30B-023 (3) The Comrrmonwealth o/ rYlassachusetts ^P *tF,ormt
Department of Industrial Accidents
QJJiice of Investigations
1 C'ongres:s Street, Suite 100
Roston, ,11A 02114-:UI
www.mass.gov/dla
Workers' Compensation Insurance Affidavit: Builders/('ontractors/Electricians/Plumbers
Applicant Information _ _ Please Print Legibly
NdI17C (13USirtess/0 rganizativNlndividual):
New England Green home-,
Address:59 East Main Street
City/State/Zip:Staffcrd, CT 06076 _ _ Phone #;360'930'7794
Are you ae 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
6. [] NeW ConSITUGhOn
employees(full and/or pan time).
2,❑ 1 am a sole proprietor or partner- hstvd on the artuchvd stwct i ❑ Remodeling
I hese sub•contracior5 have
ship and have no etnplvyecs 8 Demolition
working or mein an ca acity employees and have workers'
B y p U ❑ Building addition
[No workers' comp. insurance comp ici2;Urd7,ce
S. V r erra �u p�natiun an.? �, I C f lectrica! repairs or additions
required.)
3.❑ I am a homeowner doing all work officers have eaercisfed then I I Plurttbing repairs or additions
n t ofrx.:rn slop pc[ MCiL
myself.[No workers corn f,. � I I � !?.0 Roof repairs
insurafce required.] r c I >', vl(4)_ and a.'c Iravc I �
3 Other�
'Any applicant that checks bo.r ti l must aisv fill vet the wcllon oeiu � �=g eto�: ,�;;rt t� �;;mpcns,r:un t, ,cy:n o merlon
t Homeowners who submit this a Tidavit tndoGzfiog they arc doing all ar)d Ihen;lire ,u�bJOC mu,r subIn1t a new affidevtt indicating such.
tContraetors that check this box must atwched an addnionai sheer shn�r Ong the nanie ut tht soh-contractors and state whether of not those entities have
employees. If the sub-contractors have employees,they must provaic their workers comp policy numhet
I am an employer that is providing workers'compensation insurance for my employees. Below is the polky and job site
infornualon.
Insurance Company Name-Intego
Policy N or Self-ins. Ltc. it:NevvC424991
�
Job Site Address:All Sleets in lfi City�Statel Lipp CC,
Attach a copy of the workers' compensation policv tieclaratiurt pagr(showing the policy number and expiration date).
Failure to secure coverage as required under SeAcm%`A ni MGL c I Y2 can let:c+' to the imposition of criminal penaltie8 ofa
fine up to$1,500.00 and/or one-year imprisunrnem,as ,,c.l a_,civil penalties n, the fun11 of a STOP WORK ORDER and a fine
of up to$750.00 a day against the violator. Bc ad,f,�d that r7 copy ,t stxwtcmt+,w m�1y be forwarded to the Office of
inves[igtttions orthe DlA for insurw:GC cvvc�u�G •c.,t,..,,.
1 do hereby cerli under the acts and enaltres v rlri�ur/orrnuriun po viaeil above is true tand sorreet.
Phone#
Official use only. Do not write in this area, to be completed by city or town ofJ7ciaL
City or Town:
Issuing Authority(circle one);
1.Boa rd ofHeattb 2. Building Department 3. C'itvflvv+u C terk (:tritri,Ul tnsPcrro, h. Plumbing inspector
6.Otber
Contact Person: _ Phone 4:
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSI-)
Name of CSL Holder
Typc� Description
No.and Street
�J ('Inrestricled(Buildings U2 to 35,000 cu.ft.)
City/Town,State,ZIP -m masonry
Ell
R C Roofing Covering
Olid Fuel Burning Appliances
ilT-6-.4 Insulation
— ---- --hii::
�T e�l jep�h o n e Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HI Com Ni 7-1m,
City/Town, State,ZIP
SECTION 6: WORKERS' COMPENSATION INSURAN(F AFf'IDAVIT(M.G.L. c, 152.§ 25C(6))
Workers Compensation Insurance affidavit inust be completed and submitted with this application. Failure to provide
this affidavit will result in the denial ofthe tssuance ofthe building permit.
SECTION 7a: OWNER AUTHORIZATION TO BE COMFLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby
to act on my behalf, in all matters relative to work authorized by this building permit ap f plication.
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name beloA, I heieby atiest under the pziins and :s of perjur�'Ihat all of tile inforination
contained in this application i.�true and accurla(,c to the bust �jio�N le(jge and -incier-standing.
Print Owher's or Authorized Agent's Name(Electronic Signature) �Date
1. An Owner who obtains a bu ilding perrit it to do his/her own wot k, or an owner who hires an unregistered contractor
(not registered in the Home li-riprovenientContractor(HIC) Program), "ill t1ul have access to the arbitration
program,or guaranty fund under M.G.1 c. 142A. Other important informat7ion on tile HIC Program can be found at
WNVW.mass.gov/oca Information on the Colistruction Super,isoi- License-',In be found at -ww.1-nass-Rov/
2. When substantial work is planned, provide the information below: nuattics,decks or porch)
Total floor area(sq. ft.) (includin8 garag e, finkhed basetnt�
Gross living area(sq. ft.) Habitable room count
Number of fireplaces__ Numberol'bedroorns
Number of bathrooms Number of half/baths
Type ofheating system Number of decks/porches
Type orcooling";Ystem 1:11 closed Open
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1
he Commonwealth of Massachusetts
-- F� d of Btaildinc RegulaUon� and �, a I arils FOR
e id ��un u� &G �, t�'cio� MUNICIPALITY
th,a r r.t�,��,MA 11,060 Mas.•chusetts State BLIilding Code, ?80 ("%11Z I USE
Building Permit Application To Construct, Repair, Renirsate Or Demolish a I Revised Mar2011
One- or 7'1vo-l'-wally Dwt,llmy
This Section For Oicial Use Unly
Buiidutg Permit Number: Date Applied:
Building Official(Print Name) Siynanuc Date
SECTION 1: SITE INFORMATION
-- - _-- --- - -
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
{ I Aa Is this an accepted treet. yes__ no �'lap Nu,nber Parcel Number
r
1.3 Zoning information: 1.4 Propert. Dimensions:
Zoning District Proposed Use Lot ronLage(ft)
1.5 Building Setbacks(ft)
Front Yard tied° ard, Rear Yard
Required Provided R yuirc i I rug i,,, Required Provided
1.6 Water Supply: (M.G.I-c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Systetu:
Zone' Flood Zone`'
I Public Cl Private❑ -� `:tiIuniQipal❑ On site.disposal system ❑
�- C:heck if ycs❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
XWMI
Name(Print) City State. /11,
No4H� l elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Building❑ Uwncr Occupied ❑�Itdt>airtilsl ❑ -�Iteratien(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg ❑ �uml,cr of Units _ Other ❑ Spec ' :
Brief Description of Proposed Work
r
it
SECTION 4: ESTiMA FED(:ONS'I RUCTION COSTS
- Estimated Costs Official Use Only
Item (Labor and Materials)
---_
1 Building � � 1. Building Per-ttut Fee: S-_ _ Indicate how fee is determined:
- - 0 Standard City Town Application Fee
2. Electrical _$ ❑'1-ota1 Project Cost' (Item 6) x multiplier x
3. Plumbing S Other Fees: S __
4. Mechanical (I-IVAC:) S List._.
-
5. Mechanical —
S Total All 1 ecs:
Suppression) -
i
l � - ,� Cash Amount:_,
� heck Nv.�� C�hcck ,`lrtic�unt -- -
6 F,Project Cost 4, r Paid :r. r r,!' l t)utstinding Balance 17ue:_---
File#BP-2015-0703
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS (860)930-7794
PROPERTY LOCATION 12 HINCKLEY ST
MAP 30B PARCEL 023 001 ZONE URB000Z
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny,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
INFORMATION PRESENTED:
proved 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
Demolition Delay
Si ure of Builji; OffiaKl 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.
12 HINCKLEY ST BP-2015-0703
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B-023 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-2015-0703
Project# JS-2015-001362
Est. Cost: $1754.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 25003.44 Owner: CORLISS PATRICK
Zoning. URB(100)/ Applicant: JOHN PERRIER
AT. 12 HINCKLEY ST
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.11712015 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 Sienature:
FeeTvne: Date Paid: Amount:
Building 1/7/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner