24D-007 The Carntnutinvalih oJ'Afassacliusetts
Deparrotent uJ industrial Accidents
I Coltvv.m Street,Suite 100
Bosiun, VIA 02114-2U]7
Workers' Cornpeasationi Insurance Affidavit' Bitilders/Contractors/C lectricians/Plumbers
Applicaut Information Please Print LeElbly
Nam,:0.aMc',
Addrcss:59 Eot%t Maul *(lutit
cily'lstalc/z -Slaftulu CT 06076 lihoae „:600,930.7794
Are you oil vityloyer?Chock the apprupriulc box: Cype of project(required);
[.7 1 e'C11C1'!f'01V6,�tOr and I
I wn a crnp�ovei vvill) 1 (1)1 D Now uonsiniction
Clilplo"CC)((ull and"o., Par! !;111C) • hip., k tt-”]Ifiv
'I'lhc Jutiched sheet, Reniudeling
I all"a wiy p'ropri,�i(>r or pwrWJ
Ship and t.uti e no cmplsn c,:, 1hL',t Demolition
wvlkjll� 10) we ol any jnipli v,,�" j ri,i,e Butiding addition
(No workers`comp. jnsLltan-.,: tvjllp
required.) livv xv I'Uipwatfoll and its 10. Electrical repairs or additions
3,(D I an a homeovAlor doing al I vot k offitxi-s'iwv;�t:xervi%ed their I I.0, Plumbing repafts or additions
niy�clf,[No workers' :wnp riy;lit�A �cuifytivr;per 11401- 12 17 Roof repairs
li"SUMICT I U04iled.1• I I".� 11; 1 'il Id we 111AVC 4'
V(I y i .,v(k er�' I JJ4 o1her
*Ar,)appl4wit:AW,t�sc.,. r« I' I 11:I. t,,ii , rt.v,s � mpcnswia,i p nllirmaoon
,Kulnco%rIcrs whL,wwlw iil�)vilid, �—wq' ,I, J, A J I)—,:i,t wolia,lvi,--,7 W-1 a dcw efr4pvit ia4'WinS such.
'CGnusvotl tile 0104 lhis,ha,must 4114+.11'kj M,adilni.siai sneer'i'—" JW 11 ht sub-Contracion dna wale wticibor or rilli iWsv entines hsvc
iwvc csivloyvo,0hey mlv pvwdf 01-- comn rKijtc}'nuol"I
I am an enjiloyer that Is providing i owrokers romgl eltvxio n Ili su run e r for my employees. Below is the polky and job sari
Infortsualon.
Acted c,
Insurance Cotnpany Nimit
J'kJjjQ)r fl tic SCff. N uw";4 4 Date.
Job Site Addrciss.flli stoe(h;'irl L
Attach 11 cupy of the eke Coul riclisat toll puliC JJCCIH lrj I jon Pagf(SJJUW iQg the police number and Capir&(iQ/'
d date).
Failure to secure coverage us rC+IiRrd Widei 15A oi NICL c 152 can lend to the imposition of criminal penalties ofs
rilIA:tip to S 1,500,00 and/or one-year imprioinnein,js wee penalties in dn; rorn,of a s,roP WORK ORDER ands fine
ol'up to 5250.00 a day against the N;olatot tic adN 15%W 01111 1:(opy urdlis u0torricla may be Forw4rded to the Office of
of the i)1". fit 4-- cr�f�an vet.
t do lierir&Lertily)t4tsdvr elle r,1JM 110 1?0101be, lil thiii fll1',1P!_Jorma11oti provided abuive Is trove andcarre"
r
Off7clat use only. Do not write in this area,to he cumvle(rd by city or(own official
City or TA)"11: Pc rinit/Ut enst
ho.unlg'x 11411111 1(,) tic;(V1, weir!. I
J. 131oll rd of J V9 I t 1 13 tl f i l l L 4 1;�, 1 j L 1—1 W V i t 4 V Irk.I I i,a I 111 yvt 101, 5. Plumbing tnepecrar
Contict Fersou;---, phone 9,
SECTION 5 CONSTRUCTION SERVICES
5.1 Construction Supervisor Li cellse(C'SL)
TO - License Number _ tixpiration pate
- – _
Uamc of C' 1. Hvtdc r
t 1sl C'SI.f"ypc(arc hel(tw)
No.and Strcct rype Description
r
p f C, �^1 U Unrestricted Huildtngs up to 33,000 cur 1
{ l .1-1�1 _.�f.(___ R Restricted M2 Family Dwelling
�.ily/"Ibwn,Slatr,/(P � 11 Macurtty�
)tC Roohng_Covering
15 S W'irtuow and Siding
4l' tiohd Fuel Burning Appliances
9 3t�-' }-� t1 � �'xjGtiln /gl�m, ,r� 1 Insulauon
fietr hnm_ t matt adri.r,. C) �i. l7cntulhtun
E 5.2 Registered tionte }uaptovemeut C'on1j' ctor(HIC)
{ 13�t� , t' l _ o n Nur_. ?>�L
__._. _ __ 1I1C Rcgitratinn Nuntbcr Bxpiratiaan Otttc
Dit Copt an Nume o ffl Kee>,t�t�n�=Name Q
No.raid Strcut t `
smut a dress
Cites/lawn,State;
SECT ION 6:WORKERS' C'01"tI "t.NSATION INSURANCE AFFIDAVIT(M.C.L.c. 152.§2X(6))
Workers Compensation Insuranco alfidac it trust be completed and submitted with this application, Failure to provide
this affidavit will result in tho denial of the Issuance ofthe building pennit,
Signed Affidavit Attached" Yes
SECTION ?a OWNER R Atl 1 10RI ATION TO BE COMPLFTED WHEN
OWNER'S S A( F N"D OR(ONT10C'1 Olt APPLIES FOR BUILDING PERMIT
1,as owner of they sublet t, rte tart, htit L:b,,authort,:c �tC,y1�_ '"s�C a !1J.s-t` 7 � 4 (�tY"��'
1 to act rty behalf Sn all rnattrr'rela(ive'la work authorwcd by this building hermit application.
r
n true tt:Itctionic Stan i€urcl Date
S1 t FION h: OWNERt OR At" IIORILE D AGENT UECI ARATION
By entering my name bti)orc, I hereby 2111rii wilder the)t;airts and pcnalties of perjury that All of(tic infonnation
contained in this application i,:true xid itccuratt:to the hest ut my knowledge and understanding.
Pnn6(l _ e Authorized p ' __
7
wnc s or A}c c Na c
(}iicctrauic Jiguutun:) Date
NOTES:
1. An Owner who obt um a bu ituntt;punuj to du htsAier own work,or ten owner who hies an unrogistered writraator
(not rvgistcred in the Home ltnprovcmeni Contractor(111C) )'rogram),will rat have Recess to the arbitration
prograin or guaranty fungi under M.t i 1. c i42A t.nhet !:nport:ant information on tilt:HIC Program can be found tit
caww t�+�tiv_;�>�a tnfurrr.;,tiatrr un tilt l'nnsu'uclu,a Supcivi�;ur I.icensc cpn be (ucutd at W'ww'• SS.COV/�pg
2, When sub5ttuutal ,vurk is plannca,provide 6w h irtii>rm riitin below:
Total floor arc t(sq. f!.) _ (including garage, I'mished baselnent/attics,decks or porch)
Gross living area(sq.ti.) Habitable room count
Number of fireplaces __ _- Number of bedrooms
Number of buthrooms . Number of half/baths
Type ofheating system Number of decks/porches ,—.._
rype ufcooling SYstcm _.—..Open
3. °rural 1'fct)ct sqt laic,
t opt �t nett) tit ,utt�uuitc 1 Inc I utttl NlO,Jt.Ct Cost"
8 Z0�'� W.r
�i4 tnspections
�tectrc.Piump,p9
n
Ao,aso 1 lac �.�»ttnwntAc tlth ,tl Ala»uchuactt' FOR
iJortha Iio aid o1 Uuildin,Rcgul;rtuon-,at ndards
�.� � Ma .actru�etts Stag building Codc, 780 CMR MUNICIPALITY
USE
Building Permit ApplWatitm l"t°,Construc.t, Repair,Renovate Or Demolish a l Revised Mar 2011
(bie. or Tivo-f afailY OlveNing
This Section For Official Use Only
Building I'erniii Number .. Dare Applied:
Building otticral 1111110 N;wir.) Date
.rl,CTION I: Pr't: INFORMATION
1.1 rtv Ad r ,,: 1.2 Assessors Map& Parcel Numbers
1.la Is this alt acre pled Act! no i w �,Nun,her Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions;
J,ann,g District Proposco t ls,! ( Lot:Area(my fl) Frontage(ft)
1.5 Building Setbacks(ft)
hrurrl Yard � tilde Y a,.t^; ( Rent Yard
I utred No%idcU i2atluu�J I rovided Ruyuired Arovid l
L6 Water Supply:(NI.G I 4o §'A 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
/crnc. Ownjdv Fluid 7_onc"
Public t7 Private❑ lock iCsesCl Municipal 0 On site disposal system Q
SL'C'TION 2: PROPt RTY OWNERSHIP'
2 1 A�n� '01 l e ord:
Name i 'r❑t
_
Nu.and Street I Clephone Email Address
_. .._.. ----------
5ucrION 3. 1)L;SC'IUP TION OF PROPOSED WORK'(check all that apply)
New
Construction nstruc.tion C i xis, lwv ltuildut C) O�NJICI 1h�Iwjcd J itepatr�(5) CI Alterailon(s) O Addition C3
F
_ k_._ _,._ -__. _.__ ._
Demolition 0 � Accvssoit lolly;. U hunker c,l kills _ _ Other 0 5pecil}L
Brief Dus%;iipuvn oY Proposed Vvori. ,_ _
C�
SI t'TIC)N 3 FS"I IMA TED,CONSTRUCTION COSTS
t-,umatl:u t usis.
Item Ufficittl Use Only
t. Building Building -1 11toldmg Permit Fee 1 Indicate how fee is dedetermined,�
❑St;mkhtrd t;ityJown Application Fee
2.Electrical CI'1'utal project Cost](Item 6)r multiplier x
3.Plumbing5 ?. lather Fees:
i. Vleehrntcat
3.Mechanical (I ire _
t Suj)prtS51or7) { 5 I o ial All Fees:�..._ .._ �_.
� t'heck tit,.$jt_Check Amount:_. Cash Amount:
6.Total Project Cost I S C!Paid In Full O outstanding Balance Due:
File#BP-2015-1266
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 24 HAYES AVE
MAP 24D PARCEL 007 001 ZONE URB(100)
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out tit
Fee Paid
Tyneof 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 MATION 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
D m ' 'o elay
Signa of uil g Official 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.
24 HAYES AVE BP-2015-1266
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:24D-007 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categoa: INSULATION BUILDING PERMIT
Permit# BP-2015-1266
Project# JS-2015-002325
Est. Cost: $2424.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sg.ft.): 24698.52 Owner: SIMON GABRIEL P&JULIET M C/O JOSEPH W MECHEM
Zoning,: URB(100)/ Applicant: JOHN PERRIER
AT: 24 HAYES AVE
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:61912015 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 6/9/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner