35-110 (5) SECTION 5: CONSTRUCTION SERVICES
117
,319 -115
.I Construction Supervisor I.Acense((:SL) 10: 5 12.
License Number Expiration Date
VCSI,Holder
List("Nt 7'y1w(see belo")
Type Description
and Street
U Unrestricted(Buildings up to 35,000 cu.ft)
RP P R1 Restricted 1&2 Family Dwel!!nL
City/Town,State,%lY N Masonry
KC Coveri
Window and Siding
SF S'Olid FLid Burning Appliances
.....lntiulflttort
.........
Ocniolition
5.2 Registered Home Improvement Contractor 0110
I HI C,ontparry Nance ur'tIl�ttekis rant l�amc o p
I 11C Registration Number Expiration Date
No,and Street ,ia dr..
State,ZIP—
SECTION 0:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation ITISUMIICeaffidavit must be Lompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the issuance ofthe building pennit.
Signed Affidavit Attached? Yes .......... No ......... C3
SECTION 7a: OWNER AUTHORIZATION To BE COMPLETED WHEN
OWNER'S AC ENT OR CONTRAicToR APPLIES FOR BUILDING PERMIT
I.as Owner ofthe subject,Diu(11 hcicb" au1l101'IZC
to act ny behalf,In"a"ll t latier I 11(mi", to wk)rk, atithorizodby this building permit application.
r�s Narne'._C_Fkctronic Sign cure) Datc
SECTION 7b OWNERt 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"it this application is true and accurate to th,- best ofrily knowledge rind Understanding.
vA (z)
Date
Friloz_J,tr Akahuriico Agent's Nome(1--Aectronic Signature)
NOTES:
l. An Owner who obtains a buildutt !A crInil to do Ins,,her own work,or an owner who hires an unregistered contnwtor
(not registered in the Home Improvement contractor(I 11C) program), will not have access to the arbitration
information on the HIC Program can be found at
program or guaranty fitind unaer M,G 1, c 142A. Other important info 1TI v_/
4P
InfOrni.,ition on the (_'0I15tr1ICh0!I SUPOr"i�,()VIACeIISC�:311 be 1`�)tltld at )VWW
2. When sul)sIaotI,11 work Is planned,provide the informailon below:
Total floor area(sq. (including gat-age, finished basement/attics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number ot'bedrooms
Number of bathrooms Number of half/baths
Number of decks/porches
Type of heating system:
Type of cooling system Enclosed— -9pen
3. "Tocal Projzct Sqtiztr-Q i-00ta-"k.,TnLl} he tor lima! Project COSL"
The Cotntnon"'ealth ojJfassuc•h usetts '
Department of lndustrial Accidents
l)ffir.e o Investigations
1 t:'un��re.ys Street, Aite 1U0
UIF Boston, MA 02114-2017
I'vwiv.rr ail.goWilia
Workers' Corupensatiort insurance AffidRvit: fiuililers/('ontractors/Electricians/Plumbers
Applicaut lnf'oritlatiorl _ _ Please Print Legibly
i`r-w;i-r�c. a. d'Uccir h�n1e5
' r
:tidI77C taainca ;l irgaf;lr s +Ji,+ilh.n. e�u<rl;:
Address:59 East Moire atttool
City/State/Zi :Siaffow, CT 06070 Phone :860-930.77094
Are you an employer?Cheek the appropriate boxCyp;e of project(requited):
17 1 am a emp over with 4 4. [] I aul a ec ncl ii cvntractor and
clItpIvyceS(lull andVor pan-+ rne)-'
h,7St irNGG tfr<r�tt�-utntra Ors c) El Now consfrllctfon
l
2.F, I am a s151c proprietor or pamiv.- listcd un the uttached sheet. 7. Q Remodeling
ship and hove no emplu vk;s i GC'it'<qh•�i?8[rNC10r�hliVC I i $ Demolition
working for we In any '
Building addition
[No workers' comp, insurance � ulp trr,ur°rt<c t
1 e are it ur uratiutt and its IG.V Electrical repairs or additions
required.) �.._..� p p
3.❑ I am a honteowtaer doing all work raflicers have exercised their I I.❑Plumbing repairs or additions
myself.[No workers'comp. -igbt ui•cticrnptiun per MGL 12.7 Roof repairs
insurance rtQuired. ' I52, §t{4) yud He have nu
ctlt(�hi)ccn �At; �,trk�r5
13, Othdr .M
cotr�p ;n;;.lrttn;c• rcgUired.J
'Any applic6•ri
I Holttoow<rs H'ho Suonh`lia aada+n Ut, c ,lr:1; ii 'PJ IhO,a;n ,.atz,Ioc vvrttaoiwro m new affidavit.ndiuing such.
IC.ontrucum
that check this box must attzchad an nddcl,ua; a i i uc J''1;e soh-corrtrocrors anU state whcfhor of MI Ihusc entities have
emplvyoes. if the sub-contractors have employees,they mast prov„1r theu W,Avr S comp Policy number
saar....rm==--^-d — - - alaaaran�ulaaYlYeafaal
1 am an employer that'is providing workers'compensatlun Insurance for my employees. Below is the policy and job Me
In, urnualom
insuntnee Company Name,Intego
Nowt; 11249 1
V'Ullti}'i+vt Sel?-ills L.c b spirancrrr C7atc.
Job Site Adclrrsa:Ali Stoetu i.._n it}"7tatr
Attach a copy of the workers' compensation potic) declatadun page(showing the policy number and expiratiou date).
Failure to secure coverage as required under Seclioti 25A of MGL r 152 can lend to the imposition of criminal penalties of
Fine up to$1,500.00 andJor one-year irnprisutunenl,as well as civil penalties in 4fe form ofa STOP WORK ORDER and a fine
of up to 5 250.00 a day against the violator, tae advised thal t2 COPY of this stutcrnent may be forwarded to the Office of
IAYGSU�'U210I1S or the DP\ feu irtaurw:cc—av Iot{c cn ft,,t i1.
mar m",aCr '�l>�Y
I dv hereby certify)under the puur.5 and 0ti iliac a per/inn rhar tire in ormatlon provided above is true and corrrre'c't`'`�
Flone h
Ogclal use only, no not write in this area,to be completed by city or town official
City or Town: � -_ Pe rill it/L,ic rose N
lssuittg Awhuritr t,circic uilai:
1. Board ofttexith Z. Uuildili ;I➢cp:trtntettt i CiiS ivr,r Clerk d f'h•ctr,jl tn'pe tOr 5. t'lumhing inspector
6,Uhler
Contact Person: Moe 0:
1- ion
s1nsPe The Commonwealth of.Massachusetts
E1eo is P�i�am Board of Buildin-Regulations and Standards FOR
N0 r� Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building, Vermit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One- or l'ta,o-fanttiy 1)we ling
This Section For Official Use Only
._..
Building Permit Number ZDaie Applied:
Building Official(Print Namc) Signature: Date
SECTION I:SITU INFORMATION
1.1 Property Address: I 1.2 Assessors Map& Parcel Numbers
_ ._.._.__ _ � _ _ _._.
1,1a Is this art accepted street'' yes nip I Map Number Parcel Numiazr
1.3 Zoning Inrornration: 1.4 Property Dimensions:
/,oning District Proposed r ku (I it) Frontage tft)
1.5 Building Setbacks(ft)
t-rant Yard bide i lLk Rear Yard
l(cquacd rrmutrd Roqutred (ruvided Required Provided
1.6 Water Supply: (M.( A.c.att.§54) i 1.7 Mood Zone Information: 1.8 Sewage Disposal System:
lone: Owsrde Flewd ZooO
Public❑ Private 0 Municipal❑ On site disposal system CI
('Beck if voO
SECTION 2. PROPERTY OWNERSHIP'
11 Owner o$'Record:
Nam Pnnti t i tote /IP
No and Street I elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction[J ❑ Alteration(s) O Addition O 3 Cv p
Demolition ❑ Acce.isory Bldg. U Nunibcr of Units______ Other ❑ specily--
Briet'Dcscriptiun of Proposed Work
t ._
7 _
!. gc, ]!ON 4 ESTIMATED CONSTRUCTION COSTS
Estimated t osts
Item Official Use Only
(L.ahor and Matertals} t
1.Building i. Building Netrnit 1'ee 9 _ Indicate haw fee is dett:tmined:
❑Standard Cityl l'own Application Fee
2. Electrical ❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing g j 2. Oilier Pees: 1;
a Mechanical (l-IVA(') S List:
Suppression) S total All Pe
u e
pp _ _ ) 1 �.
' _ ___ . _
(:hec,k Ncr, :hcck Arnuunt: Cash Amount:
_ -�
F6Total I'ro'ect Cost p Pad irr lull 0 Outstanding;Balance Due:Pro _____.ll 3 . _ __ _ _-_
File#BP-2015-1267
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 29 CAHILLANE TER
MAP 35 PARCEL 110 001 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
Tvueof 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
INF�MATION 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
la
Signs ure uil ing f cial 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.
29 CAHILLANE TER BP-2015-1267
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 35 - 110 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateaory: INSULATION BUILDING PERMIT
Permit# BP-2015-1267
Proiect# JS-2015-002326
Est. Cost: $3473.00
Fee:$55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor., License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 10541.52 Owner., EMMETT SUSAN A C/O JESSE J LAFORD
Zoning: Applicant. JOHN PERRIER
AT. 29 CAHILLANE TER
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:
FeeTvpe: 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