvleW by permit awlicent 1, Building Lon (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Consbuc tion from 6 3. Plumbing Biulkll"Permit Fee ' 4. Medmnical(HVAC) J Y D 5.Fire Protection 6. Total=(1 +2+3+4+5) Check Number This Section For Otlicial Use OW Building Permit Number: Date Issued: Signature: 11 `Z -y l g Building _ of Buildings t» EMAIL ADDRESS(REQUIRED; EITHER HOMEOWNER OR CONTRACTOR) 165 WEST FARMS RD BP-2019-0671 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:35-271 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-2019-0671 Project# JS-2019-001092 Est.Cost: $1000.00 Fee: $65.00 PERMISSION IS.HEREBY GRANTED TO: QQnst.Class: Contractor., License: UseGroup: JAY BOLAND 101880 Lot Size(sa.ft.): 165092.40 Owner: OMASTA JOHN P&FAYE A Zoning: Applicant: JAY BOLAND AT. 165 WEST FARMS RD Applicant Address: Phone: Insurance: 12 PISGAH RD (413) 203-2454 Q WC HUNTINGTONMA01050 ISSUED ON.12/5/2018 0:00:00 TO PERFORM THE FOLLOWING WORK.-BLOWN-IN INSULATION AND AIR SEALING 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 France: 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: FeeTYue: Date Paid: Amount: Building 12/5/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Louis Hasbrouck--Building Commissioner