32A-233 (5) 77se Ce mronwealth of Manachuseas
Department of Industrial Accidents
Offlee of Investigations
1 congress Street,suite 100
V1 Boston,MA 02114-2017
www.mass.gov/dla
Workers'Compensation Insurance Affidavit: BuildersJContractoral'Clcctric onsi?luwbera
Aepheaut 12f2mation 1eall Prtat WWI
Noma(HusinsAS/pruniratioNtndtvitluatl:New England Green homes
Address; 1 ' % . C�! 'L 01
.
Ci /StatelZi :S1afford.CT(?8076 phone#;860-930.7784
Are you as emplayal Cbmk the oppropriste box: '{^�p4 olptojeet.�regttir>rdj:
1.[ 1 am a employer with 4 4. d I am a gencral contractor and i
employees(full and/or pen-time).* have hired the sub-contractors b. 0 New 004M0 0"
1 Q 1 am a sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling
ship and have no employees These subcontractors have 8. 0 Demolition
*w ft for me In any capacity. employses and have workers'
y. ❑Building addition
fN l
o e s 'comp.insurance Mnp.insurance,•
S. [j We wv it corywration anti its 10.0 Eleetrkmi repairs or taddition&
3.0 tam a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself.(Ate workers'comp. right of exemption per MOL 12Q Roofrepaiirs
insurance required.)� C. 152.91(4),and we haavc no
employees.f No workers' 13•(U'Other
comp.insurance required.)
'Arty appliatat titiod oks box 01 must arse fill out the motion below showing their wore rrt'eatnpentahon polity inibm alo n.
t Homio*we whosuDmlt this'slti+tavitindicating they arc doing All%0A and then hero outside wntnciva muse tulbmit tt naw atrtdovit halbating taoh.
tGoattacton that chock this bole must Attached an additional sheet showing Ike Mme ol'thc sub-sonaecion and ttatc WhEiha ornatt6txrsattiliprlNr+e
tvaplaym ltthrsub�onabadors have tanployees.they must provide their workers'comp polity number.
I ow aN efivrtoyres Below is dMepoli4i+aid jsb�i'r
14jcr>nlaaor~J.
inott Ingo Company Name:Intego
Polky#orScif im.Lic.CNewC424991 Expiration Date-
Job Site Address All Stoats In citytstatc/zipt
Attach i etpy of the warkr 'c9lupensallon policy declaration page(showing the policy number tut 01p(M69 dafe).
Failum to 3mm cover a as required under Section 25A ofMOL c.152 can lead to the imposition ofcriminill MAO O ote
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a,STOP WORK ORDER and a fine
of up to 5250.00 a day avinsr the violator. Be advised that a copy of this statement maybe forwarded to the Office of
tnvc$UgaUons of the AtA thr trwuranca vuveraise vwine-,lo-
do haVby catj&tinder the paMs d n rtes a rr tars IJypr the In vrmarion pravldrd abavr is trite atsd'corr�x
7 72r"
fte
r
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4J,jTclal rue wiry. Dv not write!x thlr area,to be comlptded by c1ry or town oP141
Clay or Town: PermltJLlcense N
Issuing Authority(eircte on*):
1,Board of Health 2.Building DepysKmcns 3.City/Town Clerk s. F:l�rrical Inspector A.Plumbing;taspecter
6,Otbgr
Con# t Pesxoac �Pltnlle�;
SECTION'S: CONSTRUCTION SERVICES'
&I Corutrueffolt Supervisor License(CSL)
sp
"� t em, License Number Expiration Dad
NamaofCSL Holder
16 -=-� � J,nom List CSL Type(see blow)
No... 1 Type [aUM*ion
VT MWit$K9 :5 Q( 1+} o U nr1wricted(BRAIZZ(BRA to 33.6vu.tt
City/Town,State.ZIP r -- R i2aar c—md 142 FAW ly Dsvailin
M Mason
RC Roofi Covering
WS Window and Sidinz
SF Solld Fwl,Bu ming Appileam
�GeR�93, llt?r��Xv q hm~roM t Insulation
Tel bona Email address D llcmolidan
S.2 Reltlstered Home 11provement Contractor(HIC)
HI a Ftl; rant Noma rliC Rcgistrciidrslt'turnberpltsSotz,Data
Ne.bad Strout ' . .
Lzl �r �
Ci !T 5 IG P Tile one
SWTION&WORKERS"COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.13L g 23C Q
Workers Comptm adon Insurance affidavit must be completed and submitted with this application Failma to provide
this affidavit will result in the denial of the Issuance ofthe building permit.
Signed Affidavit:Attached? Yes..........%t No...........a
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S,AGENT OR CONTRACTOR APPLIES it R BUILDING PERMIT
1,as Owner of the subject property,hereby authorize-_W ar-ri O do , 1AA iii
to act on my behalf,in all roasters rotative to work authorized by this building permit ap !!cation.
w)n rxl- 1Q
Print Owner's Name(Elocuonic,Signature) Dab
SECTION 7b:OWNER 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 In this application is true and accurate to the best of my knowledge and understanding.
Paint er s or Authorized Agent's Nome(Electronic Sigrwture) Date
NOTES:
1. An Owner who.obtaios a builalij permit too Elsiber own work,or an owner who HER an uaregistet�ed contractor
(not registered in the Horne Improvement Contractor(HIC)Program),will W have access to the arbitration
program or guaranty fir»d solder M.G.L,c. 142A.Other important information on the HIC Program can W found at
WWw.mass.eovfacs Information on the Construction Supervisor License can be found at www,mass eovldo
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basamcnt!attdcs,decks or porch)
Gross living area(sq.ft) Habitable room count
Number o€fmptaces Number of bedrooms
Number of bathrooms Number of hafteths
Typo of heating system Number of decitsl porches
Type of aooling system Enclosed Open
3. "Tore!Protect Square Footage"may be substituted for'Total Project Cost"
Qlumbina& A inSQa The Commonwealth of Massachusetts
11ec�+i Nor�hafiPton' Board of Building Regulations and Standards MUNICIIPRA�LITY
Massachusetts State Building Code,780 CMR U$13
Building Permit Application To Construct,Repair,Renovate Or Demolish a 14viaadMap 2011
One.or Two Family Dwelling
This Section For Official Use Only
Building Pa it Number: Date Applied:
Bu1144 Official(Print Name) SignM= Dsto
SECTION I:SITE INFORMATION
1. perty ddress; 1.2 Assessors Map&Parcel Number!
1.14 13-this an ted.str V es no Map Numbor Pare Number
13 Zoning Information: 1.4 vroperty Dimcusloss:
Zoning DisMct Proposed Use Lot Area(sq ft) Frontage(ft)
1:5 Building Setbacks(ft)
Front Yard Side Yards Rat Yard
Required Provided Required Provided Required Provided
1.6 Water Suppiy:(M.G.L c.40.JS4) V Flood Zone Information: L8 Sewage Disposal System:
Zone: Outside Flood Zonal
Pu61ic L7 Private D _ Check if es0 Municipal O On cite dispasai system
SECTION 2r PROPERTY OWNERSHIP`
2
Name Print) y� `City State.ZIP —7—
POM S, J v✓' I --3 7
Ii 7/
No.and Strut I Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check ail that apply)
New Construction O Existing,Building❑ Owner-Occupied C! I Repairs(s) O Alterations) D Addition C7
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Spec*:
Brief Description of Proposed Work
SECTION 4;BSTIMATEP CONSTRUCTION COSTS
Item Estimated Costs; OtI dal Use Only
Labor and Materials
I.Building S 1. Building Permit Fee:S ladicate how'fee is determined:
1.Electrical $ 0 Standard Cityffovm Application Fee
O Total Project Cost'(item 6)x multiplier x
3.Plumbing $ 2. Other Fees: S
4.Mechanical (HVAC) S List:
5.Mechanical (Fire $ Total All Fees:S
5 cession
Check NojCheck Amount: WJ Cash Amount:
6.Total Project Cost: $ c' )S a ❑Paid in Full ❑outstanding Balance Duel
-P .eaSiu.
NEt3N
+ 28 Spellman Fad.
Stafford Springs,CT 06076
`` C 1c,
File#BP-2016-0369
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 36 POMEROY TER
MAP 32A PARCEL 233 001 ZONE URC(58)/SC(42)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT 01 0
Fee Paid 77 L`2
Building-Permit Filled out
Fee Paid
Typeof Construction: INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessoty 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
o ' 'o elay
4nature 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.
36 POMEROY TER BP-2016-0369
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-233 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-2016-0369
Project# JS-2016-000601
Est. Cost: $2522.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 23348.16 Owner: CHRISTAKOS PETER G&DEBORAH S
Zoning: URC(58)/SC(42)/ Applicant: JOHN PERRIER
AT. 36 POMEROY TER
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.912312015 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 9/23/2015 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner