32A-083 (3) The Commonwealth of Massachusetts tFot
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Atiuticaut Information Please Print Leeibly
Name(liusines/OrganizatioNtndtvidual);New England Green homes
Address:` 2-.6 5 fDC,t i"Al\)
City/State/Zip.Stafford, CT 06076 Phone#;1360-930.7794
Are you as employer?Check the appropriate box: Type of project(required):
1.Q 1 am a employer with 4 4. [] 1 am a general contractor and f
employees(full and/or part-time)." have hired the sub-contractors 6. C]New construction
2.❑ 1 am a sole proprietor or partner- listed on the attachod sheet, 7. (l Remodeling
ship and have no employees These subcontractors have g. EJ Demolition
working or me in an capacity. employees and have workers'
8 y 9. ❑Building addition
[No workers'comp.insurance comp. insurance.•
required,) 5. [] We are a corpuration and its 10.[1 Electrical repairs or additions
3.❑ 1 tort a homeowner doing all work officers have exercised their 1 I.Q Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MG 12.0 Roof repairs
insurance required.]' c. 152,910),and we have;no S
employees.f Vo workers' 13.rM Other
comp. insurance required.)
'My applicant that checks box N1 must afro fill out the section below showing their workers'compensation policy information,
t Homeowners who submit this affidavit ladicating they arc doing all work and than hero vursido contrscwrt must submit a new affidavit indieuing such.
tContraetom thateheck this box must attached an additional sheet showing the name of the subcontractors and stato whether or not those entities have
cmployexs. If the sub-contractors have employees,they must provide their workers'camp policy number.
I am an ehyloyer that is providing workers'compensation Insurance for my employees. Below is the policy and Job site
Information.
insurance Company Name:Intego
Policy#or Seif-ins.Lic.O.NewC424991 Expiration Daten '-2l boo— _.
Job Site Address.All Steets in City/State/Zip: /t/()►Tlc l jli�L
Attach a COPY of the workers'compensation policy declaration page(showing the policy auinber and expiration date).
Failure to secure coverage as required under Section 25A ofMGL 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 inaurauscc uuveragc vcrirvativn.
— asrsrtrr
I do hereb certirbi under the pains qndpenWiriey o_f er'urt'that the in brnratlon pruvtded above Is true and Correa
at
Phone
FMYIuse only. Do not write In this area,to be comlrteted by city or town gffWai
Town: Permit/Lieense 0
Issuing Authority(circle one):
d ofHosttrb 2. building Department 3.Ciiytruwn Clerk 4. 6Ftnotricul inspector 5. Ptumbing inspector
Person: Phone :
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 106 319 12112( 16
to C?b"N"T��,R,t License Number Expiration Date
Name of CSL Holder
P)nrl try List CSL Type(sec below)
No.and Street K Type Description
VT•-MVrV% ��, ,� FRC Unrestricted(Buildings u to 35,000 cu.1)
T�-- Restricted 1&2 Family Dwelling
City/Town,State,ZIP Masonry
Roofin Covering
S Window and Sidin Solid Fuel Buming Appliances Insulation
Te! hone � Email address Demolition
5.2 Registered Home Improvement Contractor(HIC)
R3
HI t qm n Hl , eo rant Name HIC Registration Number Expiration Date
2S O *IS
No.and Street / ' --%I: Kp . [-I jg4eQ, �o"` 14 Enud dress
City/Town,State IP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.1 25C(6))
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 ..........*9 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize �R( -K � W
to act on my behalf,in all manors relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) I Date
SECTION 7b:OWNEW 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 understandinglu. � �
L'
Print er's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hiros an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will&I have access to the arbitration
program orguwwty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gpv/das
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross Jiving area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms _ NuAor of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage'maybe substituted for"Total Project Cost"
iL`= t
EE The Commonwealth of Massachusetts
C, y ttxte Board of Building Regulations and Standards FOR
MUNICIPALITY
Nor r o Massachusetts State Building Code, 780CMR
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
l ,Property Address: 1.2 Assessors Map&Parcel Numbers
l.la Is 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: � Outside Flood Zone? Municipal O On site disposal system ❑
Check ifyesO
/ ! SECTION Z: PROPERTY OWNERSHIPt
2.1 Owner,of ecord�-
Name(Print it).State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Aepairs(s) D Alterations) O Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work
4
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:aterials) Official Use Only
Labor and M
t,Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2.Electrical $ ❑'total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: S
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$ e
_ Check No,�Check Amount:t__Cash Amount:
6.Total Project Cost: S ❑paid in Full ❑Outstanding Balance Due:
NEGH
V
t'l }�; 28 Spellman Rd.
1 I t t Stafford Springs,CT 06076
RETURN IN 5 DAYS
DEPARTMENT OF BUILDING INSPECTIONS
212 Main St. Rm. 100 • Municipal Building
Northampton,MA 01060-3189
NEGH
28 Spellman Rd
Stafford Springs CT 06076
File#BP-2016-0228
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPFINGS06076(860)930-7794
PROPERTY LOCATION 46 GRAVES AVE't��} t
MAP 32A PARCEL 083 001 ZONE URC(I00)/
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
INFO 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
Demolition Delay
.rp f t 1.r sa ^v,,C
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.
46 GRAVES AVE-41 BP-2016-0228
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 c.142A)
Catego : INSULATION BUILDING PERMIT
Permit# BP-2016-0228
Project# JS-2016-000384
Est. Cost: $224.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sg. ft.): 4356.00 Owner: MCGLOIN DANIEL
Zoning:URC000)/ Applicant. JOHN PERRIER
AT. 46 GRAVES AVE - #1
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