25C-055 (6) l
I
1
The Commonwealth q/Wassachusetts
Department of'Industrial Aecidents
Office of Investigations
1 Congress Street, Suite 100
Boston, 31A 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Buil ders/Contractors/Electricians(Plumbers
Applicant Information Please Print Legibly
Name, (E3usiness/Organization/individual):
New England Green homes
Address:59 East Main Street
City/State/Zip:Stafford, CT 06076 Phone 4;860-930-7794
Are you as employer?Check the appropriate box: Type of project(required):
1.[7] I am a employer with 4 4. [] 1 am a general contractor and I
employees(full andlor pan time).' havt- hiicd tht:sub-wntractors 6. New construction
2.Q 1 am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship and have no employees These Sub-ccinrraciors have 8, [] Demolition
working for me in any capacity, employees and have workers' 9 ❑ Building addition
[NO workers'comp. insurance comp insurance t
required.) 5. [] We are a curpuratiun and its 10.7 Electrical repairs or additions
3,❑ 1 am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MCL 12.❑ Roof repairs
insurance required.)' c. 152, §1(4),and We have nc
employees. [,No workers i3'� Oche f
comp. insurance;required.]
'My applicant that.hacks box if I must also fill out the secwn bolox >hcwing their uvrkers'compensation policy information.
t Homeowners who submit this al idavn urdicaWig ttte) nro doing oil and then r,c contructy,;musr submit anew affidavit indiwing such.
;Contractors that check this box must attached an adcaionai sheet sew-mg the name vt the sub-contractors and state wheiher or not those entities have
employees. Ifthesub-contractors have employees,they must provide their warkcrs'comp policy number.
I am an employer that Is providing workers'compensation insurance for my employees. Below is the pocky and Job site
j tnjormation.
Insw-ance Company Name:Intego
Policy h Or Self-inS. Lic. 0:NewC424991 Expiration Date:
All Steets in
Job Site Rddre55: City!Stare/Zi �' '�t1
Attach a copy of the workers'compensation policy declalxtion page(s5owiag the policy number and cspiratioa date).
Failure to secure coverage as required under Section 25A of MCL 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to tho Office of
Investigations OF the D►A for insurance vtrvcrasc ort r9,.,ion.
1 do hereb certi under the alas a d ena ties•uj er'un•that the information provided above Is true and correer
,� 'I- 7`,t
1 _ Date
Phone
Off3clal use only. Do not write in this area,to be completed by city or town oJf eiat
City or Town:
Issuing Authority(circle one):
). $C4 of Health Z. Building Depxremernt 3. C:ity�rvwu Clerk 4 Electrical Inspector. 5. Plumbing Inspector
6,Other
Contact Person: phone#:
i
i
SECTION 5; CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) � 3 12117-11.5
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
't Type' Description
No,and Street _ U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M _ Mason
RC: Roofing Covering
Window and Siding
S1' Solid Fuel Burning Appliances
c13� i �(pq tL_LC�t� I Insulation
Tele hone Email address _ D Demolition
5.2 Registered Home Immprovement Contractor(HiC)
lie
HiC Registration Number Expiration
Hl Company Name o HI Re is rant Name o p
No.and Street �- Email acidress
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 ...... ..'6d No,..... .... ❑
SECTION 7a: OWNER AU"THORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property, hereby authorize NN G''"- I WN
to act on my behalf, in all matters relative to work authorized by this building permit application.
JPn't—OLW)be" 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.
) k I t1% V� F�, Y-0 /J./- - e--) v
Print O- t—nerr's br Authorized Agent's Name(Electronic Signature) Date
_ __ NOTES:
A i
1. n 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(1-11C) 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/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq,ft.) (including garage, finished basernent/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"
he Commonwealth of Massachusetts
CS 2
FOR
oar of Building Regulations and Standards MUNICIPALITY
a� husetts State Building Code, 780 CMR
jry�`-&1 G insPEct` USE
Electrlcorthm "g„� t ication To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One- or Two-Family Dwelling
This Section For Offiei Use ly _
Building Permit Number: D A
Building Official(Print Name) Signature Date
10 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.1a Is this an accented street?yes no Map Number Parcel Number
1.3 Zoning information: 1 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(fl)
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❑ I Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner'of Record:
Name(Print) State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) D Addition ❑
- -- - ---
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: _
Brief Description of Proposed Work':___
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 7` Official Use Only
(Labor and Materials)
t. Building $ 1. Building Permit Fee: $ Indicate how fee is determined
2, Electrical $ ❑Standard City/Town Application Fee
---_ 0 Total Project Cost'(Item 6)x multiplier _x
3. Plumbing $ 2, Other Fees: $
4.Mechanical (I-iVAC) S List:____
5.Mechanical (Fire $ v -- --- ---- —---- -
Su ression) l'otal All F - $ _-5_5
_ Check No:: Check Amount. _Cash Amount:
6. Total Project Cost: S� '3;) tj() ❑Paid in FUJI ❑Outstanding Balance Due:
File#BP-2015-0655
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794
PROPERTY LOCATION 41 LINCOLN AVE
MAP 25C PARCEL 055 001 ZONE URB000)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction:_INSTALL ATTIC 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
/I OMATION PRESENTED:
ARpproved 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
D o ' y
Signa re 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.
41 LINCOLN AVE BP-2015-0655
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-055 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-2015-0655
Project# JS-2015-001256
Est.Cost: $3329.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 16509.24 Owner: URBANO ALASSANDRO
Zoning: URB(100) Applicant. JOHN PERRIER
AT: 41 LINCOLN AVE
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:1211212014 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 Signature:
FeeType: Date Paid: Amount:
Building 12/12/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner