31B-150 (3) The Commonwealth ofMassachusetts PbIatF.cnsvl
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
1P Boston, MA 02114-2017
www,mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
r1aI17e (Business/Organization/individual):
New England Green homes
Addres5:59 East Main Street
City/State/Zi :Stafford, CT 06076 Phone 4:860-930-7794
Are you an employer?Check the appropriate box: 'type of project(required):
1.2 1 am a employer with 4 4. ❑ I am a general contractor and I
employees(tull and/or part-time).* have hired the sub-contractors 6. Fl New construction
2.C3 am a sole proprietor or partner- listed on the attached sheet, 7, ❑ Remodeling
ship and have no employees These sub-contractors have $, ❑ Demolition
working for me in any capacity, employees and have workers' 9 ❑Building addition
[No workers'comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3,r7 t am a homeowner doing ail work officers have exercised their I I.❑ Plumbing repairs or additions
myself.(No workers'comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] c. 152,§1(4),and we have no
employees. [No workers' UP Other 1 n -S
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 rlffidevit indicating they are doing all vvor),and then huv outside contmours must submit a new affidavit indicating such.
;Contractors that check this box must attached an additional cheat show ing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide their workers'comp poliev number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site
Inforvmwton.
Insumce Company Name:Intego
Policy#or Seif-ins.Lic.q:NewC424991 Expiration Date:
Job Site Address:All Steets in _City/State/Zip:a ' i`f r a '71" -n
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 inourancc vuveragc verification.
1 do htreb EELdA under the palmy and enalties v feerjuiF that Ike in brmatlon provided above is true and correct
bul Date /
P one# r
Offlelal use only. Do not write in this area,to be completed by city or town oftiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board ofMeattb 2. Building Department 3. City/Tvwij Clerk 4. Flecrricnl inspector 5. Plumbing Inspector
6.Other
Contact Person; Phone rx:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 105319
0-0"N 0 License Number Expiration Date
Name of CSL Holder �—
Q ��5� M��� ^�^ List CSL Type(see below)
s,
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason -
RC Roofing Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
$(A)q3�--�.' LtQ� �(y�q�oo wCpA+) I Insulation
telephone Email address- D Demolition
5.2 Registered Home Improvement Contractor(HIC) (.R 0Z1
Q HIC Registration Number Expi�to
HIC Company Name of Hit Re istrant Name o O
5M P;-v Y� rg �[' I e
.Nro,..�an�dpStreet � t� r� Emai a dress
C�r�a" � v ( r�LD�.--f -�
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 ..........'9 No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize NWaG j " _
to aOZ4 my behalf, i ll matters relative to work authorized by this building permit application.
Pr er's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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 ue and accurate to the best of my kno%ledge and understanding.
Print Owner'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.mML.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (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"
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
MUNICIPALITY
Massachusetts State Building Code, 780 CMR
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 Property Address: 1.2 Assessors Map& Parcel Numbers
i G{TYL�MhLI I I `� - __ _ --
1.1a Is this an accepted street?yes n0 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) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑
Public 13 Private❑ Check if yes❑ p 13O y
SECTION 2: PROPERTY OWNERSHIP'
Owner`of Record:
Name(Print) City,State,ZIP
1CjT am lei 1 tJ,, -7-i.1P
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK1(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s} ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units ❑ Specify:
Brief Description of Proposed Work 2: C1
7 3
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ 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) $ List:
5.Mechanical (Fire $
Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Proj ect Cost: $ ?`, t/7
� �(,r 0 Paid in Full ❑ Outstanding Balance Due:
File#BP-2015-0641
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794
PROPERTY LOCATION 19 TRUMBULL RD
MAP 31B PARCEL 150 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,Permit Filled out l/4
Fee Paid —
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existiruz
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
INFO�YIVIATION 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
D pD44ion Delay
o d g 0,0c`0 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.
19 TRUMBULL RD BP-2015-0641
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 3 1 B- 150 CITY OF NORTHAMPTON
Lot:-00 L PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-0641
Project# JS-2015-001233
Est.Cost: $2400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 4922.28 Owner: MANDELL ROBIN
Zoning. URC(100) Applicant: JOHN PERRIER
AT. 19 TRUMBULL RD
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.1211012014 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 12/10/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner