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� Ma Form
Department qJ/vdusb'/u//&cc/dcn8
Qjfirx ^l'/x,estigu/ions
/ ComXress Street, Suite 100
13o^1ox' 11A 02114-2017
IF) ww+.mu,�r.govAliu
Workers' Compensation ln*ornncrAffidavit, BuUderw/CoutrurtormUOleetrioiwmoUP|ommbers
Nanit *ew�»g�o"u_6'v,^xom'�
Address-59 E=v` ma.^ ��tre=t
Ci /S te/Zi 3mahbnd CT 06076 Phone 060-930-M34
Are you au vioptuyvir?Clii the appropriate box: rype of project(required):
ship and have no cmplovecs 8 f7 [>.-rriolltion
working for me in any capaca.,,, 9. idmg addition
Buit
[No workers' comp. insurance
required.) We ilft�it WfPUI'L1tiUtl Ind :IS 101 Electrical repairs or additions
I am a horneowitier doing al I work officers hav,! vxerci%ed their I IF Plumbing repairs or additions
'Any opp|.wm,na`rkc"`Lv^?" "w(ou"fill~`m"*u.= ,"/v" .^,"'`om`. ,"mpenpwnp! `°m" w.uo
'y^rnm"pms who^"^"`o[his wnuu°/ ".",Olt^"",^"./..^�.u.^=."^="^""""/,^^`",,..",.."b='^new ana °'ind"mingsuch.
'Commmvm that chock this^u,^iuuu/*"hed an ado.'aoai�i�et/ a/hcmmuowo0mo and 5ia*w»mxww not omsc entities Nye
°myhycw If On;s"b-motranwm»avc cmpl"ycn./�cym"uv,v,"de*= ,=rk"/m�p no,ic'nvnn^m
I am an employer that Is providing workers'com�pensafion insurance for my enVloyees. Below is the policy andjob Ykc
ofomualon.
|omumnovCvmvvmx Wamr:/
Job Site ��l�
^n o^uwt^ .// � � � /yCry
Attacb a copy of file workers' compensation policy decliii-atitill pjXt(511owilig the policy ourribvir and cxpiratiou date).
Failure to secure coverage as required Linder Sediciii 25A ut'MGL c L�2 can lead to tile itliposition of criminal penalties ofa
fine up to S 1,500-00 and/or one-year imprisoillnent,a_j well jis civil pof)aIlics in Ulu form of a$TOP WORK ORDER and a fine
ot'up to S250.00 a day agaunst the violator. t3e ddN isvd that I,copy uf this stateirient may be forwarded to the Office of
ionin
Phone 9:
Official use onol. Do not write in this area,to tile complefea by city or town officiat
6, Utbvr
Contact Person: Phone 0:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) (� )2117-116
t iceme Number expiration Date
Name of CSI.Holder
�7 v List C'SI.Type(see below) _X_--
Na.and Street Type Description
l nres s ric, d( -
tEed(Buildings up to 35,000 cu.fl.
-� — - ----- R � Restricted 1&2 family Dwelling
City/Town,State,Z[P -
"v_t N1<tson
KC Roofing Covering
WS Window and Siding
GDM' SF Solid Furl Burning Appliances
Teie hone F m
, til address D Demolition
5.2 Registered Home Improvement Contractor(HIC) .
I_ .o-2-I_ __._..
--- 'Re HIC Re isiration Number Expiration Date
Hl 'Company Name of Iii is rant Namc O o
No.wid Street E mail aadress
City/Town, State, ZIP Telephone
-^---
SECTION ti: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affida�it must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance ol'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 Uwner of the subject property, hereby authvri�e , _ . � � �_� -�._.
to act on my behat in all matters relative to work authorized by this building permit application.
4
F'tint Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW 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 application is true and accurate to the best of-my knowledge and understanding.
a -
1 1
Print OW1er s or Authurizo .A ent s Name(Jectroruc Si nwure) Date
NOTES:
j t. 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(I 11C) 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
l ww-w.mass,gpvloca Information on the Construction Supervisor License can be found at www.mas QK/, s
�2. When substantial work is planned, provide the information below;
Total floor area(sq. ft.)._— .__ __ _ (including garage, finished bit xinenUattics,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 care Project �ect S Footage- ma\ be suhsutute�l for "'I otal Project Cost"
�-q � ��
The Coninionwcalth cif Massachusetts FOR
Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code, 780 CMR USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One-or fivo-handy,L)welling
This Section For Official Use Only
--------.--T" -
Building Permit Number: Date Applied:
-------.........
Building Official(Print Name) Signature Date
..........
SECTION 1: SITE INFORMATION
1.1 Pr y Address: 1,2 Assessors Mal)& Parcel Numbers
71
1,la Is this an accepted street?yes 110 Vlap Numbcr Parcel Number
. ......... -------
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use L(t Arca(sq!A) Frontage(ft)
1.5 Building Setbacks(ft)
HOW Yard lildc yards Rear Yard
Required Provided RequircJ Provided Required ded
F-�P�10V�
1,6 Water Supply: oM (;.1,c,40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ OLI[Side Flood Zone? municipal 0 On site disposal system 13
Chcck ii'vcsD
t
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SECTION 2: PROPERTY OWNERSHIP'
2.1
tiame 4T U
01 1 n S
/3--&�` `/�i --ZVzz 413 747 mail Address
No.an d Street f ele hone
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction ❑ Existing Budding❑ I Owner-Occupied airs(s) 0 Alteration(s) C Addition ❑
0:7-1�el) I=0) 0
Demolition ❑ Accessot� Bldg. U Nuwbcrof[jni(s Other CJ Specify:—
..........
Brief Description of Proposed \VOT
>
7
SEC Ti0N 4: I,,sTIMATED CONSTRUCTION COSTS
item (Labor Use Only
(Labor and Mutvrials) I
1. Building I Buildinu Permit I-ee: S Indicate how fee is determined:
❑ Standard City/Town Application Fee
2, Electrical x multiplier
ElToial Pr'o'ject Cost'(Item x
3. Plumbing S 2. Other Fees: S.
4. !Vlechanicil (liVA(')
5.Mechanical (Fire l'olal All Fees: S
Suppression}
lieck Ncl. Cl Check Arnount! Cash Amount,.
6.Total Project Cost: ❑ Paid ill Full ❑ Outstanding Balance Due:
File#BP-2015-1055
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 13 BIRCH LN
MAP 36 PARCEL 209 001 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
INFOjiMATION 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
molifon Delay
Signature of Bw ding OtfAal 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.
13 BIRCH LN BP-2015-1055
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-209 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-2015-1055
Project# JS-2015-002008
Est.Cost: $2483.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 56192.40 Owner: HANELIN MATTHEW
Zoning: Applicant: JOHN PERRIER
AT. 13 BIRCH LN
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.51512015 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 Sip-nature:
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