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25C-043 (5) The Commanwealth of Massachusetts 'tF' � Department of Industrial Accidents Office of Investigations I Congress Street,Suite 100 Boston, ,CIA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print.Legibly NaIrie(E3usiness/Organization/individual); New England Green homes Address:59 East Main Street City/State/Zip:Stafford, CT 06076 Phone 060-930-7794 Are you an employer?Chcck the appropriate box: Type of project(required): 1.© 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.❑ l 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 or me in an capacity, employees and have workers' S Y 9, ❑Building addition [No workers' comp. insurance comp. insurance.; required.) 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions- 3.0 I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' camp. right of exemption per MCL 12.7 Roof repairs insurance required.] c. 152,§1(4),and wa have no empluyees. [No workers' 13,[ZOther�/ ��l,L /-�i comp. insurance required.] (( `Any applicant that checks box N I must also tilt out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they arc doing all tvorh and then hrry outside contrnacrs must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheer showing the name ol'the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'camp policy number. tam an employer that 1s providing workers'compensation Insurance for my employees. Below is the polky and job site Information. Insurance Company Name:Intego .- Policy#Or Self-ins. L1C. fi;NewC424991 Expiration Date: - Job Site Address:All Steets in City!State/zip:�� ��� ��'r " ✓7� Attach a copy of the workers' compensation policy declaratiun 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 fur insurance cuveragc verification. I do hereby certl nder the airs and enalries v er u,?r that the in brmatlon provided above Is true and correef Date f Phone# Official use only. Do not write In this area,to be completed by city or town ofjlclat City or Town: Permit/License�{ Issuing Authority(elreiv one): I. Board of Health 2. Building Department J. Cityauwu Clerk 4. Electrical inspector 5. Plumbing Inspector b.Other Contict Person: Phalle : SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) j 19 12.1M1 1ffi J'Q}-Vq�t '1�,F�'1 License Number Expiration Date Name of CSL Holder —T S.R !'.S� M Ai N _S}T� List CSL Type(see below) No,and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft. C�1 R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering - WS Window and Siding �/� SF Solid Fuel Burning Appliances "per I �y§ g hoo.4>H 1 Insulation Telephone Y-' Email address T D Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name of HIt Re is rant Name o O No.and'Street L5 �`2{ i -i _��� � '„ � daia 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 ..........*0 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 NE�t4 �� tmS to act on m be l , ' 1 matters relative to work authorized by this building permit application. rin per's Name Nectronic 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 applic n i�true and accurate to the best of my knowledge and understanding. PrinWwneA 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/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" I 4 201 J The Commonwealth of Massachusetts Board of Building Regulations and Standards FOR MUNICIPALITY Electric, i &Gus Inspections Massachusetts State Building Code, 780 CMR USE N rth n, MA 01060, ermit Application 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.JPrrooperty Address: } 1.2 Assessors Map& Parcel Numbers __5v 1 Z! J 1 by� 1.1a 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 Qw-nert of Re Name(Print) City,State,ZIP , No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s} ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ 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: ❑Standard City/Town Application Fee 2.Electrical $ _ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List:_ _ 5.Mechanical (Fire $ Su ression) Total All Fees: 7�-�o Chec k No. Check Amoun Cash Amount: 6.Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due: File#BP-2015-0964 APPLICANT/CONTACT PERSON JOHN PERRIER ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794 PROPERTY LOCATION 30 WOODBINE AVE MAP 25C PARCEL 043 000 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 Existing Accesso Structure Building Plans Included: Owner/Statement or License 105319 3 sets of Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INPRMATION 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 I' ion Delay i 111�< /� Sign re of Building Offic al 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. 30 WOODBINE AVE BP-2015-0964 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-043 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2015-0964 Project# JS-2015-001866 Est.Cost: $2344.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN PERRIER 105319 Lot Size(sq. 8.): Owner: TOULSON AMY Zoning:URB(100)/ Applicant. JOHN PERRIER AT. 30 WOODBINE AVE Applicant Address: Phone: Insurance: 59 EAST MAIN ST (860) 930-7794 WC STAFFORD SPRINGSCT06076 ISSUED ON:411512015 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: FeeType• Date Paid: Amount: Building 4/15/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner