17A-097 (6) The Commmwealth oJ'Hassachityelts
Deparonew of tidustrial Accidents
Qjjice of1rivestigatiorts
I Cotqres..s,Street,Suite 100
Bostoir, .VA 02114-2017
wwiiv.mass,.govl(fia
Workers' Compensation Insurance Affidavit, Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
New kny,d^c! ;'een homes
Addrtss'59 East Main street
C1 /State//ip;Stafford, CT 06076 Phone iV:860-930-7794
'-ty
Are you au employer?Cbcvk the appropriate box Type or project(required):
I
I. 1 wl,,a cmPlover will)4 4,
ecncial onmactoi and 61, -LI New constniction
employees(Cull and/or part-time).'
❑_J !, ❑ Remodeling
I F1 I am a sole proprietor or parner.
C1
11 w',ays,,, Ur, the t1(1U,2)1Vd sheet
ship and have no employee~ 1 hi-i(,>itr--onimcior)have
)eMolition
working for ine irt any capacth vniplu%ve,and hate t4!Qrkteiti' 9. Building addition
[No workers' comp. insurance comp_ Insurance-
required.] ❑ We are a eUrpumtiun and its 10.E Electrical repairs or additions
1 am a homeo%mier doing all work officers nave exercised their i l.[] Plumbing repairs or additions]
myself,[No workers' comp. ri6lit uCcxcrnptiL)ii per MCL 12. Roof repairs
insurance required.1 1, 152, §1(4),alld we 11dVC it
vnipJLj}c-1--) 1",L) workers' 13, Othcraslp;k6,�
'Ally applicant that cheeks bo,,,?i! niu3r uIj� 1io�o t sv:(r-1
qy,lnv compeis4i;o-p;,l :nrbrrm(ion
1-10MCONVAUS Who submit im5 40`idati ji moi,.-jijoe they arc'hwig"H"'o;",41�j lhvj.;niv .vnt.,4,tuo inwtt submit a new affidavit indicating such.
;Contractors that check this box must aris,:hCd an addiiimial>nect 5m-rjg lkc name of the 5uh-conti-ttoor5 and state whohor or wi aws;entities h#vc
crnployccs If the sub-contractors have employees,they mist prov%le their m4crs comp policY number.
I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and fob site
Information.
Inaw-Ulet!Collipwly
Policy 4 of S
Nti",C42419))i
Job Site Address:A11 Steets in
Lip:_."MaRL
Attach a copy of the workers' compensation policy declHi-atiuil page(showing the policy number and expiration date).
Failure to secure coverage as required under Seciioji 25A of'NIGI.,is 152 can lead to the imposition of criminal penalties of a
fine tip to$1,500.00 and/or one-year impriscifurieni, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against Lim violator. Be adviiviJ t1wi it copy of this statement may be forwarded to the Office of
InvosLty,u[jun Ut thc I)I^ Im 411.SUl tu!,:,'uNcT"6e
/do hereby cereif under the pails an enulrles (11 perji4rr that fito in Ormarluri provided above Is true and correct,
Phone 9:
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town:
Issuing Authority`(circle mic):
1. Board of Healtb 2, Bit 110 111 g DcpJ I I mt!li,1 3, 1 V Clerk .1 at jjlspect,,, r. Plumbing Inspector
6,other
Contact Person: Phone C
SECTION 5: CONSTRUCTION SERVICES'
5.1 Construction Supervisor License((SL}
m ►ms3 + �- ��i�zJ t�
V_.O t4 T> License Number Expiration pate
Name of CSL Holder � ~
u List CSt.Type(see below)
No.and Street Type Description
I I nresiricted(Buildings up to 35,000 cu.ft.
-- ------- ---k--- {---t-_ -...— R Restricted 1&2 Family Dwelling
City/Town,Stale,ZIP
tvlasurtr
KC' Roofing Covering
WS - Window and Siding
��� ----
8F tiolle FLLC
I Burning APJ 11alCC5
Q hto"-�'' Insulation
Fmail
D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I {----
- 'p � f11t Registration Nurr er E���D
IIII HI Cont any Name o H1 'Re is rant Name
o c
... _.
No.and Street Email a dress
Ci n,State,ZIP Telephony _
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be c umpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance ofthe building permit.
Signed Affidavit Attached? Yes .......... No-
....... _...... 0
.._._._.
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
L,as Owner of the subject pro pert), hereby -AQmt-s
to act on my,beef, in all chatters relative to work authorized by this building permit application.
Praia wner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUT'HORI'ZED 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 application iy true and accurate to the best of my knowledge and understanding.
I r
/ •
Print O ter s or Authnrizc Agcut's Nanic(l lcctronic Signature) lute
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(111C) 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,nlass,P-pv oca Information on the Construction Supervisor license can be found at AA)y m ss.eov/dp§
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.) — l-tabitable room count
Number of fireplaces _ _ Number ol•bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type ofcooling system Enclosed T _Open
3. "Total Project Square Footage'Wray be substituted for"'I otal Project Cost"
The Coninionwcalth ot'Massauhusetts FOR
Board ol"Buildin, Regulations and Standards MUNICIPALITY
MassachUSCUS State Building Code, 780 CMR USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One- or I'wo-1,0 nni(y L)wefflng
This Section For Official Use Only
Building Permit Number:
Date Applied:
—----------- —------
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Add 1 2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes no \lap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District PropO.Wd Use Lot Area(,sq fl) Frontage(ft)
1.5 Building Setbacks(ft)
Frow Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: c.40,§54.) r 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 0 Z-one: Ouisidc Flood Zone'.' Municipal❑ On site disposal system ❑
Check Wycs❑
__1 ............
SECTION 2: PROPERTY OWNERSHIP'
2,1 Owner of Record.,
C V&ttt
za,M e_C_t I C i State.ZIP
No.and Street I e1cphone Email Address
sEcriON 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing BLJldi1!i3 ❑ 1 Owner Occupied 11 JRT airs(siO Alterations) 0 Addition ❑
_
Demolition ❑ Accessory L31dg. Li Nuinbcr of Units Other ❑ Specify:
.............
F3rief Description of Proposed Wort _._—
SECTION 4: Es'r][MATE.D CONSTRUCTION COSTS
Estimated Costs:
Itern (Labor and Materials) Official Use Only
1. Building 1. Building Permit Fee: Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical
oToial Pro Ject Cost (Item 6)x multiplier x
3. Plumbing S
2, Other Fees: S
4.7Me,hani,al (1-1VAC)
�5.
List:Mechanical (hire
S Foud All Fees. S
Suppression)
I C'Iieck No. S`��iheck Amount: &C
Cash Amount:--,---
6.Total Project Cost: $ ❑ C)utsuwding Balance Due
File# BP-2015-1056
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 37 GRANDVIEW ST
MAP 17A PARCEL 097 001 ZONE RI(100)/URA(100)/WSP(42)_/
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
INFOR 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
tion Delay
cow
Sig ure of Erui1,dTinjO f icial 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.
37 GRANDVIEW ST BP-2015-1056
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-097 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate°ory: INSULATION BUILDING PERMIT
Permit# BP-2015-1056
Project# JS-2015-002009
Est.Cost: $1900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 9365.40 Owner: DREYER BARBARA J& SHIRLEY I SICURELLO
Zoning: RI(100)/URA(100)/WSP(42)/ Applicant: JOHN PERRIER
AT. 37 G RAN DVIEW ST
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.5 1512015 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 5/5/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner