17C-187 The Commonwealth of Massachusetts P*at Form
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
IR Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors fElectrieians/Plumbers
Aonficant Information Please Print Legibly
Na= (Business/Organizatiordtndividual):New England Green homes
Address:69 East Main Street
City/Sta.te/Zip:StafbCd, CT 06076 _ Phone #:860-930-7794
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with 4 4. [] I am a general contractor and i
employees(full and/or part-time).* have hired the sub-contractors 6, ❑New construction
2.0 1 am a sole proprietor or partner- listed on the attached sheet, 7. Remodeling
ship and have no employees These sub-contractors have g, Demolition
working for me in any capacity, employees and have workers'
[No workers'comp. insurance comp. insurance.: y. ❑Building addition
required.] 5, E] We are a corporation and its 10.❑Electrical repairs or additions
3.0 1 am a homeowner doing ail work officers have exercised their 1 1.0 Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]' c. 152, §1(4),and we have no
employees. [No workers' 13,fV)Other ( l ]�U i a,�1{;'
comp. insurance required.]
'Any applitant that checks box k 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 then huo outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the tub-contractors have employees,they must provide their workers'camp policy number.
oa+sm>•r.
1 ant an employer that is providing workers'compensation insurance for my employees. Below is the pocky and Jab site
lnfvrnsatlon.
Insurance Company Name:Intego
Policy b or Self-ins. Lic. q:NewC424991 Expiration
Job Site Address:All Steets in City/State/Zip: ' 1 2 A1,Q
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
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 inaurancc vuvcragc verification.
1 do herebLCELMA under the airs and enalties•v er'ury that the in brmation provided above 1s true and correct:
Date � �l
done
Official use only. Do not write in this area,to be completed by city or town offlciat
City or Town: Permit/License N
Issuing Authority(circle one):
1.Boitrd of Health 2. Building Department 3, City/TQwu Clerk 4. F."tectrical inspector S. Plumbing Inspector
6.Other
Contict Person: Phone#:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 105319 12.1 M1 1!5
J'O b>��7e-yFR% License Number Expiration Date
Name of CSL Holder -T--r-
s,-i � �'T M Aa N „�� List CSL Type(see below)
No.and Street Type Description
�T'plery Unrestricted(Buildings u to 35,000 cu.ft.
tt t=I R Restricted 1&2 Famil Dwelling__
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Flame Improvement Contractor(HIC) 1-430-2-1
�S�12aFc� HIC Registration Number Expiration Date
Hiff Company Name o HI Re is rant Name o p
'
S"C��5 r tai ST !e
No.and Strcet Email a dress
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 .......... No...........17
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 {4eW to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's NarAe(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 true and accurate to the best of my knowledge 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.mass,2ov/oca v/oca Information on the Construction Supervisor License can be found at www.mass.goov/das
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"
i
DEC The Commonwealth of Massachusetts
Board Building Regulations and Standards FOR
IaEs usetts State Building Code, 780 CMR MUNICIPALITY
ctrl:.Plurr' nc&C USE
�'` ttttg C'ermit ' pp tcation 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. Pr erty Add s: 1.2 Assessors Map& Parcel Numbers
Lla Is this an dcce ted street?yes 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) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
.1 Ownexio Recor dl
i4in I tflE J- u/I U
ame rint) �O ty, tate,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repair s(s} ❑ Alteration(s} O Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other A Specify:
Brief Description of Proposed Work2: —77-1) 1 LA LS
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:
2.Electrical $ 13 Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2, Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire
Su ression) $ Total All Fees:$ _
Check NotCheck Amount: _Cash Amount:
6.Total Project Cost: $ ❑Paid in Full El Outstanding Balance Due:
File#BP-2015-0643
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794
PROPERTY LOCATION 62 CHESTNUT ST
MAP 17C PARCEL 187 001 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
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existin
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
INFOWATION 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
De olition Delay
/?—ZY
Sign e ui ding ficia 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.
62 CHESTNUT ST BP-2015-0643
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 187 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-2015-0643
Project# JS-2015-001235
Est. Cost: $2524.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 11238.48 Owner: DELLA PENNA CRAIG P&KATHLEEN A GRIFFIN DELLA PENNA
Zoning: URB(100) Applicant: JOHN PERRIER
AT. 62 CHESTNUT ST
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 Siznature:
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