32A-083 (2) The Commonwealth of'MassachusetrsF -
Department of Industrial Accidents
Uffice of Inyestigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aupfiestit InkMfion lease Print ib
Name(t)usine ss/OrgunizatiotUlndividual):New England Green homes
Address:, 5 PCAI Y"A10
C1 /State/zip::Stafford,CT 06076 Phone#;,360.930.7794
Are you an employer?Cbeckthe appropriate box:
4 4. 1 am o cneral contractor and 1 Type of project(requited):
t.[� l am a employer with ❑ 8
ctnployocs(full and/or part-time:).' have hired the sub-contractors 6. Q New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet, 7, []Remodeling
ship turd have no employees These sub-contractors have $, [�Demolition
working for me in any capacity, employees and have workers'
[No workers'comp.insurance cutup. insurance. 9. ❑Building addition
requlred.1 5. 0 We are a corputetion and its 10.Q Electrical repairs or additions
3.❑ i ant a homeowner doing all work officers have exercised their I I. Plumbing repairs or additions
IF.,
[No workers'comp. right of exemption per M G L 12.❑ Roof repairs
insurance required.l r c. 152,91(4),anti we bavc no
employecs.f Vo workers' 13.(U Other
comp. insurance required.)
`Any applicant that checks box Ni must also fill out the section below showing their workers'eompensstion policy information.
t Homeawrim who submit this affidavit tndicating they arc doing all wars•and than hire vutsido writrttetva must submit a now affidavit indicating such.
TContraCtors that Chock this box must attached an additional sheet showing the name of'thc sub-contractors and state whether of not those owities have
employees. If the sub�contnctors have employees•they must provide their workers'comp policy riumher,
I ate an employer that Is providing workers'compen sadfon Insurance for my employers. Below it the polky antd job sits
Information.
Insurance Company Name:Intego v
Polley h or Self-ins.Lic. #,NewC424991 - Expiration Date:�l __
Job Site Address:All Steels in City/Statelzip: �1
Attach a copy of the workers'compensation policy declaration page(showing the policy number and ex irstioo date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance vuveragc vorificatiun.
1 do hereb certi under the pains den ties v er'un chat rke in ormation provided above is true and corrm
Dat
phong
Official use only. Do not write to this area,to be completed by city or town official
City or Town: Permit/Wcenae 0
tssuing Authority(circle one):
7.BOttrd 9 Histanis 2. Butidtng Depur•tment 3.City/rvwa Clerk J. Elrctrical inspeetor 5. Plumbing Inspector
6t Otber
Comm Person: Phone :
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSI.) f 0C's i q 121 mi 15
0
iTp(t,N T� _ License Number Expiration Date
Name of CSL Holder
18 Br yo un- pep List C5L Typc(sec below)
No.and Street Type Description
.-. U Unrestricted 13uiidin u to 35,000 cu.R
` ~�`� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
- — WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
o � 3 Q-2-1
HIC Registration Number Expinition Date
Ht CgmMWV WArne ne HI , e°(istrant Name 0 o
No and Street Etr►ai I w dress
Ci JTown,Statue Tile hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152.13 25C(Q)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of 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
i,as Owner of the subject property,hereby authorize 1zwxiE��Lyya(_
to act on my behalf,in all matters relative to work authorized by this building permit application.. ' I ht �y)I F' ►v,-- � LH I S
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,l 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.
Print er s or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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(HIC)Program),will W 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
www.masL&ov/oca Information on the Construction Supervisor License can be found at www.mass.ggv/dos
2. When substantial work is planned,provide the information below;
Total floor area(sq.ft.) (including garage,finished basement/attics,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 Project Square Footage"may be substituted for"Total Project Cost"
z 5
The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Massachusetts MUNICIPALITY
State Building Code,780 CMR USE
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
roperty Address: 1.2 Assessors Map&Parcel Numbers
C)l'ati'o
I.Ials this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rea Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c,40,154) 1.7 Flood Zone Informition: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: Outside Flood Zone?Check if yes[] Municipal C3 On site disposal system ❑
1 I
SECTION 2: PROPERTY OWNERSHIP'
Record:r—o'
Me
NampiPrint) ity.State ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ owner-occupied r-3 I Repairs(s) 13 1 Alteration(s) D Addition ❑
I Specify:
Demolition E3 Accessory Bldg. ❑ Number of Units Other El
Brief Description of Proposed Work2:
/ 17
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs; Official Use Only
(Labor and Materials)
1,Building 1. Building Permit Fee.,S Indicate how fee is detemined:
2.Electrical ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier_x
3.Plumbing 2. Other Fees: $
4.Mechanical (HVAQ $ List: ---
5.Mechanical (Fire $ Total All Fees:$ .4
Suppression) Check No/d,� Check AmountM&5 Cash Amount:
6.Total Project Cost:
$ C ❑Paid in Full ❑outstanding Balance Due,_
NEGH
28 Spellman Rd.
06 Stafford Springs,CT 06076
File#BP-2016-0229
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 48 GRAVES AVE UNIT 2
MAP 32A PARCEL 083 001 ZONE URC(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:
„� 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
Demolition Delay
r
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.
48 GRAVES AVE UNIT 2 BP-2016-0229
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-083 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0229
Project# JS-2016-000385
Est. Cost: $300.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:— JOHN PERRIER 105319
Lot Size(sq. ft): 4356.00 Owner: BONINO LORENZO
Zoning. URC(100)/ Applicant: JOHN PERRIER
AT. 48 GRAVES AVE UNIT 2
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:812612015 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 8/26/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner