36-036 (10) The ('0M totnwealth of'itilassachu.setts �tFcatrt
Department of Industrial Accidents
Office of Investigulions
I Congress.Street, Suite 100
Lloslon, MA 02114-2017
tt,u t.-.rrra ss.gry t;�d i a
Workers' CutnPensAtion Insurance xffidAvit! Build ers/t'oncractors/ElectricianstPlumbers
Applicaut Information . _ New Print Legibly
t iv'c:w riornes
:Vd7l]e tt3u.,tneas irgtir;tzuti<,rt€ttdty+dua+�.
Addrtss:59 East Main Straet
rLJt::te/Gi y�Sfdifiord CT 06076 Yl�ot�e i 800-930-7794
au emtrlvyer?Ctrrck ttir alaNroprtutr bvc ' F't'y�e of project(required):
nt a c lnpi of er with 4 I ,u I r�:er utd layecs(lull,indle.r p;tr,-tinier • atie �u! V , i� sup-wnllu�'�rr, o bl coosinCtion
m a sole proprietor or par ner. >tt'd yr the uttaJhed sheet i �l Remodeling
ship and have no empluycc.; i hPSe iuf3-ci;tl[TttCEOrS hlive $ i�emolthtm
tit�ivveea and na�u t vrkers'
working for rrte in arty capacu� ' F - 9, �Building addition
[No workers'corrlp, instirartce vtnp nsurante
`bc , e t or x;ril,un an3 its 1().;!„ Electrical repairs or additions
required.) �,'� i P
f'cers ita�� e,;er ,tied .heir �] Plumbing repairs or additions
3. C ant a honieowrrer doing all w�uk I I
mvselr.(No wof kern cutup 1,t ,t c.--irtiori pc.r MCiL
f E Roorepairs
InSrlrarii'C fY;quEiCl. r� •u f J � t 1. +-� have,,,, !
I�OtIICr(�.-F-�=�t{
'Any a�pheant that Ghccxti oox h:nium ul;, no eu,inc_ccu, r, belo, �nronnation
t Nnmrnwncra u•hu subnIr this allida,n u c 'wnp, I rd nc,-;uic,,usW�.unt;uavr>uivar subm,t a new aft,drrva indicating such.
:C0nI1vf;I0fS that Check this bux must attached an add ii(mial>nect�no.+uig,lAc na:, ,;o;;hc;Uh-GVnIrBCtCrs and Star whcthcr or not those entities We
ornpluyecs, if(tic sub-contractors have cwplvycvS,they m.,si rr¢�,^de thur wnrl:ers cmrp poney n,imher
I om an employer that[c providing workers'compensation insurance for my employees. Below is the policy andlob site
inforntwien.
Insurance Cornwar,y tinme r?tt90
ow
NC�t4 3F1':
Polley 4'of Selt L.
w,u,s. rr F xhu,ut�n t�atr Y�
Job Site Address:All Sleets a
Attacb a copy of the workers' compensation policy declaraduo pagr(shuwing the policy number and expiration date).
Failure to secure coverage as required under St-(lion 1S o' MC1t. r I Kr can kart to tiie irtiposition of criminal penalties ofa
tine tip to$1,5001.00 and or one-year iniprisonrrten,, is wcfl as t; i;I pendkics in dtc form of a STOP WORK.ORDER and a fine
ol'up to a250.00 a day agaisist thr �iolittm tic ads i.i,:d Out i,copy of this swte,now may be forwarded to the Office of
ttivcstlguttons of Me Ut:'N lu, ,r:au,w� xn,
!do hereb certi under the airrt'nrtd .enulnc�s vJ ?er/art rhru rim in/ormailon provider!alcove is true and correct,
,
u
Phone
OfJIcial use only. Do not write in this area,to be completed by city or yawn ufflcial
Clty or Town; i'rr,nit/t.irrnvr 41
issuing Auihorit) (circic onr):
1. Board ofHealtb 2. Bulltiitig Dcpatunent 3, Ivck d trical [n hector 5. Numbing Inspector
6,Otber
Contact Person: .- T Phone
5t CTION 5: C ON5'TR1 C.TION SERVICES
S.I Construction Supervisor License(USL)
-P � l.rcense?kurnber Expiration—Date "
Name ofCSt Holder
o List CSt Type(see below)
Type Description
No.and St.rect.
– �, OL ;I nresint tcd(Buildings up to 35,0{}0 cu,ti
__ R �-Restricted 1&2 F�Dwelling
City/Town•State,ZIP M — Masonry
RC Roufittg Covering
WS Window and Siding
SF So id FLcl Burning,Appliances
,rr,ulation
Tele hone 1 m+il rtddrr5ti D _ Demolition
5.2 Rester Home Improvement Cn ontrtctur MIC ) 1ilt'( Reg strdi�on N�
umber Expiration Date
110 mn�mH __r it Na__c
o 0
No.and Street Emal A dress
rsk' [— � 'icr�q =
Ci rl own,State, ZIT' 1'elephonc
SECTION ii: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidav it must be e:Wnr]eted and submitted with this application. Failure to provide
this affidavit will result in the denial of ihc. I>suancc 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 authorizek, r►\
to act on my beha fz in all matters retativc to work awthorized by this building permit application.
CIV 1' 4 A
Pant Owner s Namc(Electronic 5 gnur nr�t Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, t hereby attest under the,plains 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.
( Pnt )N er s or Authunzcf tt,Cur s ri rm a Date
L An( vvho obi ins a bui(dinu{�ermtt to do hts�lter o�+n work,or an owner who hires an unregistered contractor
(not registered in the Home liinprovcntent contractor(I IIC) Program), will not have access to the arbitration
prograrn or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
wu!w,tnas-g.ov,lo;a Information on the Construction Supervisor License can be found at www.rnass.QO.,vldm
2 W When substantial work is planned, provide the information below
Total floor area(sq.fl)_—_ _ _ (including garage, finished basenienUattics,decks or porch)
Gross living area(sq. fl,) Habitable room count
Number of fireplaces __ Number of bedrooms
Number of bathrooms _ Number of halfbaths
"Type of heating system _ Number of decksr porches
Type of cooling system Enclosed _Open
3. "Total Project Square Footage:` way be 'uUbstituttd tot"t otal Project cost
IL
MAY
f� / 1� /
�J 'D
Electric,c,Plur-,ibin,. Th Col mlOnvveaith ofma-ssacliusetts
'If J 'r 41
Norih,,.M ' 5, &�fi ildino Regulations and Standards FOR
L)7 C,
MUNICIPALITY
is State Building Code, 780 CMR I
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
01le- or I'Ivo-haund.y Divelling
this Section For Official lJse Only
Building Permit Number: _---- - Date Applied:
Building Official(}'Tint Name) Signature Date
SECTION h SITE INFORMATION
I I Proptrity Ad ress: 1.2 Assessurs Map& parcel Numbers
7cWr_
1,11 Is this an accepted street?yes 110 number F; el-Nurn
1.3 Zoning Information: 1.4 Property Dimensions:
T111kinj District Fll-p,Jsed tjse Lot Anza(sq it) Frontage(fl)
1.5 Building Setbacks(ft)
Rear Yard
Rcquifed Pw%idcd
RC(1wrcd Provided Required Provided
1.6 Water Supply: (.M.G.L c.40.§54; 1.7 Flood Zmic Inforniatiorl: 1.8 Sewage Disposal System:
/.onc, ijutslde Flood Zone"
Public❑ Private U Check if'N%-.s❑ Ntuni�;ipul 13 On disposal system ❑
SECTION 2; PROPERTY OWNERSHIP'
- - 1 ................. _ -
e q, ),r in t i
No.and"u-ccl I clephone Email Address
SECTION 3: DESCRIPTION OF PROP0,SFD WORK'(cheek all that apply)
New Construction 0 1 Existing,Building 0 Owner-occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
_=Repa P-J.
So Number of Units Other IJ Specify.
❑ _: _01()�
Demolition FA(ccess Bldg Ll
Brief D scrip,iun ofPro,osed Worl�,
S F, V1 0 IN 4: LSTIM A I LD CONSTRUCTION COSTS
I
Item stinlated Costs and Use Only
(Labor a Muwrial�)
t, Building S 1, Building Permit Fee: S Indicate how fee is determined:
❑Standard City/I'0wrl Application Fee
2. Electrical ❑ fo Project Cost.'�ltcrn 6)x multiplier x
tal Pi
3. Plumbing S 2. Orlict I`ces. S,
4 Mechanicid iliVAk",
S
5-_'Mechanical (1 ire
Su cession 1'oiai Alt Fees: S
-7 Check No. ')k-Check Amount:
Cash Amount,. —
6.Total Project Cost:_L$!
❑paid ill Full 0 Outstanding Balance Due:_.____
File#BP-2015-1057
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 5 WINCHESTER TER
MAP 36 PARCEL 036 001 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 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
De o ' ' elay
Signatt6e4 Building fficial 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.
5 WINCHESTER TER BP-2015-1057
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-036 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-1057
Project# JS-2015-002010
Est. Cost: $2522.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 11020.68 Owner: BERUBE CYNTHIA L&EDWARD A
Zoning: Applicant: JOHN PERRIER
AT: 5 WINCHESTER TER
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.51712015 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 5/7/2015 0:00:00 $55.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner