28-046 (4) i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
O ( '3 19 ?Z M1 I1!5 y
-r^ _ _
O W4��Y{4Z,\9S License Number Expiration Date
Name of CSL Holder
Q o List CSL Type(see below)
No.and Street Type Description
"A , _�, � Unrestricted(Buildin s u to 35,000 cu.ft.City/Town,State,Z[P (�I __R Restricted 1&2 Family Dwelling
M Masonry
RC Roofing Covering
- WS Window and Siding
SF Solid Fuel Burning Appliances
��2 ---'�L4 JF2A �q ]oQ.Lpt� 1 Insulation
e Email address- D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1.43 0-1?—(
"'Te��e�I #'�rz� - HIC Registration Number Expiration
HIC Company Name o HI Re istrant Name o O
N--�and�Street A -- --- - -— I e ErnaiT 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........... ❑
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`R&f 0 C-RJ
to act o my behalf, in all matters relative to work authorized by this building permit application.
61
Print Ow er'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 d accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Ag is 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.g_ov/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"
t irwl
The Comm mot Fonwealth of Massachusetts
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/ContractorslElectrieions/Plumbers
Applicant Information Please Print Legibly
N7fl1e (Business/Organizafioti'lndividual):
New England Green homes
Address:59 East Main Street
City/State/Zip:Slatf", CT 06076 _ Phone #:030'900-7794
Are you no employer?Check the appropriate box:
general contractor and i Type of project(required):
1.0 I am a employer with 4 4. ❑ I am a 8
employees(full and/or part-time).* have hired the sub contractors 6, 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 R. [] Demolition
working or me in an capacity, employees and have workers'
g Y 9. ❑Building addition
[No workers' comp. insurance camp. insurance.:
required.) 5• ❑ We are a curpurat ion and its 10.❑Electrical repairs or additions
9 ] officers have exercised their 1 1. Plumbing repairs or additions
3.❑ [ am a homeowner doing all work ❑ $ p
myself. [No workers' comp. right of exemption per MGL 12.[] Roof repairs
insurance required.1 r c. 152, §1(4),anti we have no
employees. [No workers' 13,[1 Other insk)ka�ior
comp. insurance required]
*Any applicant that checks box k I must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they are doing alt wurh Lind than huu outside writruour,must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the suh-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most provide thtir workers'camp policy number.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the polky and job site
information.
Insurance Company Name:Intego
Policy#or Self-ins.Lic. #:NewC424991 Expiration Date:
Job Site Address:All Steets in City/5tate/Zip:Frkor tx t, l 100')-
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 inzjurancc voveragc vcrifwati�n.
I do hereby certi under the paitts and a alties•v er'un•Thai the in brmadon provided above 1s true and correct
i
IDatel
P one# 25
Official use only. Do not write in this area,to be completed by city or(own oJJtciaL
City or Town: —Perm it/License#
Issuing Authority(circle one):
I.Board of Health 2. Building Department 3. City/rovvu Clerk 4. F,lectrical inspector 5. Plumbing Inspector
G.Otber
Contict Person; Phone#:
l
1
rr�.wr
�? g� The Commonwealth of Massachusetts
-� Board of Building Regulations and Standards FOR
U '! - MUNICIPALITY
a Massachusetts State Building Code, 780 CMR USE
V a
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One-or "Iwo-Family Dwelling
LI. e: This Section For Official Use Only
LLf B ilding Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
_--Cs!-r a C 1 -- —
l.la Is this an accepted 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'
2.1 Owner'of Record:
�amcs_1364da Ftorenr1 MA, 0I0C92t,
Name(Print) V City,State.ZIP
—4
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) El Alteration(s) 13 Addition 13 Demolition ❑ Accessory Bldg. 11 Number of Units Other ® Specify:
Brief Description of Proposed Work':
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 $ ❑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 $ -- —
Suppression) Total All Fees: $ _
Check No��Check Amount: Cash Amount:
6.Total Project Cost: $ �'(� \ ❑Paid in Full ❑Outstanding Balance Due:
File#BP-2015-0614
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794
PROPERTY LOCATION 77 CAHILLANE TER
MAP 28 PARCEL 046 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid ! 4*'S�1
Building Permit Filled out
Fee Paid
Tvneof Construction: INSULATE ATTIC TO TO R38 WITH CELLULOSE 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
INFOR ION PRESENTED:
pproved 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 ti
Signature Building Cficial 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.
77 CAHILLANE TER BP-2015-0614
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 28-046 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-2015-0614
Project# JS-2015-001186
Est.Cost: $1196.18
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 10105.92 Owner: BRYDA JAMES M
zoning: Applicant: JOHN PERRIER
AT. 77 CAHILLANE TER
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.12/4/2014 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 Si¢nature:
FeeType: Date Paid: Amount:
Building 12/4/2014 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner