23D-128 (5) 16 WINSLOW AVE BP-2019-1167
GIs# COMMONWEALTH OF MASSACHUSETTS
MU.Block: 23D- 128 CITY OF NORTHAMPTON
ot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeorv: INSULATION L V ILDING PERMIT
Permit# BP-2019-1167
Project# JS-2019-001890
Est Cost:$2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sa.It.): 11586.96 Owner. KRASSNER DANIEL
zoning URB(100)/ Applicant. JAY BOLAND
AT: 16 WINSLOW AVE
Applicant Address: Phone: Insurance:
233 COLLEGE HWY (413) 203-2454 O WC
SOUTHAMPTONMA01073 ISSUED ON:4122/2019 0:00:00
TO PERFORM THE FOLLOWING WORK:BLOWN IN CELLULOSE 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 4/228019 0:00:00 $65.00
212 Main Street,Phone(413)587-1240, Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
City of Northamp to
Building Departure I
212 Main Street APR
Room 100
Northampton, MA 01 0 0
58
phone 413-587-1240 Fax 41 41
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION 7 -SITE INFORMATION PERMIT
1.1 Property Address: This section to be completed by officer
Map Lot . ii;x;z UnitZone_Overlay Distrito
Elm St.District CS Distinct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record;
_V�)n 'A'u. G&SSAfjr 16
N"tCif Vng 1I
a T ' M,_
S',.Wus
2.2 Authorized Agent:
Name(Print) '4a� Do 7 Mng Add
71-� -
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost(Dollars)to be Official Use Only
comp eted bv D rmit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical 6,
5, Fire Protection
6. Total=(I +2+3 +4+5) 61 :2)o Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: /i�
Building Carmaissionerlinspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTON d-CONSTRUCTION SERVICES
8.1 Licensed Construction S y ervis w q Not Applicable
❑
Name of License No der-. Q Q 1(3 bl
/ 5—
license Nmbar
C91leFe x w�R�al� ��A 01073 1� /, J1/16
dtlreas ) r Expiration Date
�i3 ao3 , i /
Signa n, Telephone
M Homel® Not Applicable C
. e EI U on W1�
Company Name Registration Number
PCo e Q(j ' !"460(41 M6 C1673 ra 41"6
Expiration Date
Telephon � Q
SECTION 5-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....... IR" No..._. Cl
Brief Description of Proposed Work NOTE: INSULATION ONLY
-'610WY� I✓1 C'—t vU -e an , R,✓
I. ha u )n I FI Ile,ii.&J 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 and penalties of peq
Print Name / � 1'fSgneture of�Ownerl� /� n Date
I, 1 J( A ��J'J� ✓���`vY as Owner of the subject
property
hereby authorize /�u`4/'n �I il�Y1Q II
to act on my behalf, in all matters relative to work authorized by this building permit p t q
M �f1
Signature of Owner Date
i
City of Northampton
Massachusetts
DapmtnED r OF BUILDING INspr=Ms �t
212 Win Strwt • Municipal Building _
aertha ten, M 01060
IynI
Property Address: l l L
Contractor
Name: hl Mor��r /�� /l 4(iln�
Address:
City, State: Sot 40 _U
Phone: 3
Property Owner 1 /Q n�I ✓
Name: 1 I/ 11 ` u//.��J�
Address: W 14� 10 W
City, State: Q/-2nl Q Mft} Q �Q
I, y)I la,i M I J19' (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 co y of this a�fFidavi
Contractor signature
Date
RISE'';
ENGINEERING'
OWNER AUTHORIZATION FORM
I, Daniel Krassner
(Owner's Name)
owner of the property located at:
16 Winslow Avenue
(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.
V
ane Signature— \— ny
7:;? r ( 1
Date
RISE Engineering,a Division of Thielsch Engineering, Inc.
60 Shawmut Road Unit 2 1 Canton,MA 020211339-502-6335
www.RISEengineering.com
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