Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
29-096 (2)
The Commonwealth of Massachusetts Pei Fvml Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 IF Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrieions/Plumbers Annlieant Information Please Print Legibly Name (Business/Orgattizatiorvindividual):New England Green homes AddreS5:59 East Main Street City/State/Zip:Stafford, CT 06076 Phone#•860-930-7794 Are you an employer?Cberk the appropriate box: Type of project(required): I.© I wn a employer with 4 4. ❑ t am a general contractor and i employees(full and/or part-time). * have hired the sub contractors 6. 71 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 any capacity. employees and have workers' ❑Building addition corn [No workers' comp. insurance p• insurance.' 9• 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 MOL 12.❑ Roof repairs insurance required.] c 152, §1(4),and We have no employees. (Nu workers' 13,WOther comp. insurance required.] 'Any applicant that checks box H I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc doing all worn and than hue vutside eontractvns must submit a new affidavit indicating such, tContraetors that check this box must attached an additional sheet shovr ing the name of the subcontractors and state whether or not those entities have employees. If the tub•corittactors 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 polky and jab site information. Insurance Company Name:Intego Policy l#or Seif-ins. Lic. #:NewC424991 Expiration bate: Job Site Address:All Steets in Ci /State/Zi tY P: 4-ll11 iz.W0f7i� Attach a copy of the workers' compensation policy declaration page(showing the policy number and cgpiratiou 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 vvveragc vorificatiuw. I do hereb certi nder the ah v an pena l 1es•v er'urr•that the in ormation provided above is true and correct. Phone OO I I use only. Do not write in this area,to be completed by city or town of kiaL City or Town: _ t'ertnit/License N� Issuing Authority(circle one): 1.Board ofHealtb 2. Building Department 3. 0tyf['vwu Clerk 4. Electrical Inspector s. Plumbing inspector 6,Otber Contact Person: ?bone#: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 106319 }� !Z r 1-6 V —�^ O _ f O W4� "lcZ,4Z,t License Number Expiration Date Name of CSL Holder �T—T p List CSL Type(see below) X S q M No.and Street Type Description 15 p U Unrestricted(Buildings up to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding IF Solid Fuel Burning Appliances � 4FL 4,M I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) �r �p R3 OZI J� HIC Registration Number Expiration Date HIC Company Name o Hie is rant Name o 0 No.and'Street � ('l a Email address 0929a��Sig�t34! ---47 3qW City/Town, State,ZIP Telephone SECTION 6: 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 ..........'{f( 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-`ftvDsG� 1 ml's to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(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 contained in this application is true and accurate to the best of my knowledge and understanding. r7wl Print Ow er's or Authorized 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.aov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.fl:.) _(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" t� J ' e commonweinin o Massachusetts Joarc of Building Regulations and Standards FOR t Plumbing&Gas insp 1lusetts State Building Code, 780 CMR MUNICIPALITY Northampton, MA 01060 USE 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 ro ert Address: 1.2 Assessors Map& Parcel Numbers 1.1a Is this an a cepted street?ves 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) L7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes❑ p SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner t of Recor ,e C' A -17 1 17 1zN .s s Name(Print) City,State.ZIP No.and Street J Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction [] Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: Brief Description of Proposed WorkZ: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) I.Building $ 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: S 4.Mechanical (HVAC) S List: 5.Mechanical (Fire $ Suppression) Total All Fees:S _� _ Check No., Check Amount: •��Cash Amount: 6.Total Project Cost: $ t� olV ❑Paid in Full ❑ Outstanding Balance Due: File#BP-2015-0559 APPLICANT/CONTACT PERSON JOHN PERRIER ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794 PROPERTY LOCATION 24 HOLLY CT MAP 29 PARCEL 096 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid im 'v Building Permit Filled out Fee Paid Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accesso 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: improved 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 of ' elay Signs ure o uildi ffi 1 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. 24 HOLLY CT BP-2015-0559 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-096 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categoa: INSULATION BUILDING PERMIT Permit# BP-2015-0559 Project# JS-2015-001073 Est. Cost: $2806.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN PERRIER 105319 Lot Size(sq. ft.): 15507.36 Owner: KIEKE JOSEPH zoninp-: Applicant. JOHN PERRIER AT. 24 HOLLY CT Applicant Address: Phone: Insurance: 59 EAST MAIN ST (860) 930-7794 WC STAFFORD SPRINGSCT06076 ISSUED ON.•11/1712014 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 Sivature: FeeType: Date Paid: Amount: Building 11/17/2014 0:00:00 $55.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner