31B-141 (2) Property Address: / Z{ % f -5/ 4' e7` o A) 0 1 /A
Contractor
Name: , � /I�$ 54414.r 1-10ilie 5
Address: J `/ ( f
City, State: - F4 , r dcl cif
Phone: - C 3 J f ,
Property Owner
Name: 6 ✓ rtelt: 0 r, I ,A7
Address: ti -`�
City, State: ' -� l #
M'1 I ytJ , / .
I, c._.3 1 ,/ t c (contractor) attest and affirm that the building I intend
to insulate • - - - - • - - • .. - • • - - • . - _ wiring in the spaces to be insulated and
that I have provided the property ow n with a copy of this affidavit. 6 L z/ Cam, / /,/ ,v T /4 st''4
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Contractor signature
Date
f AJ Avg
The Commonwealth of Massachusetts
... .... - -- Department of Industrial Accidents
'` i 1/4‘...., °= = ,
E,. — fir'
1 Office of Investigations
- µ j l 600 Washington Street
=�� .` Boston, MA 02111
� _.,,� www.massgov /dia
Workers' Compensation Insurance Affidavit: Builders /ContractorsfElectricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): /1/ ,_57 r _ 2 j
....__,,
Address: S ` / r K r L I1 I L f ( w ' 1
City /State /Zip: . l . 1 _ - Phone th : - r _. --
Are you an employer? Check the appropriate box: Type of project (required):
1 I am a employer with �., 4. 0 I am a general contractor and I
6. New construction
employees (full and/or part - time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have g. 0 Demolition
working for me in any capacity. employees and have workers' 9 Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13,g1 Other /. / 1 t ,/ /C 1v,•
comp. insurance required.]
`Any applicant that checks box ill must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation Insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: -t / (t.1,-: V / 4 $ i /iT c'' C / (c' ✓ l r/,,'
_, Policy # or Self -ins. Lic. #:/n' *1 /4/6_: , j `/
` �5 2 ,.- Expiration Date: - ? /- >f 3
Job Site Address: -A-2 .‘ - ' City /State /Zip�� ;AZ % %' /J-"7 4' 4 (Jri V
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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 fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the Information provided above is true and correct.
Signs f. / Date: / J t] . 20/ Z
Phon #: `-&- 15 L.) e7 S v / 42/
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction S`ervlcor icense (CSL) fJ j '3/ ll _J z Z,)/
�J UG ii .',14./r7 License Number Expiration Date
Name of CSL Holder _--,—
/-'71 List CSL Type (see below) _,../
No. and Street Type Description
�.t U Unrestricted (Buildings up to 35,000 cu. ft.)
5/l Jrr`"4..),'' S te (
' - v7 R Restricted 1 &2 Family Dwelling
City/Town, State, ZIP 7 M Masonry
RC Roofing Covering
WS Window and Siding
�7 J' SF Solid Fuel Burning Appliances
J f 3 .� 7 I Insulation
telephone Email address D Demolition
5.2 Registered Home Improvement ontractor (HIC
t ` 7 � J
4 2D/
-> r/ Y ' / / / T ,O 1/ S //44'5.
HIC Reitration Number Expiration Date
Company �N or H Registr Name ,
3 / .S/ / : / )/-C to (+ )1,/
N r- e>. Street k l C � %c) J r-77. s )' _ J -27,:i/ Email address
City /Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes No ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behal :11 matter relative to work authorized by this building permit application.
4 0
)e 4
Print 0 (ner s 0, e (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
contain. n this application is true and accurate to the best of my knowledge and understanding.
� rb.. if
Print 0 's or Yirnoilzed 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 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.mass.gov /oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
RECEIVED
APR I 0 2012
The Commonwealth of Massachusetts DEPT. OF BUILDING INSPEC 0
4 14 Board of Building Regulations and Standard3 NORTHAMPTON, MA o,oeo„_tOR
1;1 Massachusetts State Building Code, 780 CMR MUNIi II EALITY
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 Property Address: 1.2 Assessors Map & Parcel Numbers
/6` /,:.. .stl / ',
1.1a Is this an accepted street? yes no / Map Number 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 Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow r , of' -cor :
Name (' Int) I City, State, ZIP'
No. and Street Telephone /(3 Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building45fi Owner- Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work
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:
❑ Standard City /Town Application Fee
2. Electrical $ ❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees : $ ✓�'
Check No.fveeck Amount :W Cash Amount:
6. Total Project Cost: $ C' / Z3 , O ' ❑ Paid in Full ❑ Outstanding Balance Due:
I
5� 1
asZ,.°
i
s 1� 1 � Office of Consumer Affairs and it usiness Regulation
4.
1
10 Park Plaza - Suite 5170
s" Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 170893
Type: LLC
Expiration: 1/11/2014 Tr# 220634
MASS SMART HOMES, LLC.
STEPHANIE WEINER
P.O. BOX 338
SOUTHPORT, CT 06890 - - -
Update Address and return card. Mark reason for change.
u Address ❑ Renewal [1] Employment ❑ Lost Card ■
OPS -CA1 C✓ 50M- 04/04- G101216
��lze 6oarcmcana�ea/ I I', - ,ltakteze .uaeett License or registration valid for individul use only
Office of Consumer A ffairs & Business Regulation g y
before the expiration date. If found return to:
4
I r � HOME IMPROVEMENT CONTRACTOR
4� Registration: 170893 Type: Office of Consumer Affairs and Business Regulation
9 10 Park Plaza - Suite 5170
�vi =�0 Expiration: 1/11/2014 LLC
�
, Boston, MA 02116
MASS SMART HOMES, LLC. 11111.1111‘,
STEPHANIE WEINER
34 SHERMAN COURT �� , 1
FAIRFIELD, CT 06824 Undersecretary '' of valid wit o gnature
\l:n.achu.ctt∎ - Dip art ill cnt ,ii Puhlic �atct
9
J Board tor Bniliiin;: 12c2ulatin . and''tan(Ltrtl
f • Construction Supervisor Specialty License •
License' CS SL 105319
Restricted to IC
JOHN PERRIER ,'
59 EAST MAIN ST
STAFFORD SPRINGS, CT 0607 r
s.--� �y--- om Expiration 12/12/2013
I .muun.i.,m r Tr 105319
■
File # BP- 2012 -0886
APPLICANT /CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860) 930 -7794
PROPERTY LOCATION 16 BRIGHT ST
MAP 31B PARCEL 141 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out % W
lilt c.�
Fee Paid C
Tvpeof Construction: INSULATE & AIR SEAL
New Construction CO/07 f 01 F' tce ` //t ��`-1 ' % c � Non Structural interior renovations
Addition to Existing / r✓l/< e.
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
INF ATION 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
P - . ' ion Delay
0 r_ j e ' // P
/. / .,...4..41■ ,
ar�ture , '13u . ,% : Of c al 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.
16 BRIGHT ST BP- 2012 -0886
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 141 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Wiring BUILDING PERMIT
Permit # BP- 2012 -0886
Project # JS- 2012 - 001261
Est. Cost: $8123.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 11369.16 Owner: JENNINGS MICHAEL D & GRETCHEN
Zoning: URC(100)/ Applicant: JOHN PERRIER
AT: 16 BRIGHT ST
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930 -7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:4/23/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE & AIR SEAL - copy of final inspection
report required
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 4/23/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner