17A-098 (3) Property Address:
Contractor
Name:
1 7-//
Address:
City, State: .57
Phone:
Property Owner '
Name: e
Name:
Address:
City , State:
LT W:r{icv,- (contractor) attest and affirm that the building I intend
to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavit.
Contractor si
Date
- —
- -
_ _
The Commonwealth of Massachusetts Print Form__
Department of Industrial Accidents
oh
M = ' Office of Investigations
1 1 Congress Street, Suite 100
0
Boston, MA 02114 -2017
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
New England Green Homes
Address :59 East Main Street
City /State /Zip:Stafford, CT 06076 Phone #:($60)930 -7794
Are you an employer? Check the appropriate box: Type of project (required):
1. F4 I am a employer with 3 4. ❑ I am a general contractor and I 6. El 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. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in capacity. employees and have workers'
g any p t) 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I 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' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 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: Paychex Insurance Agency
Policy # or Self -ins. Lic. #:MAWC344522 Expiration Date:
Job Site Address: STREETS IN 0 tate /Zip: 4144.,4 fD A
Attach a copy of the workers' compensation policy declaration page (showing the policy number and ekpiration 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 ains and penalties of perjury that the information provided above is true and correct.
Signature: G.�•- � - ,Datel l t/ (3 2L)/ 2-'
Phone ‘ - 23 , -) 7.7e7
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 #:
� 4
try
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ._ ... Not Applicable ❑
Name of License Holder : 1 /D5
Number
_Si Pi 57 Z ` G
Address Expiration Date
gnatur- Telephone
9. Registered Home Improvement Contractor , Not Applicable ❑
, er A � � 4:60 � A ame S /7 30 al
o mpany Name / / Registration Number
Address Expiration Date
Telephone &,J 93Q .7'7 9/
SECTION 10- 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 ❑ No ❑
11. _ Home Qwner,Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.3.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature _ _
4
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [❑ Siding [D] Other [D]
Brief Description of ce Proposed , / y � - /� Z. / Li ‘t - 41 ��, //� vJ�
„e „e -i 5 a:�
Work: ayr ? .Saf v.7 ',, �i /lit i G �' I 1 (. l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No .
Plans Attached Roll - Sheet
6a If N ew house " and..or " ` a ddition to exlstlnq hOUSinq, complete the followin
a. Use of building : One Family `-/' Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands? Yes . No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
c r
I, '1 f lei 0 iv 1 , 1Y ' F // , as Owner of the subject
prope
hereby author; e j Lit, C. U ." er
to a •n m .ehalf, in all matters_ relative to work ahorized by this building permit application.
. -- % (.....-- c //,/
gnature of Owner Date
<)" / (- /1
- , as Owner /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
r -- //- ' / � FV`
Signature of Owne Agent Date
ir,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning '
This column to be filled in tf t a
Building Department
Lot Size _ -_ ._.__. -._. .__
Frontage @ _ !
Setbacks Front _ E
Side L:L....,,.�- ....._ R:E. .._ Lf„: _. R: E= r �. ° _....__. LID
Rear E T4 _ [ 6 -a. l - °.. TI.
Building Height 1.___I L_..... LI�.�
Bld Square Footage i 1 I I % rh rill
Open Space % }}
(Lot area minus bldg & paved 1 __i I � l 1
parking)
# of Parking Spaces I .i El
Fill: i . -.-. ---- __..___.___ ,_._ _- -____. __.__ __._ �
---- --
(volume & Location) -- — - ---- --
. , -- A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book I L__ _____III] Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued: [-----
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location: I ,
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
w /
- —v Department use only
RECEIVED Ci y of Northampton Status of Permit
B ilding Department Curb Out7Driveyray Permit
2O �C Room 100
' 12 Main Street S ewe r T Sept ic� tvailability
Cv Water/Well Availabilit
_
Not ampton, MA 01060 Two SetsafStruetural Plans
DEFT. OP B' 1� v : N
NcP THarrf r il oii -, :41a -5$7 -1240 Fax 413- 587 -1272 P P s
Other.Specify - s '
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
,j .S , es i,/ c/✓ Map Lot Unit
7 ;./Cf..1 .'---C' Zone Overlay District
Elm District ' ' CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record;, /r_..1
i I
! `-' /f ( C" 1Z (/ virie s3 -, n /, S�
Name (Print) /` Current Mailing Address:
a/.7.: .. ,. / OJ�v e� Telephone c1 - 8 y j 0 /y/ 3
Signature
2.2 Authorized Agents �,— /7(
C 1 ( >1. 'I c-,r 1 e - ,_c" 5 t ! / t! S f - S/14 .ve-j /
Name (Print) Current Mailing Address: f,
■Isr "c`"`- `"".. -- -- -- - C <„ - - L) - 13 d 79%
Si, nature Telephone
SE o ' 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
j - A451/ 0:�a(lr'' (a) Building Permit Fee
2. Electrical �' (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 3K ,...-.7_ 9 Ch eck N l "/ ` ��
This Section For Official Use Only r
Building Permit Number. I Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0549
APPLICANT /CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860) 930 -7794
PROPERTY LOCATION 33 GRANDVIEW ST
MAP 17A PARCEL 098 001 ZONE RI(100)/URA(100)/WSP(2)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out x (�
Fee Paid ,/t l l
Typeof Construction: INSTALL WALL 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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN RMATION 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
400
' ' e Delay
//—/$—/*
Si r e of Building i f ' 'Sal 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.
33 GRANDVIEW ST BP- 2013 -0549
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 098 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- 2013 -0549
Project # JS- 2013- 000885
Est. Cost: $3629.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 9365.40 Owner: O'CONNELL PATRICIA A
Zoning: RI(100)/URA(100)/WSP(2)/ Applicant: JOHN PERRIER
AT: 33 GRANDVIEW ST
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930 -7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:11/15/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WALL 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 11/15/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner