24A-125 (4) SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
m
License Number Expiration Date
Name of CSL Holder '�'- T_ List CSL Type(see below) X
EAST'°
No.and Street Type Description
:5.,'1& l"o U Unrestricted(Buildings u to 35,000 cu.tt.
l41 (.:J R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Rooring Covering
WS Window and Siding
SF Solid Puct$umingAppliances
q3 -- � Srl�Y" ��4' 4l1tXfh) I Insulation
Telephone Email address D Demolition
5.2 Registered Home I�mnrovement Contractor(RIC) C?�1
HIC'Registration Number Expiration Date
HI Company Nam R ist,ant Name _ o 0
M pgdoc
No��Strc�N� '�- �����r �Enisi a dress
City/1 ,State ZIP Telc hone
SECTION-6:WORKERS'COMPENSATION INSURANCE_AFFIDAVIT(M.G.L.c. Ise.J 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 h1W aS(.,r 6sn t--:� Se1.I
to act on my behalf,in all matters relative to work authorized by this.building permit application. j
Print Owner's Name(Electronic Signature) Datc
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest;underthe 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 Owner's or.Authorized Agent's Name(Electronic Signature) bate
NOTES,.
I. 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 MAL.c, 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.goy/dos
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"
Petett F,c+rtt�
The Conunotrwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-:2017
www,mass.gov/dia
Workers' Compensation Insurance Affidavit: Build ers/Co n tracto rs/Elec trici anO lumbers
Atmileant Information Please Print Legibly
NZtI7lC tHusint:ss10rganirtt{ipNlndividual);
New England Green homes
Address;59 East Main Street
City/State/Zi :Staffo,c, CT Ot3070 ±Gre #.960-930-7794
Are you an employer?Check the appropriate box: Type of project(required):
1,Q 1 am a employer with 4 4. ❑ I am a general contractor and I
cntployocs(full and/or part-time).
s have Hired the sub contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner.- listed on the attached shoot, 7. ❑ Remodeling
ship and have no employees These sub•eonnotors h4YC g,
❑Demolition
working for me in any capacity, employees and have workers'
[No workers'comp.insurance cotnp. insurance. 4. Building addition
required.) 5. ❑ We are a corpuration;and its 10,❑Clectrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.0 plumbing repairs or additions
myself.(No workers'comp. right of cxcmption per MOL 12.❑Roof repairs
insurance required.) c. 152,§1(4),and we have no 13. Other C.r J,e
employees. [No workers'
comp. insurance required.]
`Any applicant thatchodu box A I must also fill out the sootion below showing their wori:ers'eompensationpolicy information.
t Homeowners whoaubmli this affidavit indiccting they are doing all w06 and then htto vvlsidc contractors must submit a new affidavit indicauns such.
:Contncton that check this box must attached an additional sheet showing the name of the sub�contrsoon and swo whethor or not those entities have
employees. If the cub-contractors have employees,they must provide their workers'comp policy number.
I am an rirrployer that is providing workers'compensation Insurance for my employees. Below Is the pocky and,job slie
lrrjortrgrtbtt.
Insurance Company Name:Intego
NewG424991 _ r Policy lorSelf•ins. Lie. i: xpraton at s
Job Site Address:All Steets in citylState/zip:
Attacb a copy of the workers'coulpensa(ban pLllcy declsratfun page(showing the policy aumber and expil tioa Batt:),
Failure to secure coverage as required under Section 25A of MOL 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 ortho DIA for inaurauice uvYeragc—rifwatton.
r.+■rrr�ocMa■�ri■■�..■mar��sun
/do hereby certify under eke aGu and enaities v e un that the Information provided above is true and correc4
Dat
Phone
Of elal use only. Do not write In this area,to be completed by city or town off 3ciaL
City or Town: Permit/License N
Issuing Authority(circle onv):
I.Boar of Heattb 2. Building Department 3.Cityri'vwu Clerk 4. Electrical inspector 5. Plumbing Inspector
6,other
Contuct;Peraon; Rbone 0:
(Z .5 The Commonwealth of Massachusetts V'n�
Spgd``O� Board of Building Regulations and Standards FOR
e, g 0� Massachusetts State Building Code,780 CMR MUNICIPALITY
c,plvn' to USE
0 >►o�"a`" Building Permit;Application To Construct;Repair,Renovate Or Demolish a Revised Mar 2011
One-or No-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
S-7 1.)%'7, C_7L
i.la Is thi 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 yes0
SECTION 2: PROPERTY OWNERSHIP`
2.1 Own r'ai Record;
—�- .��`
Name(Print) Cam,State,ZIP
Na.trod Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED'WORK2(check all that apply)
New Construction❑ Existing Building El Owner Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other a Specify:
Brief Description of Proposed Work':
`Wi'J ��i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building $ i. Building Permit Fee:$ Indicate how fee is determined:
0 Standard City frown Application Fee
2.Electrical ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire S
Su ression Total All Fees:S
Check No.-73- C2xnountv: ._Cash Amount: ,
6.Total Project Cost: ❑paid in Full ❑Outstanding Balance Due:
File#BP-2015-0855
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 57 PROSPECT AVE
MAP 24A PARCEL 125 001 ZONE URA000)
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
Buildine 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 ON 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
emolition Delay
S atu e u' g Official 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.
57 PROSPECT AVE BP-2015-0855
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A- 125 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-2015-0855
Project# JS-2015-001670
Est. Cost: $3391.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq.ft.): 9888.12 Owner: NATARAJAN NANDINI&T GOMES C/O ALEXANDER LANE
Zoning: URA(100)/ Applicant: JOHN PERRIER
AT. 57 PROSPECT AVE
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.•311712015 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 3/17/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner