29-290 The Commonwealth of Massachusetts Print Form e
t l Department of Industrial Accidents
Office of Investigations
srir
i 1 Congress Street, Suite 100
•
Boston, MA 02114 -2017
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organizati on/Individual):
New England Green Homes
Address:59 East Main Street
City /State /Zip:Stafford, CT 06076 Phone #:(860)930 -7794
Are you an employer? Check the appropriate box: Type of project (required):
1. SI 1 am a employer with 3 4. ❑ I am a general contractor and 1
employees (full and/or part- time).* have hired the sub - contractors 6. El New construction
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 tY 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. ❑ 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.
1' 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: / /2012
Job Site Address:ALL STREETS IN 0 i�� City /State /Zip: �10
Attach (}
h copy of the workers' compensation policy de page (showing the policy number and expiration date).
ttac a c py p p y p g ( g p y p )
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: .../Y Dater / - L -1/ 3k
Phone #: . J ✓ ~ l' t l
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: , ' Not Applicable ❑
, �
Name of License Holder . ) � �+ r± ✓ /CS
„ , C � �'
License Number
I / J'� ' 4 iA ✓ 7L 7 l✓��c� r�/� C _7` �G 7� l "/ ? 7 D, /
Address Expiration Date
Signa re Telephone
9. °Registered Home .Improvement Contractor . p „_,..< ,. '� E �, „„ Not Applicable ❑
cr Cv deftJ 27,0- 6: ea t-4.- /
Company Name / r! Registration Number
IA St SYGA ol'( Cr J2v�1 i - 7c' /
Address . Expiration Date
g () F J D j G / Telephone
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 6L. No ❑
iy n ^x " ,cr d "' aa r ,...
I 1... a" Io :0-witetEx6iiiption
io
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
•
..
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors C
Accessory Bldg. ❑ Demolition n New Signs [1J] Decks [0 • Siding [p] Other [ID]
B ief Description of Proposed
W k: � fl , ` ,i `' ' L 7L p r 9
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. if New <Th a ddition to existing housingCCiimpiete the fOIiowing:
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 AGENTTOR CONTRACTOr .APPLI FORBUILDING PERMIT .{
1 , ./0, rte .- . r ,i�/ / (r A , as Owner of the subject
property j
/4 ` _
hereby authorize � 1l�- w�, Ef(V l
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
- 1111111111111.111111.1111111111111
1 l n /1 6 ' , 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 pair and- Benalties of perjury.
Print 1 _
4 - --'—' --- - /4 e6 , _2 0/, Signature of •-wner/ • g-nt Date
♦ ,
r , Chi i� of Nod 'Tampion
tnn _
�S ` atissa rliusrtis c ,
. i d :,'4 i i_ . , n 3
\:b;,:;$11 " DEP ARTMENT OF BUILDING INSPECTIONS �� ! "' ` �,.
212 Main SL
V ...�\.,
\: Street • Municipal Building � `� '
Northampton, MA 01060
LO S BUILDING PERMIT FEES Phone: (413) 587 -1240
BUILDING COMMISSIONER Effective July 21, 2008 Fax: (413) 587 -1272
DEMOLITION $ 20.00 ACCESSORY STRUCTURE
$ 35.00 PRINCIPAL BUILDING — Residential
$200.00 PRINCIPAL BUILDING - Commercial
*NEW CONSTRUCTION $ .50 per square foot for 1 floor
.30 " " " " 2 floor
.20 " " " %floors, attic, basement, garage
STRUCTURAL ALTERATIONS IN ALL USE GROUPS
$6.00 per thousand dollars of estimated cost or fraction thereof,
with a minimum fee of $55.00
$25.00 WOODBURNING STOVE
*NEW ACCESSORY STRUCTURES one hundred twenty (120) square feet and over
$ .20 per square foot with a minimum fee of $25.00
*NEW ACCESSORY STRUCTURES under one hundred twenty (120) square feet
$25.00 per inspection
*SWIMMING POOLS $30.00 for above ground
$60.00 for in- ground
*SIGNS & AWNINGS $30.00
*DECKS $50.00
REPLACEMENT WINDOWS $35.00
SIDING & ROOFING
Residential $35.00 per structure
Commercial $55.00 min. per structure OR $61K of estimated cost
TENTS $25.00
*ZONING REQUEST FORMS $15.00 (includes home occupation registration)
REISSUE OF LOST PERMIT $25.00
CERTIFICATE OF ANNUAL INSP. $100.00 (minimum)
Temporary Certificate of Occupancy $25.00
PERMITS REQUIRING ONLY 1 (1) INSPECTION WILL BE A MINIMUM OF $25.00; ALL OTHERS WILL
HAVE A $50.00 MINIMUM. PERMIT FEES SHALL BE PAID TO THE ORDER OF THE City of Northampton
AND SUBMITTED, WITH THE COMPLETED PERMIT APPLICATION, TO THE OFFICE OF THE BUILDING
INSPECTOR. WORK STARTED WITHOUT PERMIT IS SUBJECT TO DOUBLE NORMAL FEE.
!! NO CASH - CHECKS OR MONEY ORDERS ONLY !!
* Filing deadline is 12:00 pm (noon) on Wednesday.
4
Department use :991y
RECENE . t
— -; y of Northampton tPer
— " 1— rnit
1 13
'Ming Department COrb'Cut/Drly0WaY . er mit
sevor,Icp
NOV A 0 mow ) C 212 Main Street ti8As;a1;iiii
il
UV g 9 OK Room 100 INate±/y4IiAv:0)1t
1N ,,„,4,,,A,Kz6i-:,,,47.-tvo,.:',,,,,f:-.:;f:,:,
riii. Pl v,,,,,,,,
DEPT.,
y.
, TW9 t" 'f, try ,-;;;.5.-.?,,,,,,-,,,-,,=.,:;,,,!.,,,,,,‘,,,,r,,,i;,:i:
-77-- - - -0'70--.64'7orii3o ampton MA 01060
- 87-1240 Fax 413-587-1272 11VS1`444
1, --j. - -;- 0 N: ,: i , :;.; - - :: ':; ::=•:- ' ' ,',, -:,-,-::,;,-,,,
NO 1-:THAM PION.
oftle(4ketf, Y'r-'''
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
/ 4‘
----- .e., Map Lot Unit
. - '
/4 ".--
+. b re -0 /. 4, Zone Overlay District
i:Ac=eg 7
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: pr.,
Mav i
g v - 6
itieet
6 7,..se.4./ 17i
Name (Print) `'''' ,
ae-J; -
Current Mailing Address:
,,,
Telephone
X ihit A . G i4 I? a I" o g t R
Signature
2.2 Authorized AcierIti
.,./ ----
f /tic, , r , L c/ „SAti'K I' -I '-:(
Name (Print) .,--- - - -
■._ ..4 „
Current Mailing Address:
.....----'"-----
ata f ' ----
Signa Telephone
SECT — TIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical ( b ) Ecsot Construction m t a r t u e c d t i T n o t from a 1 Cost (6) ) of
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
7 k 5. ,c
5. Fire Protection
Z.- C ' ('")
6. Total=(1+2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Date
Building Commissioner/Inspector of Buildings
File # BP- 2013 -0599
APPLICANT /CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860) 930 -7794
PROPERTY LOCATION 60 PENCASAL DR
MAP 29 PARCEL 290 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
g
PERMIT APPLICATION CHECKLIST J
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT A??
Fee Paid
Buildin t Permit Filled out -' _
Fee Paid n -∎ i
Typeof Construction: INSTALL ATTIC INSULATION rx (
New Construction
Non Structural interior renovations
Addition to Existing /J
Accessory Structure A Building Plans Included:
Owner/ Statement or License 105319
3 sets of Plans / Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
N 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
1 oitio. I - la
//
4 010IP
e of 'guilt mg 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.
60 PENCASAL DR BP- 2013 -0599
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 290 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 -0599
Project # JS- 2013 - 000962
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 12545.28 Owner: BRIDA MARGARET, JOHN, JAMES, WILLIAM, GARY & DONNA WALSH
Zoning: Applicant: JOHN PERRIER
AT: 60 PENCASAL DR
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930 -7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:11/28/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION - AIR SEALING
INSPECTION 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 11/28/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner