15-023 (5) 8 SHEPARD'S HOLLOW RD-266 CHESTERFIELD RD BP-2020-0031
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 15-023 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-2020-0031 .
Project# JS-2020-00004
Est.Cost: $2000.00 7
Fee: $65.00 PERMISSIONIS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sa.ft.): 203425.20 Owner: BILLINGS STEPHANIE J&FRED KIM
zoning: Applicant: JAY BOLAND
AT. 8 SHEPARD'S HOLLOW RD - 266 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
233 COLLEGE HWY 413 203-2454 WC
SOUTHAMPTONMA01073 ISSUED ON:7/12/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.-BLOWN IN INSULATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspec or of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire DeDartment 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:
Feer e: Date Paid: Amount:
Building 7/12/ 019 0:00:00 $65.00
12 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Dep
Cit y'of Northa p ori —n.f- :" r OR
Buil ing Depa men i—C I V I�D
212 Main et SULATION
Room 100 JUL - n ��' "� � E
n„
Northampton, MA 010 0
phone 413-587-1240 Fax 413-587-1272
ONLY
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY Q�.r ,3/
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property Address: This section to be completed by office
W Map_ �� Lot_L.� Unit '
1 II-"IIC�/• ,
Zone Overlay District
Elm St.District CS District
SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
c, Da✓ �a��aw l
Name(Print) Curreflt fN�ng Address: �� J
Telephone
l J
Tele
p �
Signature
2.2 Authorized Agent
Name( rint) Current
W--
Mailing
/Address: U' 0 ?
V
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building G a cl (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=0 +2+3+-4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION!SERVICES I
8.1 U-Penseid Construction S rvis • Not Applicable -03
Name of License Hoider.
i 0 �Y iGfm
^•�+ License Number
ddressExpiration Date i
Afw
( I eiephor:e I` j
1 j
I
r f Not Applicable C
4 yin InNMI
Registration Number
tyu-
Expiration Date
-(�'(�'//
Teiephon����(�I31�
SECTION 5-WORKERS`COMPENSATION INSURANCE AFFIDAVIT(M.G-L.c.152,§25C(b)) �
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....... [E""' No......
Brief Description of Proposed Work
t
j�OW Y� Y11
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 ender the pains and penalties of rjury
?'?nt Name
ze/.
SQrtat m of Owner/ Date
Z'- party
as Owner of the subject
re aoy authorize
act on my behalf, in all matters relative to work authorized by this building permit applil/I
.
f °I
a;ig.,sature of Chvner Date -T_
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite IOfJ
v Boston,MA 02114-2017
www.mass.govJdia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information
Name iBus+ness/Organizationai/indivicival):Home Energy Sloutions Inc
Address: 233 College Hwy City, Southampton
State'. MA Zip: 01073 Phone#: 413-203-2454
Are you an employer?Check the appropriate box: Type of project(required):
i
o1. 1 am an employer with employees(full and/or part time)" 0 7. New construction
t 9
2 am a sole proprietor or partnership and have no employees working for me in any ❑8. Remodeling
_l capacity.[No workers'comp.insurance required.]
€ F9. Demolition
3. 1 am a homeowner doing all work myself.(No workers'comp.insurance required]t o10. Building addition
F-1 4. 1 am a homeowner and will be hiring contractors to conduct ail work on my property. D1. Electrical repairs or additions
i will ensure that all contractors either have workers'compensation insurance or are
sole proprietors with no employees. ❑12. Plumbing repairs or additions
I F S. I am a general contractor and I have hired the sub-contractors listed on the attached o13. Roof Repairs
sheet. These sub-contractors have employees and have workers'comp.insurance.±
D6. We are a corporation..and its officers have exercised their right of exemption per MGL. o14. Other
c.152,§1(4),and we have no employees.[No workers'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 attach 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.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.
insurance Company Name: AMGaurd Insurance Co
Policy#or Self ins.uc. HOWC010506 xpiration Date:
1/4/20
Job Site Address: ,e, o o105-s
Attach a copy of the workers'compensation policy deciaratiori page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL.c.152,§25A is a criminal violation punishable by 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. A copy of this
statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification.
t- t /do hereby certify under the pains and penalties of perjury that the information provided above is true and correct,and that clicking this
checkbox and typing my name in the field below will act as my signature. /
Name: Shawn Mitchell Date:
Phone 413-203-2454 Email: homeenergysolutionsQwl
eenergy2.net
r k ., r' .. .'S� � •#' * - .�� !Y.' .. �Y•,�r. „ - �t � ."}.. .'`►! '�`, ,.'fir'; .".i�,
Permit Authorization
µye
mass save Form
Site ID: 3686593 Customer: STEPHANIE BILLINGS
owner of the property located at:
(Owner's Name,printed)
8 SHEPARDS-HOLLOW RD LEEDS, MA 01053
(Property Street Address) (City)
herebv authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtain a building permit to perform insulation and/or weatherization
work on my property.
13� 9y
Owner's Signature:
Date:
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
Participating Contractor Date
i
Name: CLEAResult
Phone: 800-480-7472
Email:
Page 1 of 1 Fcr Office Use Crit/
Rev. 102015