29-438 Property Address: 7 t / // k 4y << r .l
Contractor HOME ENERGY SOLUTIONS
12 PISGAH ROAD
Name: HuisausIGTAm, MA 01050
Address:
City, State:
Phone: y /) .L i y 2 y /" y
Property Owner _
Name: C � Q' / J ri € f to
Address: _ ,
City, State:
1 , /7d /cwm ( / (contractor) attest and affirm that the building I intend
to insulateoes 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
. The Commonwealth of Massachusetts
_*=, Department of Industrial Accidents
=.. U t . Office of Investigations
—till .
— tt1,I -= 600 Washington Street
=litt t
e, Boston, MA 02111
www.mass gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
HOME ENERGY SOLUTIONS
Name (Business/Organization/Individual): J , Ile k it l 0 g4 12 PIS(AH ROAD
HUNTINGTON, MA 01050
Address:
City /State /Zip: Phone #: 'i' / j 1 . / V . `e ' V
1 Are ou an employer? Check the appropriate box:
1. I am a employer with 4• 0 I am a general contractor and I Type of project (required):
employees (full and/or part - time).
have hired the sub - contractors o. 0 New construction
listed on the attached sheet. T. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance .t
required] 5. 0 We arc a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof airs
insurance required.] t c. 152, §1(4), and we have no ❑ �,/ y/
employees. [No workers' 13.[. Other W' f/ /kr „f `9
comp. insurance required.]
Any applicant thatdlccks box #I :rust also fin out the section below showing their workers' compcsatation policy information.
f Homeovmers 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- eontractoa and state whether ar not those entities have
employees. If the sub - contractors have employees, s, 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 Nanie: 4, !rl e' 7 X17 /'di
Policy # or Self -ins. Lie. #: WC X — 31 .f — 7 7512 I 7 _ // Expiration Date: l es ; /I0.L
Job Site Address: J r .171/ "V I - 6 0 // ,f City /State /Zip: / /i> 'ere 4 i%/ /i /1/,
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 DIAfor insurance coverage verification.
/do hereby certi under 7 z7 r and afperjury that the information provided above is true and correct.
Signature: Date: /aG,4- ,�
#
Phone . G f' � w� c2 / 2
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):
L Board of Health 2 Buikding Department 3. City/Town Clerk 4. Electrical Inspector 5. Pluming Inspector
6. Other
Contact Person: Phone 4:
-
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House D Addition n Replacement Windows Alteration(s) n Roofing n 1
Or D oors D
Accessory Bldg. n Demolition n Ne w Signs [O] Decks [D Siding [D] Other [p]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom _ Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition existing housing, complete the following:
a. Use of building :One Family Two Family Other
b. Number of rooms in each family unit: fv Number of Bathrooms /
c. Is there a garage attached? ye f
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? /
f. Method of heating? A / /- et. •iete i' Fireplaces or Woodstoves CJ Number of each 0
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction p r 4'..-' 47
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 C. a'i 7 4 j 14 f ( ^-vi f , as Owner of the subject
property _
hereby authorize i, d G /J 4 /art/
to act on my behalf, in all matters rjlative to work authorized by this building permit application.
ta 4(..w
Signature of Owner Date (,r
, e c44/1' as Owner rize
Age eby declare tha 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 .
Print Name
/
_./ u.. A L� Z
Signature of • r /A$atlt Date ,
Tit! of Nor1ltttntj tnn
r r_
+Alassttrtmsetts ;~ r ° * ,p ,„,",
; ' ,,„A,„
A
` .r DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street • Municipal Building a W wo '
Northampton, MA 01060
L UIS SBROUCK BUILDING PERMIT FEES Phone: (413) 587-1240
BUILDING COMMISSIONER Effective July 21, 2008 Fax: (413) 587 -1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING — Residential
$200.00 PRINCIPAL BUILDING - Commercial
*NEW CONSTRUCTION $ .50 per square foot for 1 floor
.30 " " " " 2 floor
.20 " " % floors, attic, basement, garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of $55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty (120) square feet and over
$ .20 per square foot with a minimum fee of $25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty (120) square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in- ground
*SIGNS & AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING & ROOFING
Residential $35.00 per structure
Commercial $55.00 min. per structure OR $6 /K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1 (1) INSPECTION WILL BE A MINIMUM OF $25.00; ALL OTHERS WILL
HAVE A $50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED, WITH THE COMPLETED PERMIT APPLICATION, TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH - CHECKS OR MONEY ORDERS ONLY !!
* Filing deadline is 12:00 pm (noon) on Wednesday.
/ /I ?.it -".' T .1,4o-
if ^ � Department use only
____\
�r
Ci y of Northampton Status of Permit:
Bu (ding Department Curb Cut/Driveway Permit .
APR 3 l •12 Main Street Sewer /SepticAvailability
L ______
o � � p Room 100 Water/WeII Availability
o> � T of aU � PTON, mao1oso, am ton, MA 01060 Two Sets of Structural Plans
h ORTHA�� p
phone 413-587-1240 Fax 413 - 587 -1272 Plot/SitePlans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
Sq F //in Rol. Map _ Lot Unit
Florence, A A O(O6o2 Zone Overlay District
Eim St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
6.,` //. 4 /(—.) (=., .°7'.. - /4J j4:( _Y-- F (/i ,'(. % d'1) , . i - - ,�G,CL':x , - f /.f •
Name (Print) r ! _ Current Mailing Address:
/\ L .:, / r-C, G c .". , , , e- c.X-�^ -ems Telephone c_-c�7 _ ~�
Signature S �7 J�.
2.2 Authorized Agent:
• HOME ENERGY SOLUTIONS
4 A' 4n/ ' 1 , 0
Name (P int) / HUNTINGTON, MA r1Tl�gbt Mailing Address:
/ L i ' y(i/ 2. / 'I' 9
Signature Telephone
i
SECTI • N 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official 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 fr
6. Total = (1 + 2 + 3 + 4 + 5) 1 3 /3"d Check Number ; (p 7 5(5
This Section For Official Use Only
Building Permit Number: I s
9 Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0946
APPLICANT /CONTACT PERSON JAY BOLAND
ADDRESS/PHONE 12 PISGAH RD HUNTINGTON (413) 214 -2414
PROPERTY LOCATION 59 ELLINGTON RD
MAP 29 PARCEL 438 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out j-47 456" �� rtdi
Fee Paid v ��
Typeof Construction: INSULATION / ' ( \'
New Construction (, j p9(4
r Non Structural interior renovations �, ,' J
Addition to Existing t)
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
roved 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
De itio 1 ela
.
Sig ire of Building Official
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.
59 ELLINGTON RD BP- 2012 -0946
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 438 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- 2012 -0946
Project # JS- 2012 - 001645
Est. Cost: $3650.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAY BOLAND
Lot Size(sq. ft.): 10018.80 Owner: THIEME CHARLES & MARIE ROGERS
Zoning: Applicant: JAY BOLAND
AT: 59 ELLINGTON RD
Applicant Address: Phone: Insurance:
12 PISGAH RD (413) 214 -2414 WC
HUNTINGTONMA01050 ISSUED ON:5/2/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSULATION - FINAL UTILITY INSPECTION
REPORT REQUIRED
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 5/2/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner