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25A-093 (3) The Co~nWealth df Massachusetts Arpartrnent of IndushialAccMents Offlce of InvesN 46,901 1 Congress Street,Suittt 1:(10 Bo4lonr MA 02114401' ww #sWs.ggvv/dla Workare'Compensation IasuranceAffidavit: Buildersl Contraetors/ClectrioisaWl;lmo-m AM,Ol Uat o xtion `lease it tt►ly N=;(ousitiowQrgppjzatiowindividtti):New England Green homes AddMSS:$9 Rapt Ms rr 60"t G1 IStatelZ :staalrab,c7 06076 hone#:e00-0sv-77" Are ou on eutptoyw?Chak1he appropriate borr TM of Project(requinid): t. 1 rim a employer with 4 4. [] l am a general contractor and 1 6, eptploytxa((uf!arxilor part-rims).' have hired the sub•contmctors New ccxtstrsic(Fgn -2.0 1 am acola proprietor or partner- listed ors:the attached shoot. 7. (�Remodeling, strip and haze no employe" These subrcontractom have � & [3 Demolition employees and have workers walOig far tae ilr�Y capacity, 9. ❑suitdM9* (NOIWQ*OMI 00010.itl3iltaw comp,insuntttc4 5. [] We are s Corporation and its 10.0 E14 w moats or stwitions > m.4 h officers have exercised their t 1. Phut blttg r>rtp:tltti of*Mk km lam.a p9bleowner doing ail work Q myself.[No workers'comp. right of exemption per M40L I2.[3 Roof repairs illstu t►co l uiCBLt. c, 152,§'i(4)6 and we;have no employ**&[No-workers' r comp.ittsurance required. 'Arty apptloltpt that box N 1 must oW.fiit out the section below thawing their wort;"',cosapon Oon policy intlsmadoo. +Homeowaen woosubash this aitidavh tndieatlna therara dams all W04 444 thra hero rwulda tonkr�crurs musystibmit`a.new attltdavit in0ioatittf,aueh kloutra#6 Ast alsok'Ws box mw aurched an additioaai sheet s "iflg the anrx of the sub IbUtora Old 00 whether of not tbM 001101 b0" 4nsjllo#+ft rOw sqb rntrltCklrs bm eespigaee,they must provide their wmken'comp policy nuwJw, nNOSSem�� X oat an twiptoyer ttrmrla p�vwf�s'wwrkera'cotivlptttsatilott t+uttrance for tuy aalp�ye�r, Bt'•tew�aaYep�tiy andieb tiy"olryaadota in+rurenotapwsy Name:intego NewC424991 Expiration Date. :Polley k or Sclfltls.Llc.�: ...__,..., -- Job Site lddressAll Staets in citylstat4;p: Athtcb ti copy afthe workers,Ompe-am"lon policy decisrallon past(showlag the policy member attd tratiost dw)' pailum to soauns coverage as required under Section 25A of MGL c. 152 can.iead to the imposition of crimin p�talc#es of q fine up to>S�1,500.00&W6r one yeut imprisonment,as wcli as civil ponaltioa in the form of 4,$t OP WORK ORDER a cline of up'to 5250.00 a.day'&,gainer the violator. Be adwisod that a copy of:this statement maybe forwarded to the Offtoe.of tnygPg ttts ofthaVIn ltbr lnow ov wrvarags vednowtton. do altla a ' sr un°that the In i oratatlott pravldtd ablt+i uaod + +� DaWl U,flk�gt go oa1y� Do avt write to this area,to hecd0ivWAdbYOty or torwrtAPkiat City,or Town; eerrnitJLkcase N lssuin Aotbority(circM ono): Y.llktXrd o;jj#attb 2.bulldiss :Departmenl 3.C:ty/Tvwa Clerk 4.Floutricai tnspactor 5.plumbing;Caapstst�or �Vt110!" .pho�lt tt �y SECTION 5: CONSTRUCTION 511010ES AI Construcd".Snpervbof is(CSL) O � ► t' : ` 11x7' cro lo4.M5 &1% % Ltcaw Nwnb* B*1196n-040 New aFC3L Holder —� 59 jis >l'- !f _ i Lim ESL Typc,isec Wow), No,sndstnxt Type Dow"" UtJtu+esttictal Rut a to it R Re!trf l&-2--gem Ilwallip C#yRotvn, suite,ZIP M M RC Roo " Covaln WS WindowandSidin SP Solid Putt Burning Appliances to 404 1 tnsuletion T Email#ddressi 0 Demolition tZ blteaistered N;mImprovement'Conuictor(H1C) s � HIC Registration Nombor �AkplrWon Ll C /Town,State IP � Ta c swn' ON 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c.I5L 1 Q) Wos Compensation Insurance affidavit must:be completed and submitted with this application: Failure to provide this,#ffidavit will result-ht the denial of the Issuance of the.building permit. Signori Affidavit Attacba 7 Yes. ... .111 No...........O SECTION Is:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER"S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERWM IS as t)vvn theaubject p ,hereby awhorizeJ' m ► to mYL, t',in ma►twv ive to work authorized by this building permit ap ilieation. 7-"t/ -/S�- ces Name is sign. e DOW SECTION 7b:QWNEW OR AUTHORIZED AGENT DECLARATION By entQr ng my maw below,I hereby attest under the pains and penalties of perjury that all of the information contained in this;application is true and to the best of my knowledge and undeusta»ding Prtnt a or 's NaM(E is Signature) ' NOTES:; 1. An Owner wire obtain a building.permit to dohis/herownwork,Oran owner who bites an utuegistercd.rmrdractor (-not regisoered in the Home Improvement Comractor(HIC)Program),will,=have access to the arbitration program or gusranty find under M.G.L.c. 142A.Other important tnfonmedon on the HIC) m can be found at w.tn48 Information on the Construction Supervlsor Licenses can btfound at wmmass—o dna 2. Wbo suUeatsntiai work.iS plantiod,provide the information below: Total fkror,,w(sq.ft.) (including;garage,flnished basgmenYattioa,desks orpocch) Bross li`ring areaOOq.R.} Habitable roots count Numb of fhplaos Number of bedrooms Nttmberofbatttrooms Num6ar of haftds Type of-heating system Number of do"porches,._. YP ot'000ling systems Enclosed _ 3. "TOW, SRuaro Footage"may be subst tuted.for"TOW Proje0tt CO nsPea�'io�$ The Commonwealth of Mawchusmts pe�tc�No Board of Boilding Regulot��ts sitd Standards FOR, Massachusetits State;Building t:acts,7$4 CMR Mt1NIU LTt Y Sg Building,Fermi Application To Construct,Repair,Renovate Or'I emolish:a R v#edll�lan2©I f One.or No-Family 1'3 0111ng" This Section For Official Use Bulldiag l'etmit Number; I Data Applied:; BuI B Otliclel(Print NAmc} Sipatu:c SECTION 1:SITE INFORMATION 1.2 Assessors Map&Parcel Numbers 1.1a is-this an C1 no Map Number Pacet'Number 13 Zoning lnt'orwation 1.4 Property Dlmeasloaut Zoniq District Proposed Use Lot Area toq ft) Fw ntW(it) is Bulldin lSetb�ka'(tt) Front Yard Silo YArda Rear Yazd Rewired Provided Required Provided Required provided 1.0 Water Supply:(M G.L c.40,;34) 1.7 Mood Zone informations 18 Sewage Disposodskittew.. Public 13 Private O Zone;-- Outside Mood Zone? Municipal 13 04 sitoddbpow'sy*m 3 Check if 0 SECTION Z: PROPERTY OW NRRSHIPt rin ner'of; St"'ZiP No,and$trod Telephone Email.Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(cleeckatl that#t") New Construction A Existing.Buiiding 0 owner-occupied 0 Ropairs(s} 0 Alterations} ❑ I Addition 0 Demolition a Accessory Bldg.0 Number of Units t?tdar C] Spedfy: Brief Description:of Proposed W SWrION 4:ESTIMATED CON$TRUCTION COSTS item Estimated costs: offt ail.Uaet Only Labor and Materials l.''Boding $ 1. Building Permit Fee:s Indicutita.tww fee R&W o standard Cityrro"Applic ►Fee Electrical ❑Total project Coss(item 6)x,multiplier x 3.Numbing $ 2. Other Fees: $ 4.Mechanical (WAQ S List 5t Mec.Wical (Fire $ Total All Fees:S' Check No. Check Amount: Cash Amount;V„_„ 6.Totell Project Cosa $ 13 Paid in Full ❑Outstanding Halaoae D" , File#BP-2016-0053 APPLICANT/CONTACT PERSON JOHN PERRIER ADDRESS/PHONE 59 EAST MAIN ST STAFFORD SPRINGS06076(860)930-7794 PROPERTY LOCATION 22 COOLIDGE AVE MAP 25A PARCEL 093 001 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 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 INFORMATION PRESENTED: proved 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 Signa re o uil ing Micial 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. 22 COOLIDGE AVE BP-2016-0053 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25A-093 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categog: INSULATION BUILDING PERMIT Permit# BP-2016-0053 Proiect# JS-2016-000100 Est. Cost: $4275.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN PERRIER 105319 Lot Size(sg_1): 6664.68 Owner: BRAZENALL JENNIFER MULLINS Zoning;.URB(100)/ Applicant: JOHN PERRIER AT. 22 COOLIDGE AVE Applicant Address: Phone: Insurance: 59 EAST MAIN ST (860) 930-7794 WC STAFFORD SPRINGSCT06076 ISSUED ON.711612015 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 7/16/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner