13-040 (2) 1'Joe Cottunwnweullh oj'Massuchusaas
Depatitnrtnt of hsdtutr1e1 AceAlknts
QhIce of�investfg�)t n
Y CQ/tglt!'SS.StrC�i!s.�'I/�lC jt�'
Boston,MA 0,2JI4404 y
wwtviouss.gowdla
Worken'Cotnp+ewation Insurance Affidavit:Builders/Controetors/Electricillaoittmbc)
Elesse ftt Left,
Nam;(814inswor izattioNlndividuai -ew England Green homes
Aidress:49 944M,00 0 80"'
q /State/Zi ;Slpford,CT 00070 Phone#:06"'Wg7S4
Ad+e you rraa entpky"I'Check ha appropriate box:
4 4. tam a eneral contractor pod t ype of.p ! t( Ia )"
I"M !'sun�►employer with (] $
ellipiolrees(furl endlor
prof-[sine).' hpvc,hirers tha sub-contractors 61 0 New conatrli019P
2.❑ 1 on a 3010 Proprietor or partner- listed on the attache[sheet: E3 Ft modeling,
ship and twe no a mployti" These sub-contmetors havt: 8. Q Demoliflon
for me in any capacity, employees and have workers 9. Q Bnildtns'* ott
(Novomm,gip,inAuanire twmp.'insurom:
requir4l 5. 0 We Ans awrporadonwwl its 10 0 Eletttcioal r0ity oir to oris
3.0>:.attt 4(tOmoowner doing ail work officers hour'exercised their I I.[]Phrmbing repaittl or t►dditivtls
Myatt,iNa workers'comp. right of exemption per MOL 12. Roof npla
irittwat o required.) c. 152;f 1(4),and wv have lo*ox
employees.[No workers' 13,( Olher-
com .10surancr required.
'Any teipllalnt that al►aeks box N i e►tust also fist ouctha seutioe below[hoeing their wod ers'compennation policy lArmittion.
e filomsoweae who submit this othdtvh indicating they Ara Aoirti+ll wort,rnd then hum ouwide commown crwu submit s Aew sM& 4iQ�aadr�,t uch.
10OWlifts:datt oheelt tktt box muu atuchad an sddhloW Awl sho%ing tho Ain of the sub,wntnctco and,90a whadw or not thsae arsine to"
IN*tab-cotttrA AO"hour:etwoytxe,they mint provade their workers'camp Policy number;
�Of�t pie ✓M�fJ,�d'�Qt�`Jt)'yDYl�$W01'+�"ttl+f's CdJI�CIJ<4Q110A�trliAt!t for'f#y;L�16J'�. Btr�BW�S'lid' ► �'a "`
1!(farrp111*'f.
tawranoa Comynrsy Name:Intego _
Policy k'or Self-im.ALlc.0:NowC424991 ^ u Expiration Date:
Jots Site Addr=.AU St"tf In GitylScetel� 6lo(, Co
Attstelt tt:40py of t+lle workers'empettaation policy declarrtlm pagt:(bbowiag the+polka^evenbeir tisd;sxptrattihis dot!).
Nittra toateetm oovMe as required[older Section 25A of MOL c. 152 can lead to the intpos tion of Dimino penal watt
tine up to 5.1,500.00 l ou0no-year inquisantnent,as well as civil penakim in the form of*S'i' p WORK ORDER tint a$tae
ofttp to S23d.00 a chy i a rtst the viotalor. Be atdvisod that a copy of this stpinment may, forwarded to die 00100"of
Invo p lon5 oftho DIA 1br irmuranoe ovvarage vwrrnvation.
I do Jrsnob ce u ortlrt` alas acrd rrlrlvs o trr ttr►that/14tr tic orrrrarlon p ulded allaYa Or Vus i carrier:
i
�l titstr aal�c Dt►not writ[In[Also au>raa,lttt bt aiMaBttdtd 6y r.�ty artatorn ap?ciat
City orTowp: Permit/Licease N
Iauwing Authority(eirele one):
1,%itrd orHealib 2.Building,Depar'tment a.�Cityt7vwa"*•clerk 4. EIewleal'iaspeetor 5,Mug bing Inspoeftr
.1
ot
co 'Phw�M:
SOMON 5: CONSTRUCTION SICRVICES
RI co,►�trucct;.oa snpsrvlsa��(G'$L) t�'�1� t:L t�1� i
# N1 , Liaenso'Number Elp+►vue
N+woof= Molder
S'9 g -r i Pd •:57`i'" List esL Type(see below):
No,indI eet ! t
,:.'r''t"�►.4x>�a�' 'S#at�t4�� u
CitylTotvn,State;2IP R RMWded ldt21Fitttl 'Dwellla
M Ma"ry
RC Rou C2ver3n
wS window_and<SidIn
SP $Wld Fuel R uning App&w=
1 lnwledpn
T Faadl D Demolition
S:2 Registered Rowe,Improvenwat Contractor(010 [a D"Z l
H1CR,Dyilstration XUmba FXpinulott Date
Hly attmm; HlNanu o _ o'
ckytrov^State?' IP' Ti!! c
SECTION 45;WO MRS'COMPENSATION INSURANCE AFFIDAVIT(?4.G L.c.M 125C(d))
Wo*M,Conpensation Insurance affidavit must be completed and submitted with this application. Failum to°provide
this-aflldavit will result in the donial of the Issuance of the.building pW'mit.:
Signed AfRdavit.Atachexi? Yes......,.,..% No . .......0
SECTION 7a:OWNER AUTHORIZATION TO BE CQMPL$TEV WHEN
OWNSAIS AGENT OR CONTRACTOR APPLIES FOR j1JRaING PERMIT
t,as the subject p ,fiereby authorize
to , my It in ntatiers 've to work authorized by this building permit ap lie;atim
eetwome nic Signature Psi@
SECTION 7bs 5WN1W OR AUTHORIZED AGENT DECLARATION
By eowft t4y now below,I hereby w at under the pains and Penalties of Perjury that mdl of the Information
contained IMINSVOlication is true aid to tlw Imastof my,knowledge an+d'understandint�, j
l f
Print s or Au rixttl. 's Name(E Ic S!znatum)
NOTES
1 An o wper wbo obtains a building per mit to do N own work,Oran owner who hiMs an tmtegisUavd,oanpactos
(trot tt�lsteresd ht tiro Notno lhiprovalnant Contractor(HiC?r'rcrgratp},wilC,gg j have aocxss to the arbltatmtlotl
In+oVem or gummniy fund un der M.G.L.c. 142A.Odw impostutlt ltlformtttlon on the H1C Pro$mm cml lot found at
�vww mass¢av/ocs lahrn a#on on the Construction Stq�visw License can bekfound ativl!'�l,mass.aov/tea
2, Wbo ii ttut W work is.plaltnod,provide dw information below:
Total.floor am(sq.t) (including garage,finlshed bawnwnnt/attics,decks or parch)
liv tlg aream(sq.tt) Habitable Loom couht
Nunow of fizaPlaces Nomber of bedrooms
Number of,batiirooms Numnber:of halfibatlma
' ofleating"ton Number of decks!porches
Type otwoling.system Enclosed
3. "TOtAi`J?rojemct Sm mJatt)'FoOtme.may be,substituted.for"Total Project Cost"
AL 13 N
tic p►u bin Gas ill P_C ions The Commonwealth of Massachusetts
Matti
01060 Boa4 Massachusetts Building Regulations and Standards FC}R
State Building,Cade,78d+CMIt; MUNICIPALITY
U�
Building.Permit'Applicat ion To Construct,Repair,Renovate(7r-Demolish a RevlsedllUim2011
0*-yr rwo-Family Dwelling
This Scdion For Official Use Only
Building,Pawlt Number. Date Applied:
Bu1W*g 0ftId(Pdm Ns=) Signature
SECTION 1:SITE INFORMATION
I. Add 1.2 Assessors Map&.Parcel Numbers
1.141s dds an Strew yes no Map Number Parcel Number
13 Zontag Information 1.4 Property Dimensions;
Zoning District Proposed Use Lot Aro(sq R) Frantap eft)
14 BuHd!!j Setbacks,(ft)
FronsYwd Side Yards ttW Yard
Required Provided Required Provided Required Provided
1.4 Water Supply:(M Gi.L c 40,fsa) 1.7 Flood zone Information: 1.8 sewage Dispoetni SyNeur
Zane: Outside Flood Zone?
Public p' Private E3 -- Municipal D;On sita'dIsposai sys#arn '0
Chock if ye93
SECTION 2 PROP IERTY OWNERSHle
2.1 g�1 ocord: 0 LJ
tarnc{i?rint t'C' ,stoic.ZIP
/..3 -'
S �(
,and Street Telephone Email Add".
SECTION 3:OESCRIPTION'OF PROPOSED WORK=(chock all tltet app.Iy)
New Construction A Existing Building 17 Owner-Occupied 13 Repairs(s) 13 1 Alteration(s), 0 Addition
p4motition Q Accasaory Bldg.0 Number of Units I Other 0 ifr',
Brief6wc-rintian Prapoaed Waric
SECTION 4:ESTIMATED CONSTRUCTION CO Ml
Item Estimated Costs: 011kia1.'Use Only
Labor and Materials
it B�:ildi� � 1. Building Permit Fee:$ Indic=hoer*e is d ina
0 Standard CityiTown APPlication F'ee
'
$ 0 Total Project Costs(Item 6)xr multiplier x
3,PJumbing $ 2, Other Fees: S
4.Mechanical (HllAQ 5 List:
S.Mt local (Fitt S Total All Fees:S S
an
-' ChockNo.lop Check Amount: Cash,Amount
6.Total Project Cost: $ .a j Q/S O Laid in Hill Cl Outstanding BalUp L7Q+e�'
File#BP-2016-0054
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 409 NORTH KING ST
MAP 13 PARCEL 040 001 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 ,r ,�J!� /
New Construction (� �)f [
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
INFO MATION 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
i Delay
Signature of$uil i g Of 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.
409 NORTH KING ST BP-2016-0054
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13-040 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categorv: INSULATION BUILDING PERMIT
Permit# BP-2016-0054
Proiect# JS-2016-000101
Est. Cost: $2015.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sa. ft.): 30317.76 Owner: DESGRES RICHARD JOHN&CINNAMON A
zonine: Applicant: JOHN PERRIER
AT: 409 NORTH KING ST
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.711612015 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 Occupant/ Signature:
FeeType: Date Paid: Amount:
Building 7/16/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner