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12C-025 (4)
38 BURNCOLT RD BP-2019-0771 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C-025 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: INSULATION BUILDING PERMIT Permit# BP-2019-0771 Project# JS-2019-001271 Est. Cost: $5500.00 Fee:$65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: JAY BOLAND 101880 Lot Size(sq. ft.): 12458.16 Owner: Mariah Shore Zoning: RI(I00)/URA(100)/WSP(100) Applicant: JAY BOLAND AT. 38 BURNCOLT RD Applicant Address: Phone: Insurance: 233 COLLEGE HWY (413) 203-2454 WC SOUTHAMPTONMA01073 ISSUED ON.1/7/2019 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 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 Occugancy Signature: FeeType: Date Paid: Amount: Building 1/7/2019 0:00:00 $65.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck--Building Commissioner !;UA/uti,c/.-rr rvN ordy slimCay of NcxthsmP ss#.Pe u Bukling©epalTiectt per.Cu l 212 Main Street ` Room 100 Noslt��o , MA 01060 TrroS � P} 4'E3-587-1240 Fax 413�- -1272 A OW OR TWO FAI ALY DWE.UNG APDL ATM TO CoiRp"Cl Ad. - Z i.1 em"MaNsw p DEPT.OF f't-M DVrl CJI 1�� NORTHAMc>TON,Mn oved" zow ca obbio- S i'lttkt 2-PRCIPE MEET p jJ T� r SLC!'#Ql�l. •^• C0—M offow use only Cost(pole W be Btern (a)suk*v Perrtft Fee Surldirtg wed Told Cost of EWcftml gagdbV Pe` Fee 3 Pturx L,J` 4. Madwtiecd(MVAC) 5.Fire PrOtscWn Ctvack Number` �+2+3+4-r5} '� �3C a. Total=t This:yOCWD For d Us* DWe BtAdsng perrfA s�snat Deft �sU**%P .Ail#'IMSS E#7 SER fWMEOMM CR CONTRACTOR) SECTKM 5•UESCRWMW QF P�oPosEti tslroRlc# ail s N"House Addifion Repbownerdff n&Yjn AWrvfion(.)GrOOOM [� P40fmgSneQ Accessory WJg. DeMoWpoj t*W Sens Docks [E:1 -%ding M Odw f OeScrtT of Proposed m f zr Attached wee g bedroom Yes No A�rw-w beck Yes Noaom �d ba�nrtertt Yes No Ptans AftackW Rod -Sheet a. Use of building:One Fancy Two Facey Odw Number of room in each farmer urs NWTt W of SaftOoms c. IS Mare a gaffe a'ttadhed? c• Proposed Square of new construction. Dirruwmions e, Number of stories? McMod of ? Fireplaces or Woodstoves Number Of each s E y Cormovation Comp. MasOmx k Entergy Comps farm artlached? Type of cartstuc6on is construction witttat 100 ft of%vedands? Yes No. is cion wfthin 100 yr. ffoodpWn Yes Na Depth of basement or cedar floor below firushed grade Will NA&V conform to the Budd ft and Zoning reports? Yes________No_ Septic,'f atstc Cify Bearer Private well MY water Supply SECTJM za-E AD'f*XWATM TO BE COOK M tAil*i O TOR COWMACTOR APPLES FOR BtUBM PERT r 1 t C ✓1 V1 SkoA as C7"er of the subject prop" nereby aud"ize W Get e- to act on rrry in a relative to work autwtwd by this bring permit app4cabarj t- ' 4—kluxe aim Date �-� as O~Audxwized Agent heir declare#vat the siaWmft and kibrmiabw on the foregOft aft aye true and accurate,to the best of my ivtoradedge and belief. signed under the pains and—of penury. w Intrad -ILS 3o SoUornq 04 OD POMP a4R u# Sas#M W.8PW W ap(ACud Cq :j'vole sn.a tom poquWa pUs Hca aq WILU WePW cul UORs9JsdUJO3 SIO)POM ag)ow$7Sl " o*3omw 3DltWllEtm N©11111 eamw mewx)#A—ot mouo3s ' apa dx3 L AAAJOWInN N Q 09809WV ION I i s3 -a w=as City of Northampton f - - l+tassacbasett s A, Use OF ZMVZ=CM 212 main Street o gbmi=pal Ruaduq YOzth=q*AM, !f6 01060 Debris Disposal Affidavit in accordance of the provisions of MGL c 40,854, i adm wledge that as a condition of the building permit all debris resuftft from the mv*ucbon activity governed by this BW1ft Permit shall be disposed of in a properly licensed solid waste disposal fatty, as defined by MGL c 111,S 150,A- The 50AThe debris from constuction work being performed at (Please prot house manber a name) Is to be disposed of at Momv,4 - - L liag 'Sgrin�'p—, ),_& (Please Pftt nWW and location Of%CWW Or will be disposed of in a dumpster onsite rented or leased from: (Company Name and Address)/''' 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 Bukft Department as to the iomtion where the debris will be disposed. RISE ENGINEERING OWNER AUTHORIZATION FORM I, Mariah Shore (Owner's Name) owner of the prop"located at: 38 Burncolt Road (Property Address) Florence, MA 01062 {Property Address) hereby authorize (Subcontractor) an authorized subcontractor for 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. Ow is Signature r- --k .......... Date RISE Engineering,a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton,MA 020211339-502-6335 www.RISEengineering.com The Commonwealth of Massachusetts 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 Applicant Information Please Print Legibly Name (Business/Organization/Individual): D lJ�� uvcL, SoIA -o ni I Address: � ,.)�j (c) City/State/zip:_SOA Ck 44 o Il�� 01613 Phone #: 413J03 S Ll Are yon an employer? Check the appropriate box: Type of project(required): 1.EZrI am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y p Y• 9. E] Building addition [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 10.F] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no `` II employees. [No workers' 13. Other l 11S�1 ai'r o ll 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. 'Contractors 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: Uy rC CA, CO Mpa Policy#or Self-ins. Lic. #: ()�d 57O V Expiration Date: f ! '7 N6 Job Site Address: J� U01a)14 d City/State/Zip'loa yI ce, AMI- (71662 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 ve ' ion. I do hereby certify una pains jury that the information provided above is true and correct. Signature: ~' Date: / f�� 117 Phone#: qrs, 03 9145-91-` 5— r 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#: Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration Type: Corporation HOME ENERGY SOLUTIONS INC Registration: 193885 68 RUSSELLVILLE RD Expiration: 12/04/2020 SOUTHAMPTON,MA 01073 Update Address and Return Card. SCA 1 as 2OM-05117 .Ti Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation before the expiration date. If found return to: Reaistrat+on Expiration Office of Consumer Affairs and Business Regulation 193885. 12/04/2020 1000 Washington Street-Suite 710 HOME ENERGY S(XUTK)NS INC Boston,MA 02118 SHAWN MITCHELL 68 RUSSELLVILLE RD SOUTHAMPTON,MA 01073Undersecretary ,� Not valid without signature a RAI C x p -� Jay Boland �l l G)Om m Gi w i ass Nave z O ' Massachusetts Qepartment of Public Safe Board of Building Regulations and Standa "d License: CSSL-101880 l Q, . ,i �, ti'P'' � �• JAY R 190LANp t� 12 PISGAH RD HUN71NCdTON MA 01060 r '""` C� '• ��l.fCi(.G•ti' 'ITiy7d�_.. Expiratic 'Commissioner 12/27120 OL 1 l LA