38B-312 (2) The Commonwealth ofMaasachusetts
Department of Industrial Accidents
Off7ce of investigations
1 Congress Street,Suitt 100
Boston,MA 02114-2017
www.mass.gov/dfa
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrieil n&Tlumbers
1 c tin r1eally Print Wbly
None(t$usiness/Orynn�irettavtnalvWwl);New England Green homes
Address:
g /State/Zi :Stafford,CT 08078 phone tl:(1130-9307754
Are you on empioyer7 Check the spproprivte box: Type or project(required);
1.0 1 am a employer with 4 4. t.J I am a general contractor and
ctnploytcs(ful)and/or port-time).
liuvc hired the sub-cuotnwtors 6. ❑New CQnStTletiOn
2.(� 1 am a sole proprietor or partner- listed on the ottached shoot. 7, 0 Remodeling
ship and have no employees These sub•contracion have $, C]Demolition
working or me in an ca acit , employees and have worker(;'
8 Y P Y 9. ❑Building addition
[No workers'camp.insurance comp, insurancr.t
required.] 5 p We ury n curyurutiun and its 10,C)Electrical repairs or additions
3,[�1 rim a homeowner doing at work officers have exercised their i 1.Q Plumbing mpahs or additlons
myself.(No workers'comp. right of exemption per MG l2.❑Roof repairs
instvamce required.]' c, 152,§1(4),atstl we have no
ampluyt:cs. (No workers 13.( J Qther
comp. insurance required.)
'Any appiieast that chCt a box N I must also fill out the section balow shotvsng thou won:ert compensation policy inromwion.
r HomativAm woo suiosit this amdavn indicrting they are darn(01,.ors and ihsn hav vuisids contnCtvrs mutt submit i now aflRdavit indicad;j aweh.
tCowsamon that cheek this box must stuched in uklitional shat shah Ong the nanx 01 the tub-cwtvactay and Soto Whether or not chow etitides Mere
employcoa, iftba suV ooancw have employees,they must provide then workers'comp policy number.
I am an eirrployer that it provMdiny worksrs'eon Vensadon insurance for my coWlaytes. Below b tkt 077 00,0 aW
triwortaotton.
lusualwsoe Company Name:Intego
Policy N to Sclfdn:i.Lic.tl;NewC424991
Job Site AddreuAJi Steet&in _.City/State/Zip /7)W 016 4
Attach a topy of the workers'eotnpc;.utter'policy declaration page(showing the polity number slid espiratioo date).
Failure to securo coverage as required under Section 25A of MG L c I S2 can(cad to the imposition of criminal pertaliics of s
fine up to$1,500.00 and/or one-year imprisorunew,as well as civil penalties in Use form of a STOP WORK ORDER and a flna
of up to$250.00 a day against the violator. 9c advised that a copy ofthis statement may be forwarded to this Offiict of
l[Jy*XlgitttOns Or the Dirt rbr ussurwtco vu mas...�in.,..,W...
C do hereby ceri6 under the alns d ex tits v PITY'ury that the In orm4rlon provided above is trite and correa all
41
Off kkl use tarty. Do not wrUt in this area,to be comptered by chy or sown pfjkial
City or Town: _ _ �......__ PermitJt lconsr t♦
Issuing Authority(circle one):
11,Ike 014ralrh 2. 13uUtting Ocisartntcnt 3.City/Tvwu CIrck d vtrctricat inspeetor S. Plumbing Inspaetor
6,ptbar
Contxtt?emu-. Pbnne q:
S94MON s: CONSTRUCTION SERVICES
5.1 Construct Supervisor License(CSL)
it
To 1'1.K 2 1 GF2, � License Number Expiration Date
Nutty ofCSL Holder
left 1,Vdy -� P)L ,l xD List CSL Type( cbelow)
No.and Sitrte
Type Doscription
; U Unrestdete+! 8uikiiri s u to 35,000 cu,ft
CitytTown,State.ZIP "� �� o R _Rcstrictcd 1&2 Parttiiy Dwetlin&
M Masonry
RC Roofi Covering
WS Window and Sidin
SP Solid Pucl Burning Applianccn
2 43�-- � ex-4S �to�ly hoo.(p .1— Insulation
Tele fione Finalt address D Demolition
3.2 Registered Home Improvement Contractor(HIC) �if��
1A I
v Nt
HIC Registration Number Expiratlanmate
HI Nam Yd v o
No,ape street --
ErtW rasa
City/Town,City/Town,State,FP Tel one
SECTION6:WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G.L.c. 152. 25C(6))
Workers Conipensatlon 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..........'a No..........,0
SECTION Ta:OWNER AUTHORIZATION TO DE COMPLETED WIZEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize NR%1 a�c� ]D �
to not on my behalf,in all matters relative to work authorized by this building permit ap llcation.
te r' J s
Print owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that alt of the information
contained In this application is taste and accurate to the best of my knowledge and understanding.
4P ,A
Vs or Authorized Agent's Name(13le:tronic Sil,na(ure) Date
_ NOTES:
(. An Owner wha 0 a buNding permJz tt)do h' )er own work,or an owner who hires an uttreg sterott contractor
(not registered in the Home Improvement Contractor(HIC)Program),will W have access to the arbiandon
program or guaranty fund tinder M.G.L,c. 142A.Other important information on the HIC Program can be found at
www.mass.gnv/oca Information on the Construction Supervisor License can be found at www,mass.g2Y/dos
2, When substantial work is planned,provide the information below:
Total floor tinny(sq.ft.) _Y(including garage,finished basement(atiic3,decks or porch)
Gross living area(sq. 9.) Habitable room count
Number of ftmptacos _ _ _ Number of bedrooms
Nurnberof bathrooms Number of half/baths
Typo ofheadng system Number of decks!porches
Type ofcooling system_ Enclosed Open
3. "Tonal Project Square Footage'may be substituted for"Total Project Cost"
OCR 13 2(x!5
�ut�o�nG iH U�cr�oNs
�a
IW4
NOR�At� The Commonwealth of Massachusetts
Board of Building Regulations and Standards iOR
Massachusetts State Building Code,780 CMR MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a R*vised Mar 1011
One-or Two-Family Dwelling
This Section ForOtTiciel Use Unf
Building Permit Number: Date Applied:
Suitding OfUW(Print Name} Signature
Date
SEC'T'ION 1;SITE INFORMATION
Address- 1,,2 Assessors Map&Parcel Numbers
Lla Is this an accepted sweet?yes n0 11.4 ap Number Percaf Nwnber
L3 Zoning Information: Property Dimensions:
Zoning District Propoxed Use ot Area(sq ft) Frontage(fl)
1.3 Building Setbacks(t't)
Front Yard Side Yards Rat yard
Roqul! Provided Required Provided Rcquirod Provided
1,6 Water Supply.(M.C.L c.40,j54) 1.7 Flood Zone Information: 1.8 Sewage Dismal System:
Public Q Private Q Zone: ^ Outside Flood Zone? Municipal O On site disposal system O
Check If cs[3
SECTION 2: PROPERTY OWNERSHIP'Owttcr'of Reco r L«
�G�
` %! ! 1
-�
Name(Pr CI V,state.ZIP
No.toil Sum Telephone � Email�A'ddress `-
SECTION 3:DESCRIPTION OF PROPOSED WORK(chock all that apply)
New Construction O Existing Building Cl Owner-Occupied ❑ Repairs(s) O Aheration(s) O Addition O
Demolition 0 Accessory Bldg.O Number of Units Other 0 Specify:
Brief Description of Proposed Work 3:
r
L
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building S t. Building Permit Fee:S indicate how fee Is determined:
O Standard Cityfl'own Application Fee
2.Electrical S D Total Project Cost'(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) S List
S.Mechanical (Fire S 'total All Fees•S _
Suppression) --- �`�
Check No, :ck Amount. mash Amount:
6.Total Project Cost: S 0 paid in ull 0 Outstanding Balance Due:
J)1;_a,0L AtIM/L NEGH
28 Spellman Rd.
Stafford$frrinc�a,CT 06070
File#BP-2016-0476
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 130 SOUTH ST
MAP 38B PARCEL 312 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T peof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existina
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:
_A,,�pproved 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
li ' n Delay
S afore of oil n fficial 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.
130 SOUTH ST BP-2016-0476
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B-312 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-2016-0476
Project# JS-2016-000799
Est. Cost: $5840.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 4835.16 Owner: HOLLAND EVELYN J
Zoning: URB(100) Applicant: JOHN PERRIER
AT: 130 SOUTH ST
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860)930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.1011412015 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 10/14/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner