32C-228 (8) The Common wealth of Massachusetts pt Faun
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
tp) Boston, IA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianOlumbers
Applicant Information Please Print Lezibly
Name(business/OrganizatiotVtndividual);New England Green homes
Address:59 East Main Street
Ci /State/Z_ip:Stafford, CT 06076 Phone #;860-930-7794
Are you an employer?Cbeck the appropriate box: project(required):
1.2 1 am a employer with 4 4. [] I am a general contractor and 1 Type of
employees(full and/or pat't-time)." have hired tht 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 S. ❑ Demolition
working for me in any capacity, employees and have workers' q ❑ Building addition
[No workers'comp. insurance comp, insurance.:
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3,❑ l am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MOL 12.7 Roof repairs
insurance required.] c. 152, §1(4),and we have no
employees. [No workers' 13,[�] Other
comp. insurance required.]
'Any applicant that checks box N I must also fill out the section below showing their workers'compensation policy information.
I Homeowncrs who submit this affidavit indicating they arc doing all work and then hero vutside controctvrs must submit a new affidavit indicuing such.
;Contractors that check this box must attached an additional shoot showing the name of:he sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp policy number.
I am an employer that is providing workers'compensation Insurance for my employees. Below is the pocky and Jab site
trtjartawien.
Instu'aitee Company Name:Intego
e011Cy b or Self ins. Lk;.
Expiration Date:
lob Site Address:All Steets in City/State/zip: j '
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiratioa 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 die 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 inauranec c:uveragc verification.
I do here certi under the airs and enallies•v er'uiy that the information provided above is true and correc,4
Date
boric 9. �f.
0jflcial use only. Do not write in this area,to be completed by city or town ofJ7ciaL
City or Town: Permit/Llcense ti
Issuing Authority(circle one):
1.Board ofH"Ilrb 2. Building Department 3. Cityavwa Clerk 4. Electrical Inspector 5. Plumbing Inspector
6,Otber
ContnetPerson; Phone#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) r '3 + G 12 j2,1 15
"0 lj l<,(I(Ten R��1� License Number Expiration Date
Name of CSL Holder F I—�--`-�-
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu,ft,
R Restricted M2 Family 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 Home Improvement Contractor(HIC) f--3 OZr
rlf2 _ HIC Registration Number Expiration Date
HI Company Name or M Re is rant Name 0 0
Sg ens- t" iM z: I\) �r r e
No.and Street .�.-�� T,) 3�� � Emai a dress
City/Town,Sta e ZIP ��� T le hone r
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 ...........X No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize NR&f e'
to act on my behalf, in all matters relative to work authorized by this building permit application.
n.
Print wne)r'sqName(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.
Print 0 is or Authorized Agent's Name(Electronic Signature) Date
NOTES:
L 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.gov/ans
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
FOR
Board Board of Building Regulations and Standards MUNICIPALI'T'Y
C, 201 assachusetts State Building Code, 780 CMR USE
Z Building P mi Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
as I duoM One-or Two-Family Dwelling
r� ton,M^ This Section For Official Use Only
orthamp
wilding Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 ProDerty Addres : _ 1.2 Assessors Map&Parcel Numbers
r
I.1a Is this an accepted 4-eet?ves 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.C.L c.40,154) 1.7 Flood Zone)nformation: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system 13 Public❑ Private❑ Check if yes❑ p
SECTION 2: PROPERTY OWNERSHIP'
2.1 ner'of Record:
G{�
57 "Name(Print) City,State.LIP
CJ f __ /
No.and Street �� Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) O Alteration(s) O Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed i%Jork2: ' " ; Y�'. '1 r"�.I t Y?? f,(, =)�UYL
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) Y
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4-Mechanical (HVAC) $ List-
5.Mechanical (Fire
Suppres sion) $ Total All Fees:$ G_
$ Az,
Check No. ' Check Amount: Cash Amount:
6.Total Protect Cost: boo 13 paid in Full ❑Outstanding Balance Due:
File#BP-2015-0816
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 78 HAWLEY ST
MAP 32C PARCEL 228 001 ZONE URC(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 Existings
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 TION 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
Z Dem y r�g
"ttz's-
in�— �ee6fficiarDate
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.
78 HAWLEY ST BP-2015-0816
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 32C-228 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-2015-0816
Project# JS-2015-001584
Est. Cost: $1710.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sa. ft.): 6708.24 Owner: MOORE ERIN
Zoning. URC(100)/ Applicant: JOHN PERRIER
AT: 78 HAWLEY ST
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:212412015 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 2/24/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner