36-306 (2) u�^ Vie [otrmnouoault60,Mu.ysuc6oze/o
0epurtomn/oj /adusviu/Accide ts
(j/ croj Ix'rn(gu�oxs
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Street, Suite 100
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Workers' Compensation losurxm,c Afldovit, 8oUd*ry/('un[ructury/iiluu1riciWnV/P/ummbers
�Applicarit � Please Print Legibly
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Address-59 swu Mw. ) ovov^
c /stute/%i SmnuW CT 00076 ybo 000-830 77$4
[No workers' winp. insuraji�e Electrical repairs or additions
required.) 1
3. 1 am a honieo�viier doing ull wotk otltcei�'have t�xercised their I 101- Plumbing repairs or additions
'My xpn|.ov"mw*,,.^xm": m",'".^ u "j _'j �'i^= ',nvrp..,/,`/ � yunnm"o
' x°.nc"°,cni who^"o=..^.,mou4411 ni(', ni, ,Ii '`..^ j,.=^.,,"".:"=^,".w.."",.,"`="""""mds=~^icminxsuch
^c"m=uon that check o,`tw°must""^,h")""Uja"°,".p. "..,"...q .°=""..Ai,,""'".="ix,°.o talc~h*^worov,m"ie entities hove
erliplcyccs. ooic haw.snpj"n='ow*�/,'°,"*'hr" ,~'^''` "'=r policy v"m»,
I am an emplo),eir that kv pro viding workers'conT ensarion Invurance for my employees. Below is the policy andjob site
|pcwmce Company >bm,.»nte9»
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Job Site ad4tc» }«| Sm*u�,»
Amcbucopy of th,workers' compensation policy dec|xm/kmpq%(shulpyvng tile policy uutinherand capiratioawate).
Failure m secure coverage u`required uoJ,'Section 25Aoi MGLc |�2 call |c*d it)the imposition mf criminal penalties o[o
0vQ tip mo.5ou,oupu/mone'y,arimyr.,umum,.w ^a/^`c:`/, pc;-uc` ix ti—,c caof^STOP WORK 0RDER and ufine
^fupto525U.0V^day against Thrvm|ato, oruJ`.moot"'u,^p/ ^r,k.,rta*m""/may b° forwarded mthuOffin uf
Of se only. Do not write in this area, to be completed by ciry or town officiaL
6,Other
Phone 0:
SECTION S: CONSTRUCTION SERVICES
5.1 Construction Supervisor I.Jeense(t st,)
010 - -
tJ I teense number Expiration Date
Vanc ofCSL Bolder
�
+. _ v I r,t t"SI tv xr(see()etak)
No.and Street - ype Description
t�lt�i'nresirlcted(Buildings un to 35,000 cu.ft,
Restricted 1&2 Family Dwelling
City/Town.State,l.tl' tq �:rsonry
�. —
KC ooting C-overin _
acrd Siding
SF i Solid Fucl Burning Appli rnecs
Telephone _� I r r ri i adur�,r. D t)entotrnon
5.2 Registered Home Improvement Cuntractor(I11 C)
p.e y - -- _.__ HI onegi,tr,uit�Number Expiration Date
IiI l Jnl t ,mi e U r ii_ 4 IS rai i. v in1G
Nu and Strcet
I'mai a dress
C'tt�Town State,GIP _ I :le borr�-
SECfION 6., WORKERS' CONIVENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.§ 25C(6))
W'orket's C'umpensation Insurance of fidavit must be completed 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 ❑
SECTION 7a: OWNFR AUTHORIZATION`I'O BE COMPLETED WHEN
OWNER'S AGF,NT OR C ONTRAUFOR APPLIES FOR SGILDING PERMIT
t,as Owner of the sul$ct, ru rt rt , ,iere(t�,authorize � � _
to acct ny behalf,4n all riiattcr'p la6vc to %Wrk authorizod rry this building permit application.
f'
J ,1
PruiC vn r'a Name(Eicctronic S,n,n,turr'e) Date
S C'TION 76 OWNN Rr Ott AI fHORIZYD AGENT DECLARATION
By entering my name below, I herebv attest under the p•ems and l7cnslties of perjury that all of the information
contained in this application is true and accurole to the best of my Iutowlcdge and lnclerstzuiding.
0 VA ) _ _ 7 - / S
Panko ne v`s or AlRborizCll Agent's Mime i,,iccinmic pit na(wc) !late
NOTES
L An Owner who ubt4ttn5.i building,pennit to do InOier own work,or an orsner who hires an unregistered contractor
(not registered in the Hume hitproverneni Contractor(I 11C) Program), will not have access to the arbitration
i program or guaranty full(] under M.(; 1.- c 142A C)ther irnport:tnt information on the HIC Program can be found at
Inf i -ition on the c.nn�an'utaiim Supervissor License can be found at wyv muss. ovl p
2. When substantial work is planned, provide the information below:
Total floor area(sq. ti.) _ (including garage, finished basementlattics,decks or porch)
Cross living area(sq. ft.) _ _ _ Habitable room count
Number of fireplaces _ Number of bedroorns _
Number of bathrooms Number of half/baths
Type of heating systen; Number of decks/porches .
I-ype of cooling system t:ncivsrd _�.OPen ..
3. `fof2tl proavJt 5quarc,' b e L,r`",01t<) f)f(iic ci
—_--'
MAY 2 2011
FOR
0 Mas,�aCIILISCM Stale building Code, 780 CMR
USE
Building Perniii Number:
Applied
Building Official ijInnt Manic) Date
1.1 Property Address: 1.2 kswssurs Map& Parvel Numbers
1.[a Is this an accepteLi strect'? c,
Proposed Lk-,�
1.5 Building Setbacks(ft)
How Y,.ird "Ide Id i Rear Yard
Provided
1.6 Water Supply:(M.6T c.40,§,�4) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
1 .14unicipal 0 On site disposal system 13
SLCTION 2-. PROPERTY OWNERSHIP'
No,-and Sueo I Cie 'C',Ic Email Address
SECTION 3: DESCRIPTION Of PROPOSED WORK'(check all that apply)
47���j I Addition 13
cl
SECTION 4- ESTIMATED CONSTRUCTION COSTS
Item Official Use Only
Indicate how fee is determined:
ta.1 j City/Town Application Fee
2. Electrical
0-1,01al Project Cost" (lieni 6),\ multiplier x
3. Pkllnbm�
4. Mechanical (IAVAC)
5.Mechanical (Fire
0/1 ash Amount:
Check Nk).,jjVy_Clicck An)uunt:ka--> -C
6.Totul Project Cost 0, Paid in Fuil 0 Outstanding Balance Due:
_
File#BP-2015-1188
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 100 CARDINAL WAY
MAP 36 PARCEL 306 001 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
INF=Approved ATION PRESENTED:
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 molitio elay ---
Signature of Building 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.
100 CARDINAL WAY BP-2015-1188
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-306 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2015-1188
Project# JS-2015-002227
Est. Cost:$3673.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq.ft.): 20168.28 Owner: FRANK ELLEN R
Zoning: Applicant: JOHN PERRIER
AT.- 100 CARDINAL WAY
Applicant Address: Phone: Insurance:
59 EAST MAIN ST (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:512812015 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 Sienature:
FeeType: Date Paid: Amount:
Building 5/28/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner