31D-231 16 FRUIT ST BP-2018-1094
GIs 4: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 D-231 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGLLcc.1144/2�A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2018-1094
Project JS-2018-001971
Est.Cost:$3000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouo� JAY BOLAND 101880
Lot Size(sa.h.): 5749.92 Owner: MORYAWN
zonine� URC(100)/ Applicant: JAY BOLAND
AT. 16 FRUIT ST
ApplicantAddress: Phone: Insurance:
12 PISGAH RD (413)203-2454 O WC
HUNTlNGTONMA01050 ISSUED ON:4/25/2078 0:00:00
TO PERFORM THE FOLLOWING WORK.BLOWN-IN-I NSULATION 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:
FeeTvue: Date Paid: Amount:
Building 4/25/2018 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
QoCity of Northampton status of pemat
Building{Department Curb CubDnveway Penna212 Main Street Sewer/Sep is AWlabilityRoom 100 WaterAKe6 AvaiMbikyNorthampton, MA 01060 Two Sea of structuralPians _
phone 413367-1240 Fax 413-567-1272 piausita Pkw
APPLICAVOK TO CONSTRUCT,ALTER, RENOVATE OR AONE OR TWO FAMILY DYaELIMG
SECTM 5 -SITE 1NFORMATWN QI P^ ( 7^ f CR V
nemc � '�w,+s Th sestionMtx oampla6eLL byotaee
Lrl) Let
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Map
I k'(t1A Zone_, Overlay Disbicll
Eft SL D1st4ct ca Dbbkt
SECTM 2-PROPERTY OWNERSMP/AUOIORLD AGENT
t \a of ReeoN:
01
0'to IY\C)✓ _
Name(Pdnt) Curtest 7
A44u[h llTekw»x� i �eC 3
6 ,aa
Name(Pma) Cue Ma.WM Adtlresa"� (f (J
Sgnaaaa Toia kcoe
SECTION x pcnNeTED COMMUCTIM COSTS
item Estimated cost(hollers)to be oraciei use Only
eted R a liars
1. BuN(fing y, (a)is ifd&W Peon Fea
2. Ekck+cat U (D)F-atinadad Total Cast of
C"bjxbonlmm 6
3. %Umaing Bu6ding Permit Fee _tJ
4. ME:chanical(HVAC)
5.Fire Protection Check Numbe��,_.. �a
& Tatai.(1 +2+3+4+5) 0c
Ttda Section For Offiaiet Use
Date
Suddag Permit Nkvnber .. issued'
Signature:
goadsV of Bkadrop Tk18
EMAIL A,pp .ESS{R£t3UtRE0;EITHER HOMEOWNER OR CONTRACTOR)
SEAN 5-DESCRIPTION OF PROPOSEO WORK felwck au apitu ab e)
New House ❑ Addition ❑ Replao irmat Windows Afteration(s) ❑ Roofing ❑
Or Doors C3
Accessory Bldg. r❑ Darnoiffien ❑ New Signs M n Decks LQ Siding 071 Other
Wodr0escnPtia'of
Alteration of ehtistirg bedroom yes—No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roll -Sheet
as.If New house and or addition to existing housing comptele the following
a. Use of building:One Family Two Family_Other
b. Number of rooms in each family un0: Number of Bathrooms
c Is there a garage attached?
d. Proposed Square footage M new consNtlion. Dimensions
e. Number of stories?
I. 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 R 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 confornto the Building and Zoning regulations? Yes No.
I. Septic Tank_ City Sewer_ Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO 13E COMPLETED Y11�N
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMR
I, A V-, my as Owner of the subject
property
h naby act on y behalf,
G( M 1
f4 act on my behatl,in all matters relative to work autimdxed by Nis bu0dirg parent
� 66kwj V T 3 I Ips
Signatum of Owner Date
1. �5���,>n U as timer/Aulhorcmd
Agent hereby declare that the statements and information on the foregoing appliotion are true and accurate,to the best M my knowledge,
and belief.
Signed un r pains and penalties f perjury
Print Name
/5AZ�F Y '-� '
SigreWre of OwnsdAgent Date
SECTION 8-CONSTRUCTION SERVICES
8.111censed Conshruclon Supervisor Not Applicable ❑
Nemo of licensewor Holtler: �. - � jelx�r�
3
Telephone
8.Realsbeffid Homme me Contractor
0A Me �110A-qt/ 'U i 0 k j Not D l0 I ❑�_
Regisha6e
y3
70dress , Ezpirabon Date
Telephone
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVrr(M.G.L a 15Z§25C(6))
Workers Compensation Insurance at&lavit muss be Completed amt submitted with this application.Failure to provide this affidavit will result
in hie denial of the issuance of 8ie building pennil.
Signed Affidavit Attached Yes...__ D� No...... ❑
City of Northampton
:,'�.• Massachusetts
nSPAR"IMM OF Sm=1NG zowtCrzons
as in
212 atmat • a aipal a idiog J
t I Z
narehampten, va 01060 rsrp `eco
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes. Prior to
performing work on such homes,a contractor mast be registered as a Home Improvement Connector("HIC").
M.G.L.Chapter 142A requires that the"recpisbuc¢on,after ttion,renovation,mpek rrrodemizEwm,o,,v&ajan,
improvement remoyai,demolition,oremsbuchon of an addition to anyji e ;tshw owrter-accoplad bWAd rg containing
at least one but not more than fourdwaffing on&....orto structures which are adjacent to such resMenoe ortwadirg"be
done by registered contractors.
Note:If the homeowner has contracted with a corparadon or LLC,that enihyhe registered
Type of Work: ;ralQ 00
Address of Worldd U_J Sq_ 0 0J Q kU, 41
Date of Permit Application:
I hereby certify that:
Registration is not required for the following real ut s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENIEMG INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L Chapter 142A.SUCH OWNERS ALSO ASSUME THE MPONSBILITES FOR ALL WORK
PERFORMED .
UNDTHE nMWI,,G PERMIT•5EE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
1 hereby aply for a building permit as the agent of the owner.
Date Contractor Name WC Reastraiam No
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
�' alaasachus®tts +'
axean2k0107 or anxauurc acsrartsops =
2121 3t 1, -� W e Idi q
iortbYpton. lW blow �t9 3'11
Debris Disposal Affidavit
in accordance of the provisions of MGL c 40,554, t acknowtedge that as a condition of the building
permit aN debris resulting from the construction activity governed by this Building Permit shall be disposed
of kr a properly tiaensed solid waste disposal£adlity,as defined by MGL c 111,S 150A.
The debris from construction work being performed at.
1<� ` f i , <, j _
(Ptease print hawse number and sheet name)
IS to be disposed of at
W*jwj�—�k S N ,Id �am and location off �Y'ty
Or will be disposed of in a dumpstar onsite rented or leased from:
(Company Name and Addessr }
Signature of Permit APpiirart Owmer 4ate
if,for any reason,the debris vnll not be disposed of as indicated,the Applicant or Owner shall notify the
Building Department as to the bcxhtfon where the debris will be disposed.
.rte t,onraonwealth ofMassachrtsetts
Department oflndastriat Accidents
Office oflnuestigations
' 600 Washington Street
Boston,MA 02111
www.rnassg"Idia
Workers' Compensation Insurance Affidavit: Bullder6/Contractomw-leetriciansmumbers
Applicant Information Please Print Lespilitv
m
Nae(Busi ess/Orgairmilon&dividualy Umquo
{r( t� ,rep 1041 in(.
Address: C{Idl12Gz C tl4h
City/State/Z* WAQIrMOnA Imp 01(,45 Phone#: y[3 - �6 �- ��/SL/
Are you an employer?Check the appropriate box: Type of project(required):
1.29I am a employer with kE- 4. ❑ l am a general contractor and 1 6. []New coo aniciion
employees(full and/or pan-time).* have hired the subconttacturs
2.❑ I an a sole proprietor or partner- listed on the attached sheet t 7- []Remodeling
ship and have no employees These sub-contractors have g. Q Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers' comp.insurance 5. ❑ Weare a corporation and its
required.] officers have exercised their 10.Q Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption Per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]1 employees.[No workers'
comp.insurance required.] 13E Other + a
`Any ap I.—thatchecks box k1 mast also fill cot ftn cfim below showingtlxirwmktW campemnionpdkmy ifiommdon.
t Homeovm.who submit thmdrWi,va ia&MMg dmy aredoxg all vmrk and dwn him;ontsidecontmema mausubmitarnw nlrMavit iaMipting mch.
Tcoa tura that rbeck this bozmuslattached aaadditiomishod showing the name of the suh-ma4actms and their wotbis'comp.policy ivfocmnaoo.
Ion an esnptoyerthat is providing workers'corxpensatian insarancejor my emnhmeoe a r.....».xeP..a..y wtaJoosee
inforwaNna. ((�� I� - /+
Insurance Company Name. 0V(kbP)adJ TA.5uravic,_ t-O:N1�nP:1
r �� '/ i
Policy#or Self-ins.Lyic.#: �' W C. '7 Expiration Date: l t
Job Site Address: 1 O l l ,.- City/Statemp:� 010 6
Attach a copy of the workers'compeasadon policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required ander 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
0u 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
F da hereby certifypains�a!nd nrl'Haat rhe injormorion provided a is and correct.
ii I
OJfeW ase meta Do not write in this area,to he cornpkwd by cdy or town oAiclat
City or Town: PeCaIiUL[ceBSe
ies.rieg AetL.e.aa'(o:`oro ono).
1.Board of Health 2.Bonding Department 3.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:_
< )Iumbla Gas
"! N I1 IS,;KIIUSCU.S 60 Shawmut Road, Unit 2 Canton, MA 02021
A NiSource Company
OWNER AUTHORIZATION FORM
I, Yadin Mor
(Owner's Name)
owner of the property located at:
18 Fruit Street
(Street)
Northampton, MA 01060
(Town, State, Zip)
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.
The Permit will be secured by the insulation contractor, at no additional cost. It is the homeowner's
responsibility to close out this permit by contacting their municipality at the completion of this work.
-Gustd ersignature
-Sign Date
3/22/2018
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Office of Consumer Aftairs and Business Regulation
10 Park Plaza•Suite 6170
Boston, Massachusetts 02118
Home improvemeirt Contrttotor Registration
Corpastlon
Horne Energy Solutions Inc m8�on 01IM2018
88Russellvlllerd
Southampton, MA 01073
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shaven whell08 RLWOKIO rd
SOWhampton,MA 01073 —
Underaeoretary KGOWtd Without Etgnature