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36-260 (5) Bardwell Woodworking & Remodeling Highlighted Contractors working on this job 49 Main ST. Hatfield Ma. 01038 413-247-0226 CONTRACTORS INSURANCE POLICIES: Company Name: Phone # Insurance Company Policy # Exp. Date Jonathan Bardwell 413- 247 -0226 Farm Family Casuality Ins Comp 49 Main St 2008x0043 3/13/ » /)- Hatfield Ma 01038 Korpita Masonry 413 - 256 -8541 Blair,Cutting & WC59747007 P.O. Box 263 Smith Inc. Deerfield Ma. 01342 Mistarka Home Improvement 413 - 575 -1271 Amherst Ins. Agency.Inc. P.O. Box 205 20 Gatehouse Rd. Box 48 Northampton Ma. 02061 Amherst, Ma. 01002 AM /PM P &Heating Inc. 413 - 256 -8541 Blair, Cutting & CCP9863020 6/4/08 P.O.Box 527 Smith Inc. Hatfield Ma.01038 Thomas G. Sullivan Dream Tile 413- 863 -9994 A.H. Rist Insurance Agency, INC. 13 H St Box 391 Turners falls,Ma 01376 Turners Falls Ma. 01376 SCP 35693283 Harris & Gray 413- 781 -0416 IRM Insure' Bresnahan M7488266 P.O. Box 300 Insurance Agency Ashfield Ma. 01330 Dion & Son Floor Contractor 413- 538 -7862 Webber & Grinnell CBP1158366 7/8/11 74 Russell St. Insurance Agency Hadley Ma. 01035 James Crowell Carpenter 413 - 247 -5467 Whalen Ins Agency ART0360451 84 Elm ST. Hatfield Ma. 01038 M &S Electric Inc. 413 - 247 -5330 Phillips Ins. Agency s1841019 10/7/08 119 Elm Street Inc. Chicopee Ma. Hatfield Ma. 01038 All Seasons Heating & Air 413 - 247 -9842 Webber & Grinnell MPP45108 Elm Street Insurance Agency Hatfield Ma. 01038 David Michalowski Plumbing 413- 665 -8384 Cray -Dowd Ins. Agency. INC. CBP 5808744 4/7/12 & Heating 17 Graves Street South Deerfield , MA. 01004 Urban & Sons Insulation Co. Inc. 413 - 783 -0701 McClure Insurance CPA018807911 8/1/08 385 Liberty St. Agency, Inc Springfield Ma. 01104 Right Way Drywall 413 -586 -2412 A.H. Rist Insurance CCX0396682 5/15/08 C/O Brian Johnson Agency Inc. 206 Coles Meadow Rd. Northampton Ma 01060 Foster Electric 413 - 296 -0219 Webber & Grinnell MBI95049 4/25/12 C/O David Foster Insurance Agency 24 Stage Road Williamsburg, Ma 01096 Justin Jaquay - Wlison Tile 413 -625 -8501 A.H. Rist Insurance CBP8650804 4/18/12 DBA Justin Jaquay Wilson Agency Inc. PO Box 7 Guckland Ma. 01338 Turomsha F Painting 413 - 296 -4578 Finck & Perras Ins. MPO8901T 3/12/12 Peter Turomsha Agency Inc. 182 Old Chesterfield Road Williamsburg Ma. 01096 • The Commonwealth of Massachusetts �-- Department of Industrial Accidents a., j . _•. t 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): •id r■44 qAJ 86- rr ki.. Address: If ? n1 a (x) (gf • City /State /Zip: MM a lei • L 103e Phone #: '/!3 2g 7 o z Z. C, Are you an employer? Check the appropriate box: Type of project (required): 1.0 I am a employer with 4. 0 I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. El New construction 2. AI I am a sole proprietor or partner- listed on the attached sheet. 7. tgi Remodeling ship and have no employees These sub - contractors have 8. 0 Demolition working for me in capacity. employees and have workers' g any p ty t 9. 0 Building addition [No workers' comp. insurance comp. insurance. required.] 5. 0 We are a corporation and its 10.1g Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.[A Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other 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: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State /Zip: 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 verification. I do hereby cert f under the pains and penalties of perjury that the information provided above is true and correct. Signature: e-� Date: / 2 71 j l Phone #: Y/ 3 2- "('7 6 Z 6, F 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction upervisor: Not Applicable c ❑ Name of License Holder : OIv/4rf� /9 nS gj 1T 7Z Ltct L / /e) License Number d C (fL'�i N ( S7 -- c l �+ ( � (fG'uf • 6/036 `- / /0 / /7- Address Expiration Date •� `�1, Z'17 Sig Telephone 9. Registered Home Improvement Contractor: • Not Applicable ❑ T/Zi�W� =Z f L WOO 41 1'1 2 &,t-.. /6/ ?„5 Comoanv Name t Registration Number wtaito St-. 11-(4/44(d 1/h . 6/630 c, /J /! Address Expiration'Date 6.449 ?,Q� mgr 49 Telephone I/ / 6 )3 2Y 7 d Z Z SECTION 10- 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 buil ng permit. Signed Affidavit Attached Yes No Ott 'S V « e l a t° Cl 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 1083.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature Proposed work at 151 Maple Ridge Road Florence Ma. Master Bath Room 1. Remove existing shower stall 2. Rebuild existing shower stall to area to accept tile 3. Install all new plumbing fixtures 4. Install new tile 5. Install new shower door 6. Replace existing bath fan with new Kitchen 1. Remove and replace existing counters 2. Remove and replace existing appliances 3. Remove tile floor and replace with hardwood 4. Add new cans in ceiling 5. Install under cabinet lights Porch 1. Remove and replace existing FJP rotten posts with new Turn craft poly - Classic Porch posts 2. Replace rotten porch deck boards with new SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [] Addition ❑ Replacement Windows Alteration(s) 0 Roofing ED Or Doors 0 Accessory Bldg. ❑ Demolit • n ❑ New Signs [D] • ke Q Siding [D] Other rszu 1 , i- fi / r Pi ` 19"Fr , " '" _ ' '�7 0 11 Brief Description of Proposed � � l ��� Work: - 5C a :}•{-e.CLAe. Alteration of existing bedroom Yes 410 Adding new bedroom Yes 'V Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll hee 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? 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. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, (7L W• OS O S k , as Owner of the subject pro. • rty her: •, autho i 1 C.NOC -L-v - jekvetkU *.e ` to - , on my If, in : matters relative to work authorized by this building per it application. / 1 30 li Sign 3 re of Owner Date I, '\ Q h.L•{ -L►,. IP RO-; kitJ V k , 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 perjury. 1 iv�,tr.:J��`ti�'1Z �a�+i�I = "= I NCI- ■ . r . I r Print Na 0 NI . i .tli, - 4.° 1 Mil 6 22- 1 Signature of Owner • gent Date e Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW () YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO © DONT KNOW ( YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO *7 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 60 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only _ --- --- , City of Northampton Status of Permit: : i E SA Building Department Curb Cut/9: T;.r 212 Main Street Sewer /Se e i1 — 1$ 6 ZU I 1 Room 100 Water/Wel ' : bility orthampton, MA 01060 Two Sets o • urns 6 no - . . >- _ ,. e • 3 -587 -1240 Fax 413- 587 -1272 Plot/Site PI Other Speci . , e c ►NspEmioN$ ` APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A • ' • R TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office /4/ /'Y Apx. /2. 'D6C , ,Jfy Map Lot Unit Flog EN C E. MN. A. 0/ d d 6 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: i N.AN E s 0 504 s k ti 47 , pu . /tort b 1. , G m it., Na t (Pr t) r Current Mailing Address: 0/ b 6 0 0/ 13 kr$ I/ 8S'a / Jam__` Telephone Sign �ture 1 1101.1 ' -- 2.2 uthorized Agent: O r.1 Ttt-Rit w iftf2IDbc cLLr L I e t AAA Zn1 S}-. .'t- 44at0k AP ► 01 638 Name (Print) Current Mailing Address: C '',6 , 4,3ZZt) r , '113 zj 02Z. 6 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only , completed by permit applicant 1. Building 3q 18 1 , j (a) Building Permit Fee 2. Electrical 5 3 1 8 , 4 - (b) Estimated Total Cost of `J { Construction from (6) 3. Plumbing ( 3 b, 2— •C C) Building Permit Fee 4. Mechanical (HVAC) �i � C 5. Fire Protection fiA /' A' l f O � ,• �7 /' ' 6. Total = (1 + 2 + 3 + 4 + 5) { 1 4 Z G 2- . 3 Check Number ' ` 9 4- L6 5 , 0 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2012 -0257 APPLICANT /CONTACT PERSON JONATHAN BARDWELL ADDRESS/PHONE 49 MAIN ST HATFIELD (413) 247 -0226 PROPERTY LOCATION 151 MAPLE RIDGE RD MAP 36 PARCEL 260 001 ZONE SR(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Cy �% �1! ?( 8 Fee Paid ��// 77 Tvpeof Construction: REMODEL MSTR BATH, KITCHEN & PORCH REPAIR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 055910 3 sets of Plans / Plot Plan THE FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I FO ATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission _ Permit DPW Storm Water Management = • . P elay 7 • _ ature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 151 MAPLE RIDGE RD • BP- 2012 -0257 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36 - 260 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -0257 Project # JS- 2012- 000402 Est. Cost: $4444262.00 Fee: $265.80 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JONATHAN BARDWELL 055910 Lot Size(sq. ft.): 51400.80 Owner: OSOFSKY JAMES R Zoning: SR(100)/ Applicant: JONATHAN BARDWELL AT: 151 MAPLE RIDGE RD Applicant Address: Phone: Insurance: 49 MAIN ST (413) 247 -0226 HATFIELDMA01038 ISSUED ON:9/16/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL MSTR BATH, KITCHEN & PORCH REPAIR 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 9/16/2011 0:00:00 $265.80 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner