29-156 The Cotntrumw•ealth of Massachusetts tie tF•orrr►
Department oJ'lndustrial Accidents
Office uf'Investigations
1 Congress.Street, Saite 100
1P Boston, MA 02114-2017
www.mass.govidia
Workers' Compensation Insurance Affidavit: Bui)tiers/('ontr2etors/Electricians/Plumbers
Appiieaut Information _ — Please Print Legibly
Nev, tngiar`d G!een homes
NdSAg tHuSinessl0rganizctiortllndividualj:
Address:59 East Main Street
Ci y/State,'Zip.Stafford, CT 06076 i'ho�e t•:860-930.7794
Are you as employer?Check the appropriate box: `Type of project(required):
1.0 1 am a employer with 4" 4. ❑ I am o general contractor and i
en1p10ydCS(hill atlCi/Or part fimej. hav, hired tnc pub cont� tors i 6. Q New construction
2.Q 1 am a sole proprietor or partner listed on the attached sheet ?. ❑ Remodeling
ship and have no employees I here sub-conlnmors htivc 8. �] Demolition
working or me in aii capacity employees and'nave workers'
B Y p Y 9. Building addition
[No workers' comp. insurance corn[. insurance.•
required.) S. ❑ We arr a �orpvrutiun ,ind its 10- Electrical repairs or additions
3.❑ I eim a homeowner doing ail Work officers have exercised their I I. Plumbing repairs or additions
gltt of!cmpior per MGL
myself. (No workers ,Drop. 12.E] Roof repairs
insurance required.] 1 , 3 t(4�-, nn,1 n c h.vc i
c nlpl)yr u o,kerS
t
Any applicant that Checks bo•Y o 1 mw alsv till Jul 1h 'V t t t mpen,al'. n . 'n16 mnhOn
t Homeowners who submit this affidavit wdicating they arc do :i,ad oe ar 'lhcr,;r,it swo „,u3t submit a new affidavit indicating such.
!Contractors that cheek this box must attached an addrtionai,heel ;hc nerve of'.he and state whether or not those entities hive
employees. if the sub-contractors have employees,they mtlst provide then wurkcrs rorrp policy n.im'her
I am an employer that is providing workers'compensation Insurance for my employees. Below is the polky acid job site
Mfornudion.
o
Insurance Company Name'Inte g
Policy#or Self-ins. Lic- # NewC424991 t \piration Date.
Job Site Address:All Steets in _ _ ,ry�StateiLip:
Attach a copy of the workers' compensation policy declaration page (sh(twing the policy number and expiration date).
Failure to secure coverage as required under&action 2 5 A uf'MGL c 1 S2 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year irnprisumnew. as wcl! as civil pe Iii 11[,, ;n the Torn;of a S-rOP WORK ORDER and a fine
of up to$250.00 a day against the violator 13c ad,iscd that a copy elf r;)Ls statement may be forwarded to the Office of*
inycstigatlons or chc DtA t-br injuiw!cC crvcraKc c'.-i fl�.,t••vii.
/do hereby certr under the aur_s and enalries u ;veriun rhut rh�.r�nl�rrn�nun pru.ided ubuve is true and correct,
r-
i
1 -
Phone#• ( ` r L–) 4 92
official use only. Do not write in this area, to be completed by ciry or town offIciai
City or Town:
issuing Authority(circle o,te):
1. Board0(heaith 2. Building Department 3 City lvs+u C'1eri+, u p:l,tri,al insNcctor s. Plumbing Inspector
6.Other
Contact Person: Phone#
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1,icenscNomber Lxpiration Date
Name of CSI.Holder Dst CSI Tvpc(scc below)
-Type Description
No,and Street
U Unrestricted(Buildings up to 35,000 cu.ft.)
t A R Restricted 1&2 Family DwelliriL_
City/Town,State,ZIP Im Masonry
RC RoofingCovering
WS Window and Siding
SF Solid Fuel Burning Appliances
V I -
Telephone Email addres, D Demolition
5.2 RecriRtered Home Improvement Contractor(HIQ
I-IIC Registration Number Expiration Date
HI C Company Name o?HI C Re is rant Na-me 0 0
t\1
No.and'Street -- L - - -- - —.� �jgrlMa dress bPA
-City/Town, State,ZIP —
SECTION 6: 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 building permit.
Signed Affidavit Attached? Yes ......... It No ....
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property, hereby
authorize � _ —
to act on my behalf, in all matters relative to work authorized by this building permit application.
V1 PC M
Print Gwrier's Name(Electronic Signature)
SECTION 71b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true ')Mi accurate tO the best of m\ knowledge and understanding,
Print Owner's or Authorized Agent's Name(Electronic Signuture') Date
NOTES-.
1. An Owner who obtains a building pennitto do his/her own work,or an ownerwho hires an unregistered contractor
(not registered in the Horne Improvement Contractor(HIQ program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.rna e Construction Supervisor License can be fOLMd at�Kw—w.r Ld�s
5-5.goylo�a Information on th
2. When substantial work is planned,provide the inforinati011 DeIO"
Total floor area(sq. ft.) Inished !)aseirierrt/artics,decks or porch)
Gross living area(sq. ft.) Habitable room COUni
Number 01 bedrooms
Number of fireplaces bedrooms
Number of halUbaths
Number of bathrooms
Type of heating system Number of decks/porches
Type occooling system Enclosed Open
3. "Total Project Square Foolag,:' inay be substituted for"Iota] NuJec[ Cup[-
I'
i,f he Commonwealth of Massachusetts
Board of t'fiilding Regulations and Standards FOR
Electric, Piumbin � tset s State Building('�adc. '80 t: 11�
MUNICIPALITY
N [ham
9&Gas l+�spections USE
To('onstruct, Repair, Renotiate Or Demolish a Revised Mar 2011
One--or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Siguawrc Date
SECTION 1: SITE INFORMATION
1.1 ProRrty Address. f 1.2 Assessors Map& Parcel Numbers
l.la is tnls all aCCepted s rzet'yep iiu �'''-p r Parcel Niumher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use LO(Area isq El) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Lone Outside}Mood Zonc°
Public❑ Private❑ i ('heck vcs❑ Municipal ❑ On site disposal system ❑
SEC I IO.N 2: PROPERT2 O11 NERSHIP'
2.1 Ow er'of Record: i
Name(Print) G . State.ZIP
No.and Street 7 elcphone Ismail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check(check all that apply)
New Construction ❑ Existing Building❑ U��net t_)ccupied 0 �Kepatrs(s} ❑ Alteration(s)
❑ Addition ❑
Demolition ❑ Accessory Bids, U Number of Units Other ❑ Specity:__
Brief Description of Proposed Work' '��j _-_. }S A1�,�`� ,? �-j C— --_ __,-----_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
F',sttnlatcd Cults:
Item ( Official Use Only
(Labor and Matrtr�,ls)
1, Building X Building prnnit 1-ee: $ Indicate how fee is determined:
2.Electrical ❑ Standard City Fown Application Fee
❑7 otai Project Cost(11em b) x multiplier _ _
3.Plumbing 2. Other-Fees: S
4.Mechanical (14VAC) S List:
5.Mechanical (Fire
S hotrt) Alf Ices S 55
6. Total Project Cost: S -
Su resston)J Check No. C)l�ck amount Cash Amount
�__ ` � ❑Pald i�+ Full ❑ outstanding Balance Due:
File#BP-2015-0711
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794
PROPERTY LOCATION 47 BRIERWOOD DR
MAP 29 PARCEL 156 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 105319
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
emo on elay
Z-
' ignature o Buildi O icial 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.
47 BRIERWOOD DR BP-2015-0711
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 156 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-2015-0711
Project# JS-2015-001377
Est. Cost: $2474.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq.ft.): 13982.76 Owner: KUNSANG TSULTREM
Zonine: Applicant: JOHN PERRIER
AT. 47 BRIERWOOD DR
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.11812015 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION
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 1/8/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner