25C-033 (2) The Comwnweali`h ofMassachuretts
Delrartnoerrt of fudwrlat Accidents
Cfflce of Investigations
1 Congress Street,Salts 100
Bostorr,MA 02114-2017
www,ntass govldia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electrician&Tlumbera
Agglicant Intomition rjeasg Print Legibly
Name(duSinoworgnnizatioNtndiyidual):New England Green homes
Address:I 41111vij
C /State/Zi :Stafford,CT 08078 Phone#.600.930.7794
Are you an esapdoytar?Check the opprepi iatt box: Type of projeet(required)
1.0 1 win a cmployer with 4 4. d I am a general contractor and t
en""loyccs(full and/or part-time).* have hired the sub-contractors 6. Q New t OnStlltCflOn
2.0 1 am a sole proprietor or partner- listed on the Attached sheet, 7, 0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
win .insurance.; Y. IQ BuiidLtg addidort
f No workas comp.insurance P
��l 5. 0 We urn n corporation and its 10.E Electrical repairs or additions
3,Q i act t hosuoowner doing all work officers have exercised their 11,0 Plumbing repairs oradditions
myself. o workers'comp. right of exemption per MOIL
12..❑Roofrepairs
insurance required.]' p c. 152,§1(4),avid we have no
cmpluyees.f Yo workers' 13.01 Other
comp.insurance required.]
`Any applicant thatcheck3 box#1 must abo fill out the soetion below showing thoirworkars'compensation policy iitlbt'mat{ort:
t Hotttoawaars who submit this%Mdavil indirsling they are doing all%ori,and then biro aooldc coninows must submit it new SMduril indicasity trek
lCoetwors that check this box mum snachatt in additional sheet showing the name or ft sub-coatreeton and rata whethor or not boss watitla 1Nve
twttployw ifthe sub.conbaeton have employees,they must provide their workers'comp policy number.
I am an ragrlcyer MW It prnvldi8,f workers'eorapeasatfon Msurance for lay emy�lo m littlow Ir t/tepe AV etr+ldt #iris:
Worrtxuloa.
Insurance Company Name:lntego
POlky#orSeif-inx.Liu.NsNewC424997 V w Expiration Date,--viia-
Job Site AddcessAll$tt)ots in City/Statr/Zip,,,,
Attach s ropy of the workers'compensation policy declaration page(showing the policy number and°e xpiratio date),
Failure to switre coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties ota
fine up to$1,5017.00 and/or one-year Imprisonment,as well as civil penalties in the forth of a STOP WORK ORDEA-attd a fine
of up to$250.00a day against the violator. Eke advised that a copy of this statement may be forwarded to the 4ffitt of
1nVottg4lionS Orthe DIA for tnatwanca vuvcrage—rific tiw,.
I do hereby ctrl tender thr ales 4n it en ties o er an that the in ormatlon provided above Is true aptdParma
4 rA
0,Q7eW use overly.' Do kot`wrlteIn shit area,to beArvowided bycity or town oftiaC
City Or Town: Permit/License N
TsYUta$Authority-(circle ens);
1,board of Health 2. auildlni;oeprrtmen+ 3.City/rv"a Clerk J. Mt trice)Insprrtor S. Plumbing inspector
b,lhhit
t~tf�f�Ct LI 'Phone f1
SECTION S. CONSTRUCTION SERVICES
&I Construction Supervisor License(CSL) 105311 12112 I�'
14N w _ License Number Expiration Date
Nam ofCSL Holder
1 � List CSL Type(see below),--
No.and'street Type Description
Ogg W0044i R Unrestricted F *ml Dwe lip ooa cu.ft
city/own.State.ZIP M Masonry
RC Rooring Coverin
-- —--— —
WS Window and sidin
SP Solid'Fuel Burning Appliances
C13!P qm 1 Insulati_, on
Tel bone Email address # D Demolition
ill Registered Home Improvement Contractor(HIC) [4302-1 abal
HIC Registration Number api
HI v A n 4 - irar►tTiame o
nt ,� em;l -AA
C /Iown,State ZIP Telephone
SECTION 6-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.13L i12SC(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 ofthe building permit.
Signed Affidavit Attached? Yes..........10 No...........0
SECTION'7st OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S.AGENT OR CONTRACTOR AI'POS$FOR BUILDING PERMIT
t,as Owner of the subject property,hereby authorize _ -iY1
to as on my behalf,in all matters relative to work authorized by this building permit ap$11cation.
Print Owner's Nam(Electronic.Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pedury that all:ofthe Information
contained in this lication is true soul accurate to the bust of my knowledge and understanding.
Print�—er tt or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who.obtains abuiiding permit to do h own work,or an owner who hires an unregistered contractor
(not registered In the Home Improvement Contractor(HIC)Program),will W have access to the*rbitratbm
program or guaranty fund touter MAL.c. 142A.Other important Information on the HIC ProVam can*found at
www.masLPay oca Information on the Construction Supervisor License can be found at}v nass"gpylS=
2, When substantial work is planned,provide the information below:
Total floor area(sq.ft,) (including garage,finished basemtnt(atties,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedroom$
Number of bathrooms Number of hal9baths
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"
D
SEP 282016
tl a plumbin &G The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOP"
Massachusetts State Building Code,780 CMR MUNICIPAUTY
1)58
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revlied U&2011
One-or Two Family Dwelling
This Section For Official Use Only
BtuiWipg Para it Number. Date Applied:
Building Official(Print Norm) Signaturc Doc
�SEC-TnION 1:SITE INFORMATION
I•I� �y ddLem- 1.7,Assessors Map&Parcel Numbers
i.1s 19.this an accepted strect?yeS no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning district Proposed Use Lot Area(sq ft) Frontage(ft)
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Rcquircd Provided Required Provided
1.6 Wster Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1,8 Sewage Dispoul:System.,
Zane: Outside Flood zone?
Public 0 Private U '® Check if cs[3 Municipal O On site disposal system 0
SECTION 2., PROPERTY OWNERSHIP'
2.1 ner`ofRee rd:
amc(Print) City.statc.21P
No,and Street r elephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(chock ail that aprply)
New Construction 13 Existing.Building 0 Owner-Occupied 0 Repalrs(s) O Alteration(s) 0 1 Addition (3
Demolition 0 Accessory Bid&13 Number of Units Other 0 Specify:
Brief Description of Proposed Work;:
U Iii
W-QIUYIY�7071 77) OD-0,11
SECTION 4.,ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ufficlal Use Oaly
Labor and Materials
1.Building S 1. Building Permit Nee:S indicate how fee Is determined:
2.Electrical $ 0 Standard City/Town Application Fee
0 Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: S
4.Mechanical (HVAC) S List;
5.Mechanical (Dire $
Suppression) Total All Fe •1$
Check No. heck Amount: Cash Amount:
6.Total Project Cost: $ �,S 3 0 Paid in ull 0 Outstaruling,Balance Due:
1 1 IVEGN
� 28 Spellman Rd.
Stafford Springs,C7 06076
File#BP-2016-0423
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 33 NORTHERN AVE
MAP 25C PARCEL 033 001 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:
pproved 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
De litio
Signature of Buil mg ff ial 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.
33 NORTHERN AVE BP-2016-0423
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-033 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-2016-0423
Project# JS-2016-000672
Est. Cost: $1653.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 10018.80 Owner: PRASHAKER SAMANTHA
Zoning. URB(100)/ Applicant: JOHN PERRIER
AT. 33 NORTHERN AVE
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:912912015 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 9/29/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner