28-022 (3) 21 O'DONNELL DR BP-2019-1073
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mao:Block:28-022 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-2019-1073
Proiect0 JS-2019-001742
Est Cost $3500.00
Fee $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sq. ft.): 17818.04 Owner- SMOLENSKI WALTER A JR&MARGAR
Zoning: Applicant: JAY BOLAND
AT: 21 O'DONNELL DR
Applicant Address: Phone: Insurance:
233 COLLEGE HWY (413) 203-2454 O WC
SOUTHAMPTONMA01073 ISSUED ON.312912019 0:00:00
TO PERFORM THE FOLLOWING WORK:BLOWN IN CELLULOSE INSULATION, 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 3/29/20190:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
10 73
City of Northampton �. ,�
Al
Building Department
212 Main Street "
Room 100
Northam ton
p one �/`-'�TA �x1 -58 1272 (�
r
APPLICATION OR I SU N lt E O TW FAMILY DWELLING ONLY
SECTION I -SITE INFO ATI N LATION PERMIT
1.1 Procell Atltlress: outlom:. - Ttk section to be cpmPleted by office
NORTHAMPIhN.IAP 01f`80 Q ��{{
Map /�l O Lot 64:;' Unit
Zone Overlay Disbkt
FJm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owne of ecord:
—ILL
Nalm/�e,(1nnQ�,/� f Curzent Mailing Atltl I J
IT l"1Nl. l� Telephone
Signature
2.2 Autharii
� �IP� IGvv1 >7 01
Name Ends) IC rent Mai d(1s�Atltlre^s/
/ lz
�- V�'
Sign me Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Oficial Use Only
completed by permit applicant
1. Building (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. Total=(1 +2+3+4+5) O Check Number
ILT This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: �✓-Zq-�J
BUYtling Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Constroct, n S ervi 1 Not Applicable
c n I r
Name of License Holder, Q Q C t 1 lo I qp Fp
„� _ / L<ense Number
i ��Ilpiktu'�` -� t frotc; NA UIGt3 ) I � I�6
Adi E Poston Date
Telep �'3
Signa re hone
i
9.Reemred Nwea lmnoeemwtk Canfraelor Not A
p
p
licable C �
Com n Name ) Registration Number
M
'Address Expiration Date
Telephon { f
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6l)
Worked,Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
iI. the dental of the issuance of the building permit.
Signed Affidavit Attached Yes....... iN No, , ❑
,Brief Description of Proposed Work 0.0.1
0TtINSULATION ONLY
�
VAI / Se,1, pq
� J
I
I n �Aq J L ^
Syla(t m yw l j C IW'l I ,as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief
Signed under the pains antl penalties of periu .
Shaci
'rinzName
onat_re of O^^wnler n 'X.
r Da,e
l as Owner of the subject
oroperty
hereby aumonze 1W
to act on my behalf in all matters relative to work authorized by this banding permit
Signatvre of Owner Dale
City of Northampton
Massachusetts `
�Q, DEPART T OF BUZUuNG ZNGPaCSZONs
212 Naim street a Municipal Bu Iding Via.
NextDamptlann, M 01060
Property Address:
Contractor
Name: Om
N ^ ,�/
mA_ E'�IY
Address: 43 3
(70 1
IW
City, State:
Phone: VE
Property Owner '
Name: � I1 lc `n��lti
Address: /
t 7 411
City. State: � 6- 2 t V 1 V
/\ IMC
V 1 I C0 (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
Date
RISE
ENGINEERING
OWNER AUTHORIZATION FORM
i, Walter Smolenski ,
(Owner's Name)
owner of the property located at:
21 Odonnell Drive
(Properly Addrass)
Florence, MA 01062
(Properly 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 Signature
Date g,
RISE Engineering,a Division of Thlelsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton,MA 020211339-502-6335
www.RISEengineering.com
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