36-162 (7) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 109
IF ,6oston, MA 02114-2017
www.tna3s.gov1dia
Workers' Compensation Insurance Affidavit: Builders/C:'ontractorsl'Electrician3/Plumbers
Aupficant n t11 tion Please Print Legibly
Name(Husiness/organizationitnatviduall;New England Green homes
Address:59 East Main Street
Ci /State/Li :Stafford, CT 06076 Phone #:660-930.7794
_ __...
Are you so employer!Cbcck the appropriate box: Type of project(required):
1.0 1 ain a employer with 4• ❑ 1 arts o general contractor and 1
-- --- ti, ❑ New construction
earployces(full and/or pan-time).' havc hired the sub-conaraotors
2.❑ 1 am a sole proprietor or patrner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity, employees and have workers' 9. ❑ Building addition
[No workers'cornp.insurance comp. insurance.:
required.] 5, ❑ We area corpur"ation and its 10.[D Electrical repairs or additions
3.0 t am a homeowner doing all work officers have exercised their I I ❑ Plumbing repairs or additions
myself.(Nu workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] c. 15" ,§3 1(4),arld w'c havc rtu 4 '
employees. INoworkers' 13.�Other _'4.. LZ%t
camp, insurance required.]
'Arty applimnt that checks box N 1 must also fill out the section bolow showing their workers'compensation policy inrotmation.
t Homeowners who submit tilts afriidavit indicating they arc doing sll Nwr} utid then hire vulsi*wntrnctvrs must submit a new affidavit indicating such,
;Contractors that Check this box must attached an addnional sheet shaving the nurse of the sub-coniraciors and state wheihor or not those entities hive
employees. Ifthesub-contractors havc cmployocs,they must provide their workers'comp policy numher.
I am an employer that is providing workers'eotwensation insurance for my employees. Below Is the polky and fob stir
Information.
Insumce Gomptu)y Narne:lntego"ry^ _.
x,
Policy b or SCIf-ins. Lic.fi:NewC424991 ,_. Expiration Date; `
All Stoats In
Job Site Address: �__� Ciry/State/zip:
Attach a espy of the workers' cot ipensstiol:lF(3t.:s;'declarat#ran page(shaving the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL c 1,Y2 can lead to the imposition of criminal penalties ore
fine up to$1,500.00 and/or one-year irnprisunnlen(,as well a;i-ivit pcnaltics in Use fort7i of a S'1°OP WORJ{ ORDER and a fine
of up to$250.00 a day against the violator, 13c advised that a copy of this statcrment may be forwarded to the Office of
In Yt*0846OgS Or the DlA to l' irt�urruuc carvcrat{t vcrif icucwn.
I do hcreby certifyynder the aitu and eenalfies qf perju r),rhai the in ormatlon pruvided above is true and correct
Sim
-
Offlelaf use only. Do not write in this area,to he completed by chy or town offlclal
City or Town;
Issuing Authority(circle une);
1.Board of Health 2. Building Department 3.C'ily(Y—it Geri+ 4. �le.:iricul inspector 5. Pit mbing inspector
b.Utber
comet Person; Phone 0:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 105319
J"O�N do license Number -Expiration Date
.Nam of CSL Holder List CSL Type(set below),.—T—,,
5 9 F^ " Type Description
No.and Street
--C)— Unrestricted(Buildings up to 35,000 cu.ft.)
—51rp,f;-,r KP Restricted 1&2 Family DwellinjL
City/Town,State,ZIP V1 Maeonry
--RC Ruorin&Covcring
WS Window and Siding
SF Solid Fuel Burning Appliances
Staff q34,—q::H14 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Re,�,Ntrdfion Number n Date
-HHTJC=mpa,Y1N3am!1eo?fill�Registrant Name
No.and Street cmai a dress
5T—Af F-tK-P- I
Cityrrown,State,ZIP T;1e2hone
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........... 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BU ILDING PERMIT
1,as Owner of the subject property,hereby authorize— R --��QfRf� AOWL--s
to act on T-Y-.bahaWLnA1!rnatters reiative to work authorized by this building permit application.
,
ri
It
AnO ner's Name lcc�t-'Ionic SignatLlr�T- Date
SECTION 7b: OWNEWOR 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'applicyion iS true and accurate to the best of my knowledge and understanding.
"A
p�.
Prin��wner',,,',or Authorized Agent's Name(Electronic Signature) ate
NOTES:
h 1 unregistered tractor
1. An Owner who obtains a building permit to do ltis/hcr own work,or an owner who hires an unregistered con
' hires I
(not registered in the Horne Improvement Contractor(HIC) Program),will not have access to the arbitration
— the c '
program or guaranty fund under M.G.L.c, 142A.Other important information on the HIC Program can be found at
H
www.mass,gov1(LLa Information on the Construction Supervisor License can be found at www,mg51mv/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 ...... .. ...... Numberof half/baths
Type of heating system Number of decks/porches
Type of cooling system -- --ppen
3, ,Total Project Square Footage"may be substituted for"Total Project Cost"
LJ
APR 14 2U15
The Commonwealth of Massachusetts
Electric, P &Gas inspections Board of Building Regulations and Standards FOR
N r n,MA 01060 Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One- or Two-Fancily Dwelling
This Section or Official Use Only
Building Permit Number. __- Date Applied: -
Building Official(Print Name) Signature Date
SEECTION 1: SITE INFORMATION _
1.1 Propeily Ad ess: 1.2 Assessors Map& Parcel Numbers
1.la Is this an accepted street'?yes no Map Number Parcel Numtser
1.3 Zoning;Information; 1.4 Property Dimensions.
zoning District Proposed Use Lot Area(sy ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
_ Required Provided Reyufrcd Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
zone: Outsidc Flood Zone?
Public❑ Private❑ Chcck if yes❑ Municipal O On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of Re •
Name(Print) / , } y City,statte.ZIP
No.and Street �4 Telephone t•mail Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 01 Repairs(s) 0L Alteration(s) O Addition ❑
Demolition ❑ Accessory Bidg, ❑ Number of Units Other Cl Specify.
Brief Description of Proposed Work' s Z
SF,C'TION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials) I
1.Building $ — 1. Building Permit Fee: $� _ Indicate how fee is determined:
�`- ❑Standard C;ityffown Application Fee
2.Electrical $ 3
❑'total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4,Mechanical (1.1VAC) $ Lisr -- _
5.Mechanical (Fire -,--
Su ression' S Total All F
Check No. Check Amount: Cash Amount:
6.Total Project Cost:
C.7t�- 0 Paid in Full ❑Outstanding Balance Due:
Filc,#BP-2015-0963
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 1086 BURTS PIT RD
MAP 36 PARCEL 162 001 ZONE
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-
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:
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
D ' ion Dela
Y/Y/vim
Signature of Bui inf6fficial 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.
1086 BURTS PIT RD BP-2015-0963
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 162 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-2015-0963
Project# JS-2015-001865
Est.Cost: $2087.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq.ft.): 11543.40 Owner: ROBINSON EMILY T&MARK B WAMSLEY
Zoning: Applicant: JOHN PERRIER
AT. 1086 BURTS PIT RD
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 Signature:
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