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31B-043 (4) 25 SUMMER ST BP-2019-0713 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:3 1 B-043 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-2019-0713 Proiect# JS-2019-001165 Est.Cost: $2500.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JAY BOLAND 101880 Lot Size(sa.ft.): 7013.16 Owner: GOODMARK ROBYN Zoning:URC(100)/ Applicant: JAY BOLAND AT. 25 SUMMER ST Applicant Address: Phone: Insurance: 233 COLLEGE HWY (413) 203-2454 O WC SOUTHAMPTONMA01073 ISSUED ON:12/28/2018 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 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 12/28/2018 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner mouse only f City of Northampton Status of P..ermit: } Building Department Ctob CtAIwwI "P""* 212 Main Streetepbc Room 100 terse Northampton, MA 01060 TWO�tscfshwtw*plans phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT, I MAN A ONE OR TWO FAMLY DWELLING SEC710N Z-WM D FORMATM 7 r7 �.� PaooerAr Adat+eDEC 1 3 2018 rift secdm to be comptMed by orae ��-- �, 3/)5 Lot Un t DEPT OF BUILDING INSPECTIONS NORTHAMPTON,MAZOM i f Ekn 8t Ce ObVkg SECTION 2-PROPERTY OVOWERSHNMUTHORIZED AGENT 2.1 Owo o mrd: 6"')r4a Sv yo J�ae A,- cLC�o o T �3 I sig 2.2"MvMjftd - 'S 3 Ile Name(Ptitit) Ma : �t�3 Y/S - a '%grTdeptww SECTION 3-ESaAT®CousmCnow COSTS ' Item Es&nated Cos#(Dabs)to be offlim Ilse Grey i. Budding Q 6� (a)&tDdin9 Pwmlt Fee 2. Ebctric al (b)Eked Total Cost of Coon froth 6 13. Plumbing SuNdIng Pwmk Fee 1/ 4, till(HVAC) l.` 5.Fire Protection 6. Total=(1+2+3+4+5) 60 Check Number This Sec*m For OCL Use Only Date Budding Pemnt Nwnber: Issued: Signature: 12- 29 I of Date ESI.ADDRESS(REQUIRED; EITHER HOMEOWWR OR CONTRACTOR) SECTION 5-QED TION OF PROPOSED WORK(check a{i aibbel New House ❑ Addition ❑ oReplacemift r Doors ❑MW*m (s) E] Roofmg ❑ A=essmy BMg. ❑ De lon ❑ New SWw Decks [[a SlAft Odd IN work:- lr Alteration of wasting bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovat uAnished basement Yes No Plans Atteched Roll -Sheet Ga-ff Mew bouseandgr; vn:to.eatbou CvwoieAe;#e foupwilum a. Use of b :One Family Two Family Olher b. Number of rooms in each family unit Number of Bathrooms c. 1s there a garage atteched? 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. Arc Energy Compliance form attached? h. Type of construction i. is consfisclion within 100 ft.of wedends? Yes No. is mon within 100 yr. floodplain Yes No j. Depth of basement or caw floor below finished grade k. Will bum conform to the Building and Zoning regulations? Yes No. t. Septic Tank City Sewer Private wed City water Supply SECTION 7a-Qvmst aUTHoRQATMm-TO BE COMPLETED VA*31 OMU[j ABET OR CONTRACTOR APPLES FOR Bt LDNIG PERMIT °� D ,/�/ as Owner of the subject property authorizet to act onmy in all me#=relative to work authorized by this bung permit l Signage of Owner oats i, V tAN1 I V L 4Pjc t l Owner/Authorized Agent hereby declare that the and ffdbnrk-IUW on the foregoing mon are true and accurate,to the best of my knowledge and belief. Signed under the pains and penaltleg of -ury. Is t Prt lane Lq k.r— Date l� SECTX M 9-MMMUCMM s+Ear ICES 8.1 Lamed CesrdEacMon Sw2aft r Not:AppkaW ❑ Name of License Fk:lder: GA J81 6 ( t ase Nmnber --_-12 IAddrem 1 Expiratim Date E Not Applicable ❑ Region Number TOM &U& -SIUIOY�3 Inc I /.? /if AddreExpiration Date w 1933 1t SECT M 10-WORKEW COWENSI1T M DISURAMCE AFF kVrr Vi.ML rw Mb $26C#6» Woricers.Compensation Insurave affidavit must be completed and submitted with this application.Failure to provide this affidavit will result in the denial of the muance of the building permit. Signed Alkiavit Mached Yes....... Of No...... ❑ City of Northampton M"sachuaetts ' nEPAR22EW OF BVXW W 2XSPSCTI0PS y' 212 tram Street • umni.cipal Bnildiaq J`•.,� �a *=tSaePtM' ma 01050 AFFIDAVIT Home haprovenwat Contractor Law Supplaeeat to Peru Applcxtien The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and subcors performing improvements or renovations on detached one to four family homes.Prior to performing work on such homes,a conftwtor must be registered as a Home Improvement Contractor("HIC"). N.G.L.Chapter 142A requires that the"mcora&Lv %,afts§om mnovaf#on,repay,nmdw&gff ,=werstan, kr p ovsrent mnx wa 1,aFarnoMS^ or cons&ucdon ofan adcRian to any pre-e dsft ownsr led tamdaV rarfeing at feast one&#not mom f m faun dwaffiW unhs..-or to s&uchm Wmoh are adlaoent w such msfdence or b~be done by contractors. Notes Ifthe kameowxer has c oa&a ted wrtk a emporation or LLC,&at entity am&be regiwened Type of Work�a�� Est.Cost: Address of work: S4- 4- Date of Permit Agglication '�/ (� f I hereby certify that: Registration is net 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 THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGLSTERED CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME B4PROVEMENT WORK ARE NOT ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER M.G.L.Cbapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIRHXM FOR ALL WORK PERFORMED UNDER THE BUILDING PERMff 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. &avn # ck �tM61 Date Contractor Name HIC Registration No. OR: Notwifl standing the above notice,I hereby apply for a building permit as the owner of the above property: Date Owner Name and Signature City of Northton Massachusetts i t MWAP42MM Or BtJZzxaw ZWSB>i= WS 212 Main 6tzeet •Ifmicipsl Huildirq xwetb=q t=' IQ 01060 I)ebr1S D15k?43e .2 Affidavit In accordance of the provisions of MGL c 40,S54, I advmwkWge that as a condition of the building permit all debris resulting from the construction adlvlty governed by this Buil ft Permit shalt be disposed of in a properly lied solid waste d'w"favi ty,as defined by MGL c t 11,S 150A. The debris from comMuction work being Perfomned at SU M ay JL S4 (Please print house number and street name) Is to be disposed of at (Pfease pftt note and location of UciWV Or will be disposed of in a dumpster onsite rented or leased from: (Company Mame and Address) 4. ;41;00 ge Signature of Permit Appkant or Owner©ate if,for any reason,the debris will not be disposed of as indicated,the Applicant or Owner shall notify the Bulling Department as to the location where the debris will be disposed. � �.�Y{i.` l 1;{,j�{.''.�1.�a+'A�'f..F.���'.��`..��;>4,T I�7( i"6�'. (.£l •� 6'•��T.�.�'4�!�JP�'•(./I�..�'����.!" Ofte of Consumer ARAIrs wW Business RegWation 10 Pw* w i ulte WO 021113 Home itxtp p r Registration T • Gorpapr'stOon RistroWn, IS024 Home Energy Solutions Inc $,,� xlsiraflon: 01/0312019 ISS Rus**114111e rd51 Southsrrlpicm, IIIA Q 147 ' �:� '�''� ..........w....�._,.�......�......�.,...�__�..�...,,..,.�:....,.�.,.. . Update Addreso and r+019rn 00(41. Mot V"SOn far ohi 90 + 4:r .?4N4"iris!r 171 Addre" Ll Aon#vsO.T1 f tr►ploymont 0 Loot Card ..'. `��.''(��,�irrr�r,arra+rsi0ll�r,.�_%yJrraxrr�r�,irf(ds 4"100 of Conwmar MNdrn t 00144501611on HOMt4 IMta14OWMIM 00WRAG ORstrMtan vid1d for Individual ueo anry TYEs Ccxr►nrMfot► M �14t►Illtfto, It found tetum to, t;M04 Af600 and Outin+ S ftgqul0tion 01/00010i4►i t%"-tuft 61" �1II�A Mis3 Wm Energy undeneq olory hit V$410"bout$19n tyre t z Jay Bolati zG)0rn Q> µ,'fli ti p _`� i i i it t• f 1., I , A Massachusetts Department of PUblit: Saf Board of Building Regulations and Standi License: CSSL.-101880 r» t„` ; rm. {� ,r,lS'r��� tltl�l , !. 1`ft3-( 1 `• {,4,r �,!+` t JAY R BOLAND 12 PISGAH RD NUN7IN+CRTON MA 41040 d2 Expiratl Commissioner 12/27/2( t n DeparaNad ofIndusbW Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mas&gov1dia Workers' compensation Insurance Affidavit Baikiers/Contractors/Elechiciansfflumbers AMLIic_"t Information Please Print LtMbly Name(Busmess/orprimfionAndividi n Inc Address: (0 lqhL*SL v C am&_MA O/C .15 Phone M ity/StateiZ Are you an employer?check the appropriate be= Type of project(required): 4. 0 1 am a general contractor and I I. 1 am a employer with 6. 0 New construction ees(full and/or part-time).* have hired the sub-contractors employ listed on the attached sheet. 7. n Remodeling 2.L'J I am a sole proprietor or partner- listed sub-contractors have 8. 0 Demolition ship and have no employees I working for me in any capacity- workers comp.insurance. 9. E)Building addition [No workers'comp.insurance 5. ❑ We are,a corporation and its 10-[]Electrical repairs or additions requhed-] officers have exercised their 0 Plumbing repairs or additions right of exemption per MGL 11. I am a homeowner doing all work myself. [No workers' comp. c. 152, §1(4),and we have no 12.E]Roof repairs employees.[No workers' t 13JKI Other insurance reqwred- t�, U 4-�� 10 a comp.insurance required.] �A)iy applicmt thatchecks box#1 must also fill Out ftsectiou below showing their workers'compws8fiw policy inftMatior- Homoownm vAo submit this affi&vit todlaiting they are doing all work and than him mftde caoftactOm mom submit a new affidavit indicating such. Conuwtm that dx&this box must aMWW an additional sbAnt*Owing the agme of the subcwtractca and their workers'coulp.Policy Minn. I am an C4940y;er dW is providing workers'congnmadon inswwwe for lav ewnLww" information I insurance Company Name- A ff\ =o icy#or Self-ins.Lic. Expiration Date: I n 1066 -lob Sire Address city/Statemp: Attach a copy of the workers' COMPesufloD policy decls"tioU page(showing the policy number and expiration data)- allure to secure,coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Tine up to$1,500-00 and/or one year imprisonment,as well as C'vU penalties in the form of a STOP WORK ORDER and a fine )f up to$250.00 a day against the violator- Be advised that a copy of this statement nmy be forwarded to the Office of 'nvesfigFitions of the DIA for insurance Coverage verification. rrry Mal the informadox provided above is true and correct do herebycerfift paw and Da : 1�� 1� ffCW useuseody. Do .twrite i.tkis area,to be completed-ted AY COY Or W**n oftk"'L rerIOULK*M City or Town: Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector1.Board of Health 2.Building 6.Other Phone#-._ contact Person: HISS ENGINEERING' OWNER AUTHORIZATION FORM 1, Robyn Goodmark (Owner's Name) owner of the property located at: 25 Summer Street (Property Address) Northam p ton, MA 01060 (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. owner's fignature Date RISE Engineering,a Division of Thielsch Engineering, Inc. 60 Shawmut Road Unit 2 1 Canton, MA 020211339-502-6335 www,RISEengineering.com City of Northampton Massachusetts �� DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street t Municipal Building Northampton, MA 01060 Property Address: Contractor Game: - r . Address: ' $ f City, State. r Phone. f Property Owner Name: KnkQnQ� t � Address: { Yyt,'A_4 city, State. I MA 1, ShA (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. r* 000, Contractor signature r+ Date