25C-038 O
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t Massachusetts A � * � ,
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4 DEPARTMENT OF BUILDING INSPECTIONS y J
' 1 1 1 0 212 Main Street • Munici al Buildin
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P 4 has.', A r
N orthampton, MA 0106
Property Address: // /Ui / /Or Li 4L/
Contractor
Name: �C lam/ 4-? -7 le)
Address: 7 5 3--/-- , ///f4 ('0 S
City, State: �. /7 / t - 7 - 04 J
Phone: `c�c � ✓ i ,) G - 7,7
7
Property Owner
Name: ,_ _S / � ( , / g 7
Address: // /0i / -4 Ave
City, State: //3 /IA Lvpil
1, 4 f,/'J C/ (contractor) attest and affirm that the building I intend to
insulate does n ot 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 sign
Date / - 0 - 6o/
AIIPIIIIIIIIIPIMIIIIIIIIIPP
The Commonwealth of Massachusetts
Print "Form
Department of Industrial Accidents
s" r Office of Investigations
tip
5. ttimi
-�-- 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. A I am a employer with 3 4. ❑ 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. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working capacity. employees and have workers'
g for me in any p t) 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.+
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ 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 insulation
employees. [No workers' 13. SI 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. # Expiration Date: 2/21/2013
Job Site Address: STREETS IN City /State /Zip: d/ l �r/ 64
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration 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 certil under the I ains and I enalties o i er'u that the in ormation provided above is true and correct.
Date
Si nature: -w► --- / \ /1 � -7
Phone #: c -? 3`
" - ` l . 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 #:
0
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder L -
Gi - N / j /✓ / i
License Number
Address Expiration Date / 2,-, 2
1 '
ignat re Telephone
9 Registered Home;lmprovemerit Cunt actor a E , a, 11 - =:, „ ,:; Not Applicable ❑
�� f ✓t�G�� � ✓ �,� � �1��� f� �s / 7 ?J
Company Name Registration Number
Address m Expiration Date
Telephorti‹
-1;3°7 .171
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 ❑
L.C4loillt ,OVOlteixEieMPtiOn.
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 I I
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other [O]
Brief Description of Proposed 64/ /
Work: -4-41(5 v /4 L c e � �. f L,/m' /j /
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa If:New house and or addition: to . hou sing,ecomplete:the:followi
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
s
SECTION 7a ;OWNER; AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR, APPLIES FOR "BUILDING PERMIT ,
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, vUh ../V) , as Owner /Authorized
Agen° reby 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 anc of perjury.
W/
Print e /
IOW
Signature of Owne /Agent D to
•
Department use only
-- - — City of Northampton Status of Permit:
R i i _ _. pi., Department Gurb Permit
2�12 ain Street Sewer /Septic Availability
f 201 Rom 100 V1/a #er/well Availability : '
N ortham ton, MA 01060 Two Sets of Structural Plans
e_4.1.3 -5137 -1240 Fax 413- 587 -1272 Plat/Site Plans
DEPT OF BU , .�iNG 1NSP I
NORTHAMPTON, MA 0706 Other' Specify
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
/1 4_7L'/1 4L /e Map Lot Unit
Zone Overlay District
EIm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: /4 / ./(/0 /
Name (Print) -1 y ,, f , Current Mailing Addre l
: ,, „ y
x y/3 c,
.,, __ e-0C ' ° „'„r Telephone
Signature
2.2 Authorized Agent: —) ----�-
1-, ci 1 � ,--S / 5 / /i 1 /4 5/ /-4 /f .'---'1
Name (Pn Current Mailing Address:
6) '30' )
Signa Telephone
SEC' • ' 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
(a) Building Permit Fee
/e-Mly L id ( ); )' °
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection /6 / '5 —
6. Total = (1 + 2 + 3 + 4 + 5) /(,)7)0. 0 ,) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2013 -0704
APPLICANT /CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860) 930 -7794
PROPERTY LOCATION 11 NORTHERN AVE
MAP 25C PARCEL 038 001 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 )6q 11 Fee Paid
Typeof Construction: INSULATE ATTIC
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
IN FO 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
t 2,Z / aJ
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.
11 NORTHERN AVE BP- 2013 -0704
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 038 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 -0704
Project # JS-2013-001165
Est. Cost: $4002.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 6011.28 Owner: HALLER LESLI G & MATTHEW G
Zoning: URB(100)/ Applicant: JOHN PERRIER
AT: 11 NORTHERN AVE
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930 -7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:1/23/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: I NSU LATE ATTIC
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 1/23/2013 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner