17B-008 (14) ZN The Commnweafth oj'Mussuchzelts
ry" Departinent of Industrial Accidents
Qjfice uj'lnvestigations
I C'ongress Street,Suite 100
Bu. Ion, MA U1114-1017
wk)tv,mass%g0v/dia
Workers' Compensation Insurance Affidavit- Builders/ContractorstElectrician$fPlumbcrs
Applicant Information Please EE!Rt Le�,ibly
Nev, England een hDfne,,
Addrtss'59 East Main retreat
�'-,*affc,-d' CT 06076
;i1-E1j0-930-11 34
Are you au employer?cbcvk the appropriate box: type of project(required):
air;a crrip)oycr lv)t)l 4 4, tifli il e I
and
1 0-. ❑ New consinictiQ(I
you e
a e-
loycc5(full and/or par-time).* IW\k: 1HIZU Uh:Sub uvl�UaclDr;,
-rnp
2 D Fcn I p
M I arr a sole proprietor or purint•r- listed on the tittuched sheet Remodeling
ship and have no employees I hesc �iin-conirictor,tiuve S. ❑ Demolition
working for me in any capacal� uno halve \kQrktr.�' 9. ❑ Building addition
[No workers' comp. insurance c:ooip
required.) L We a1 v it -1 Pk-16-1,111d its I().� Electrical repairs or additions
3.❑ 1 am a homeowner doing ull work officers have exercised their I 1 (:1 Plumbing repairs or additions
myself. [No wul-kers, comp. �)Vvx,-1111)1100 PCI M(--)L" 12.�Roof repairs
insurance.required.I 15,�, §i(4), and wu hjvc it
13, Otherif
nsurar.,k,
"Any npphcant that chacks'uux li`. must also fail,ut th��cction Del��+ .,�. �.ri t�<<r,. �rl,�n ecmpt� anon p�!'.y:rrUrmatinn
'Contrac-iors that check this box must attsAcd aii ad&101141 v!',he 5ut)-6jatracioti and 5141C WhVhCr or not thust cnNieshlive
trilpluYm If the subcontractors have employees,ihq rn.jsi provide th;nf worl v cairn owicY mirnher.
I am an employer that is providing workers'compensation insu ran e e for my employees. Below is the policy and Job site
Infornsw1on.
Insurance Company Man,:Inte9c)
Nuvv(.424 9�)�
✓
Policy h or Suif-ws. LiL, 0
Job Site Addrcss:All Stouts in C frN Statef
Attach scupy ui`tll'; wurkeis' %:0wrJc1I.SA6U11 told �, dadia(i'xl
Failure to secure coverage as required under Siclikw ;-;\,1U- c
fine up to 51,500.00 and/or one-year imprisonmew, as well as t)Yil pertahies in O)r fbrrn of a STOP WORK ORDER and a fine
ol'up to 5250.00 a day against the Oulator. be advised that a cop) of this statement may be forwarded to the Office of
Itl40sligutioll5 UT the Die\ run 1r1zU1W1,-,V '.kOciab,:
I do herelil cer4 under the p aijL5 and pen alties o1j)erjjj rl,that fit o in zormaiion provided above Is true and correct.
J
V
phone 4:
Official use only. Do not write in this area, to be completed by city or rowte official
City or Town:
lssujrig Au(bority(circle unc):
1. Board of Heatilb 2. Building DcliarL(itcot 3. ivc t,itaj inspector s. Plumbing Inspector
6,Otbur
Contact Person: Phone 0:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSI.)
cro t to >, License Number Expiration Date
Name ofCSL Holder
9 eAv`—T— u List CSf.Type(see below)
— __.. i_ Type Description
No.and Street
t 1I 1 t [restricted(Buildings u to o 35,000 cu.ft.
R C strictcd I&21t�nilyDweUing
.__ _.
('itylTuwn,State,ZIP N _Ntasonr
RC Itoofing Covering
I Window and Siding
�,'
$F Solid Fuel Burning Appliances
Insulation
Telephone Email address -D..—_ . Demolition
5.2 Registered Home Improvement Contractor(HIC)
tilog � Number Expiration Date
HI Can any Nam .H 'Rant Name
ycj
No.turd Street � Emni a dress
City/Town,State,ZIP Telephone _��
SECTION b: WORKERS' COMPENSATION INSURANCE.AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance surance affidao it 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 _._.... 6Q No--__..._ ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
to act}orttnt behalf all [natters reltativv. to work t authorized b this } .
J property, �z �l_7 LlL~
y y is building permit application.
flint wner's Name(Electronic Signature) Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the ruins 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.
.�.._ l
Print 0 per's or Aut tit's Name tGlcctronic SiE,nuurc} Data
NOTES:
I. An Ocaner who obtains a building pernut to do hisihci own work,or an owner who hires an unregistered contractor
(not registered in the t-lome Improvement Contractor(1110) 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
NVww.1 lilss,.gt y_oca Information on the Construction Supervisor license can be found at www.mass. ov!do
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. it.) Habitable room Count
Number of fireplaces.._-__ _ Number of bedrooms
Number of bathrooms Number of halt%baths
Type of heating,system _ Number of decks!porcltcs
Type of cooling system Enclosed -
3. "Total Project Square Footage" may be substituted for"-iota[ Project Cost"
t ,
l�~ APR 2 4 Hili
The Commonwealth of Massachusetts
FOR
Electric,Plumbin i .�pections Board of Building Regulations and Standards MUNICIPALITY
Northampt n; 60 Massachusetis State Building Code, 780 CMR USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One- or 1'vvo-1"(n?n1y 1)wellirig
This Section For Official Use Only
Building Permit Number: _ Date Applied:
Building Official(Print Name) Signature llate
SECTION 1: SITE; INFORMATION
1.1 Pr 1ae ty A Tess; , I,' Assessors Map B Parcel Numbers
_ . :, .. , ?.1,. �;;r,': r Parse:
>a rl[;� u�ncd StrElt: ��� riU r
1 '
1.3 Zoning Information: 1.4 Property Dimensions:
i-7 Orlinj District Proposed Use Lot Area(,,;q 11) Frontage(ft)
1.5 Building Setbacks(ft)
F'r c
mt Yard i;dc Yards ; Rear Yard
-- T-----
Required Pro id _ Required ( Provided Required Provided
1,6 Water Supply: (NI (i.1.c 40,§54) 1.7 Flood Zone Information: - 1.8 Sewage Disposal System:
Lone outside Flood Pone? ! Munici ai O On site dis oral s stern ❑
Public❑ Private❑ ---- _ p' P Y
('heck ii'ycs❑
_SF,CTION 2: PROPERTY OWNERSHIP'
I-2,1 owner'of Reco
Name(Print) State.PIP r
No.and Suroct 1 elePhoue Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK WOR (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bid& ❑ 1- - ----._
' � � Number of Units Other O Specify:—
Brief Description of Proposed Wor{v' � r __
777(�1.
.1_ '4-L.-,-
' 1
SkC IION1 ISI1MA1VIJ CONSTRUCTION COSTS
F'stimated Costs Official Use Only
Item (Labor and Materials)
L Building g 1. Building Permit Fee: S_ Indicate how fee is determined:
- ,- -- -- F1 Standard City/Town Application Fee
2. Electrical s
___ O Total Project Cost (ltern 6)x multiplier_X-
3. Plumbing j S (rthei Fees: S
3
Mechanical IF{VAO l h l .at
Su cession) --
_—_. .
y� :heck No.y heck Amount __....Cash Amount!-
6.Total Project Cost: $ 0 Paid in Dull ❑Outstanding Balance Due:,_..
File#BP-2015-1022
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 444 BRIDGE RD
MAP 17B PARCEL 008 001 ZONE RI(100)/RR(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
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 ATION 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
clay
Signature of B ldin l 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.
444 BRIDGE RD BP-2015-1022
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17B-008 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-2015-1022
Project# JS-2015-001946
Est. Cost: $2462.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 135036.00 Owner: HUTCHINS FAMILY PARTNERSHIP
Zoning: RI(100)/RR(100)/ Applicant: JOHN PERRIER
AT. 444 BRIDGE RD
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860)930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:412712015 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 4/27/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner