17A-066 (9) 256 BRIDGE RD BP-2018-1101
GIS#: COMMONWEALTH OF MASSACHUSETTS
MaDR]o k: 17A-066 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-2018-1101
Proiect# JS-2018-001981
Est Cost, $2000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY BOLAND 101880
Lot Size(sp.ft]: 31101.84 Owner: SIEGEL FREDERIC&JENNIFER
zoning: RI(100)fUPA(100)/WSP(94)/ Applicant: JAY BOLAND
AT. 256 BRIDGE RD
ApplicantAddress: Phone: Insurance:
12 PISGAH RD (413) 203-2454 n WC
HUNTINGTONMA01050 ISSUED ON.4/3012078 0.00:00
TO PERFORM THE FOLLOWING WORK BLOWN IN 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:
FeeTvoe: Date Paid: Amount:
Building 4/30/2018 0:00:00 565.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck-Building Commissioner
Department use only
City of Northampton Status of Permit
>f .. Building Department Curb Cut/Ddvemay Pemdt
t 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 ProVSite Plans
Other Specdy
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH ApONE OR TWO FAMILY DWELLING
SECTION t -SITE INFORMATION B
, (���//d/o
t.t Property Address: Map �ifQ Lot bec 01(/
This section to p y office
R Lnit
dS(,( a 6J— � r
Zone Overlay District
Elm SL Distrla CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 9mer ofWord: �
�S(0 R 9AQ )d
Nam'(( dnln Cement Mai gAd }
dres v o''
I Telephone (
Signature
2.2 Authorized Agents p'
Name(Pont) Cuaent Maihn Addr
it 3 )a3
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
mrn leted by permit applicant
1. Building QO 0 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee o/
4. Mechanical(HVAC) �/
5. Fire Protection
6. Total=(1 +2+3+q+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commiss' r/Inspector of Buildings Date
EMAIL ADDRE$S (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all anolicahlel
New House ❑ Addition ❑ Replacement Windows Alteration(s) EJ Windows ❑
or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs (O] Decks [q Siding[p] Other[Cj
Brief of Proposed n f avyl., ;a ,F la�i le - /S�
Alteration of existing bedroom_Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement _Yes No
Plans Attached Roll -Sheet
Ba.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 stones?
E Method of heating? Fireplaces or Woodstoves Number of each_
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
In. Type of construction
i. Is construction within 100 ft.of wellands?_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_ PmatewellCitywater Supply_
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize )��nWV\ 1111�ViLQ���
to act on my behin a I matters relative to work authorized by this building perm
a it a icatio
Signature of Owner y�nn I Date
,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. c\ ,y/1y�� L
Signed under the pains penalties , gjjj�F J� 1 ' '( I Ve- Il
�� ` awe
Print Name )
Signature of OwnerlAgent Data
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction ewisor: Notl:Name of License Holden J ��J I3�O
'' II License Number
U 144 c UU 1 -y a Ton Md 0/GL3 Number
l i X
Add Expiration Dale
yne
S' to Telephone
9. e Ictemd Home Im rowmem Contractor: Not Applicable I I
qv" EnaV -SlAtr 5 f�(,7gy
comoanvName 11 '' Registration Number
933 G11Q(e HWV I I_!� / /7
Address�I �n // Expiration Date
S(),/T{'�a,VY1 n M (9 W3 Telephone?
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6))
Workers Compensation Insurance affidavit must be wmpleted and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuanw of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
City of Northampton
5
.9 Massachusetts
r. � F
1 DSPAa14ffii1' OF BUILDING ZNSPSCTZONS >
n
212 Main Btteet •Musiei Building
MO \\n`
� LttamptOe, MA 01060
\ 01 a
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
asp
(Please print house o6mber and street name)
Is to be disposed of at: � �1I �I✓I
wfl lol�q odes VNFA1� )1�YI✓tP�� e.�V lflrr
(Please print me and location dt tad!!W)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
City of Northampton
Massachusetts
F?
x
DEPAEO`MENT OF BpILDZNG INSPECTIONS x
212 Main Street * Municipal suilding ZV ca`
\. Northampton, MA 01060 rsyW �`so
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 must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction, alteration,renovation, repair, modernization, conversion,
improvement, removal, demolition, or construction of an addition to any pre-existing owneroccupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building'be
done by registered contractors.
Note:If the homeowner hd.
las contracted with a corporation or LLC,that entity must be registered.
Type of Work: �YI< a—I fro- Est. Cost:
Address of Work 'Y ' YI Q ^lJ- . I 1 OV rice
Date of Permit Application: —I r jo j
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law(explain):
Sob under$1,000.00
Owner obtaining own permit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
yNO I I� Sri Wn mid,, 11 1 �6�)&/
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,l hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
Nr 0((cr..,so/
ni��xr� rr��rrlrlll
Cffloe of Consumer Affairs and Business Regulation
10 Park Plaza•Suite 6170
Boston, Mgssaohusab 02118
Home Improveme'tit06r9ractor Registration
,�,' ' RepletreUoPd, �tbn
Hone Energy Solutions Inc r i,'•`? axp mloA 01103M013
68 Russellville rd
Southampton, MA 01073
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. 1nri'.�,` TYPE,CorporMkn berore dO v"aft Ntd gogg mar
Ctxosk Rw- mer 8170 and BMNnaea xaxWMlon
'��'-' : 180749 gi�epte 10 Pork Plw• 8170
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Home anergy BokdlMne Aro
ohm&Whe7
98 Ru$nM k rd C - —.—
emNhempton,MA 01073 —
Undereaoret" Not Wid without xlgaature
I
I
Jay Boland
ID#201'1.584
nngdrdal{h„ 1•'hrr.,)I ILII, ,•IIS,
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Massaohusstts Oepertment of Public Safety
Soard of Building Regulations and Standards
License: CM 10ft
Construction Supervisor"OtmNy
JAY R SOLAW
1e PIS®AN RC
NWMINSTGN MA 01060
"ppl664 .a'[, Egptratlonl
Commiseloher 121gi1¢01A
I
I
the t,otnatonwealtk of Massachusetts
Department oflndustlid Accidents
Office of-Investigations
9 600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit. Builders/Contractoms Electricians!Plumbers
AvulicantInformation + -I Please Print Le ' t
Name(Business/Organvatiodtndividual): WowE .q 1 �-
A&Iress: C51�e H („I
City/State/Zip: _SaA0,MK/k MA ON-73 Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.M I am a employer with k9- 4- ❑ I a n a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet t ?- ❑Remodeling
ship and have no employees These sub-contractors have 8- ❑Demolition
working for the in any capacity- workers'comp- insurance. 9- El Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I1.❑ Plumbing repairs or additions
myself.[No workers' Camp. c. 152,§1(4),and we have no 12-0 Roof repairs
insurance required.]t employees.[No workcis'
comp.inamance required] L
13E Otherj4) 1(A 11
t
;Any applic®t that decin box#1 men also fill write section below showing thelrworkew cumpnestion policy hnromration.
Bama+wttas who submitdtisatridavis iodi®tirtgtkry asedoing all work®dthat hire onbide contrumrsrnmt submit nttew aifMarit ifrdiatin%such.
iConaacfoa tins check Wu box mustatlacbed as additional sheet showing the same of the mbmotracrors sod theaworkeo'comp.policy infamadan.
I em as employeramt is providing workers'compensation insamncejor my etnnbrvaea a,.r.»..:.a,p..rAy warJoa sa¢
Insurance Company Name: '' II `` ''��l`)Uptir✓-'tom IISurGntz_ 1-OMpn�
Policy#or Self-ins.Lie.#: N1)W1 G q�j-1 Yt, Expiration Date: 1 '7 l�i,f9�1
Job Sire Addr A,S� �Il/� 0 CiVState/Zip[I6Vfsrk- /rl if 010G�
Attach a copy of the workers' nsadon policy declaration page(showing the policy number and expiration date).
Failure to sectne coverage as required ander Section 25A of MGL c. 152 cart lead to the imposition of criminal penalties of a
fine up to$1,500-00 atul/or one-year imprisaument,as well as civil penalties in the form of a STOP WORK ORDER and a fine
if up to$250.00 a day agamic the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage venficatwo-
t do hereby Certify un pairs and ury d ua the Jaforrrraaon provided a and correct
ir M � o I g
ii to e:
'hoe : 11
7�--7
ase only. Do ant write in skis area,to be romplkwd by my or roam ofJ9ctut
Town: PBIWII/IrICOHSClI
A na d of fleBuilding Department 3.City/To"Clerk 4.Electrical Inspector 5.Plumbing Inspector
r
onact Persn: Phone#•_
■ ISE 60 Shawmut Road, Unit 2 Canton, MA 02021
ENGINEERING
OWNER AUTHORIZATION FORM
Jennifer Siegel
(Owner s Name)
owner o'the or, located at
256 Bridge Road
tStreet)
Florence, MA 01062
(Town_ State, zip,
herebv author ze YYC,-' _
;Subcontractor]
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
Dern-it and to per#ocm work on my property,This `onn is only valid with a signed contract
The Permit will be secured by time 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..
-Customer Signature
112
-Sign date
1/1212018