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11A-070 (9)
The Commonwealth of Massachuselft '.,.., Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricions/Plumbers An ficant Information (lease Print Legibly Namc(tiusiness/Organizatiort/individual);New England Green homes Address.. 2-6 5 fDCA1 V"0i\_) -P) A_ .... .. Ci /State/Zi Stafford,CT 06078 Phone 1i,860-930.7794 Are you an employer?Check the appropriate box: 'type of project(required): 1. 1 am a employer with d 4. 0 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 1❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7, ❑ itemodeling ship and have no employees These sub-contractors have g. []Demolition working for me in any capacity. employees and have workers' 9. Building addition (No workers'comp.insurance cotnp. insurance,- required.) 5. [] We are a corporation atui its 10.❑Electrical repairs or additions 3,❑ 1 am a homeowner doing all work officers have exercised their I I.[]Plumbing repairs or additions myself.[No workers'comp. right of exemption per MOL 12.[]Roofrepairs insurance required.] c. 152,§1(4),and we hart no employees.(No workers' 131y1j Other comp. insurance required.] *Any applimt that checks box Ni must also fill out the section below showing their workers'compensation policy in[brmation, t Homeowners who submit this affidavit indicating they are doing ail worA and then htm wisido contractors must submit a new affidavit indicadns such. lConttactors thst check this box must anached an additional sheet showing the name of ifhe subcontractors and slate whether or not those tsntitief have employees. If the subcontractors have employees,they must provide their workers'comp policy number. I em on roployerAd Ls providing workers'compensatlon Insurance for my enVloyeeL Below is the po&y and jab sloe lrefo►w wkn. Insurarioo Company Name:Intego Policy#orScif-irss.Lic.#:NewC424991 Expiration Date:�,�_. Job Site Address:All Steets fit City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to sm ft coverage ru requir W under Sectio 25A.:ic.0 M can i:ad to M e imposition of crintine! ialtiL!ofa 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 flue of up to 6250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations or the DI fbr inaurattaa juverago Yuri Scut ion. �rnetemssssnswt 1 do hereby cerlds under the p airs 4nd en ties v Le er'uoy that the Information provided above is true and correct: f at Flom / d -3 Of elal use only. Do not write to this area,to be coipnpietetil by city or town afficiac City or Town: Permit/License l/ hisuing Authority(circie one): 1.Board of Heaths 2. Building DcPartmcnt 3.City/t'owu Clerk 4. Eieatrical inspector s. Plumbing Inspector 6.tither Coaster Person: Phone#: SECTION S: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 15 f IV_0-0 kN Ti�1Q,i�t License Number l Expiration1Datc Name of CSL Holder a �� n� List CSL Type(sex below) No.and Street 7 7 � ) Type Description U Unrestricted(Buildings up to 35.0Ut!cu.ft r-`1--; 1 R Restricted 1&2 Family Dwelling_ CitylTown.State,ZIP M Maso RC Roofing Covering WS Window and Siding y SF Solid Fuel Burning Appliances Step'!3�" '��,1#%p.+lfzt"' lvQjq •�'oM I Insulation Telephone �� Email address D Demolition 12 fostered Home Improvement Contractor(HIC) (. HIC Registration Number Exprration Date HI C v N a HI . e ' t Name o a No.a W street E S City/Town,State,SLIP Tote hone _ SECTION b:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.$25C(Q) 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..........0 No...........0 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 NI DQMD I tY1 to act on my behalf,in all matters relative to work authorized by this building permit ap Beaton. �'1z Print Owner's Name(Electronic Signature) Date SECTION 7b: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 and accurate to the best of my knowledge and understanding. ` I t Print er s or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home improvement Contractor(HIC)Program),will W 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.mass.govloca Information on the Construction Supervisor License can be found at www.mass.eov/dns 2, When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" rvny � i t ut Llhj AUG 19115 LFORDec d The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code,780 CMR MUNICIPALITY USE Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Zroperty Address: 1.2 Asse ors ap&Parcel Numbers 1.la is this an accepted street?yes no Map Num er Parcel Number 1.3 Zoning Information: _ 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Requimd Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone lnformition: 1.8 Sewage Disposal System: Public❑ Private 13 Zone: Outside Flood Zone? Municipal D On site disposal system ❑ Check if yes0 SECTION 2: PROPERTY OWNERSHIP' 2.1 1pC� Na errn� C'�=/�%1 ✓ J 7� C11y.State ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building la Owner-Occupied ❑ Repairs(s) D 1 Alterations) D Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other O Specify: Brief Description of Proposed Work 2: ✓�ClI r/ °f f"I/?a r7 r SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 0 Standard Cityfrown Application Fee ❑Total Project Cost(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) S List: _.._. 5.Mechanical (Fire $ Total All Fees:$ Suppression) — Check No. Check Amount:W Cash Amount: 6.Total Project Cost: $ �`,3 ❑Paid in Full ©Outstanding Balance Due: /" ,teJ r,� File 9 BP-2016-0227 APPLICANT/CONTACT PERSON JOHN PERRIER ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS06076(860)930-7794 PROPERTY LOCATION 53 EAST CENTER ST MAP I IA PARCEL 070 001 ZONE URA000)/ 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 INFQRMATION 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 Demolition Delay Signature of Building Official 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. 53 EAST CENTER ST BP-2016-0227 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: I IA-070 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-2016-0227 Project# JS-2016-000383 Est. Cost: $2173.00 Fee: $65.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN PERRIER 105319 Lot Size(sq. ft.): 31798.80 Owner: MASENIOR JACOB Zoning: URA(100)/ Applicant: JOHN PERRIER AT. 53 EAST CENTER ST Applicant Address: Phone: Insurance: 18 BROADWAY POND RD (860) 930-7794 WC STAFFORD SPRINGSCT06076 ISSUED ON.812612015 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 Siunature: FeeType: Date Paid: Amount: Building 8/26/2015 0:00:00 $65.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner