38B-270 �.. 5 City of Northampton ,
SAS .: s%
Massachusetts
DEPARTMENT OF' BUILDING INSPECTIONS y,
., 212 Main Street • Municipal Bu12ding Jam'' h�rD
Northampton, MA 01060
Property Address: `
Contractor
Name: &&,e
Address: ze
City, State: U(�J
4V V
Phone: d D(/
Property Owner
Name:
Address:
City, Sta
I (contractor) attest and affirm that the building l intend to
ins ate have any open (knob and tube)wiring in the spaces to be insulated and that I have
p ovide t roperty owner with .Dpy of this affidavit.
Contractor signature /J
Date
�r
The Commonwealth of MassachusettstFcrs
Departosent of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, ,MA 02114-2017
www,rnass'.gov/dia
Workers' Compensation Insurance Affidavit: Buil(lers/('ontractors/Electricians(Plumbers
AmAiraut Information Please Print Legibly
Nami (Business/Organization/tndividua)):New England Green homes
Addi-ess:18 1Br-�(�
City/State/Li :Stafford, CT 006076 Phone 0.860-930.7794
Are you on employer?Cbeck the appropriate box: Type of project(required):
1.2 1 am a employer with 4 4. ❑ I urn if general contractor and I
employees(full and/or part-time).
have Hired the sub-contractors 6, E] New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached shed 7. ❑ Remodeling
ship and have no employees These sub-Contractors have 8. ❑ 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 corporation and its 10.[I,, Electrical repairs or additions
3.❑ i am a homeowner doing all work officers have exercised their I I Plumbing repairs or additions
myself.(No workers'comp.
right of excrnption per Mt L. 12.❑ Roof repairs
insurance required.]' ':. 152,§1(4),and we havc nu
empluyecs. [,No workers' 13.Fk!'Other )
comp. insurancc rcquired.]
'Any applicant that checks box H I muss also till out the section below showing their tisorkers'cumpensauun policy information
t Homeowners who submit this affidavit tndicatiog dvey arc doing alt�wr> unJ then huv outside contracWre murt submit a new affidavit indicating such
!Contractors that check this box most anached an additional sheet showing the name L)!the suh-contractors and state whether or not those entities havc
employees. If ttte sub-contractors havc anptoyccs,they must provide their workers'comp policy numher
r•�.�aavn���®fir ---rs-�.-maenea �ira�aaatataa�o+�^^�+�-.'�••�-'-.."'
1 am an employer that is providing workers'eornpensarion Insurance for my employees. Below is the poticy and/ob site
Informrulon.
Insurance Company Name:Intego
Policy N or Seif-ins. L.C. H;NewC424991 Expiration Date: L 3 ^V 1 P
Job Site Address•All Steets in _ City/State/Zip. IPA
Attseh a copy of the worker"I compensation policy declaration page(showing the police number and expiration date). o(.,�o
Failure to secure coverage as required under Section 25A of'MCL c 152 can lead to the imposition of criminal penalties of a
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 i iourcuice cwcralrc •criReutl-
sr�ena
l do hereb certi' under the ai(ss and enalties v er4,that(ire in iumation provided above is true and correct
/� Date
Phone 9
Offteial use only. Do not write to this area,to be completer)by city or(own vf)7ciaL
City or Town: Vcrinit/L.itcn.se N—._
Issuing Authority(circle one):
1. Board otHeatlb 2. Building Department 3. City(I own C`lcl-k 4 virttrieal inspector 5. Plumbing inspector
b.Utber
Contoct Person: Mae h:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 105319
-,TO tkN � I.icense Number Expiration Date
Name of CSL Holder
18 - B - Aj List CSI,Type(see below)
No,and Street Type 7- Description
Ll Unrestricted(Buildings up to 35,000 cu.ft.)
i4k§� R Restricted 1&2 Family Dwelling
City/Town,State,ZIP m
RC Roofing Covering
. ....... WS Window and Siding
SI, Solid Puct Burning Appliances
tStep.? Insulation
Telephone mailaddress D Demolition
5.2 Registered Home Improvement Contractor(HIC)
0 0-2-1 !t la
N I;Zlel:41 HIC Registration Number Expiration Date
HIC Company Name of HI Re is rant Name
No.and'Str t Eniai a dress
City/Town,State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 ,.........x No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO 6E-COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize_
to act on my/behalf, ' ll matters relative to work authorized by this building permit application.
APrint e(Electronic Signature) ate
SECTION 7b: OWNEWOR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
c o r,rained i,ne, n this is applicati n is tru and accurate to the best of my knowledge and understanding.
Print Owojr's or AuthorizvAgont's Name(Electronic Signature) Dite
NOTES:
I. An 6-wncr who obtains a building permit to do his/her own work,or an owner who hires on ed contractor
(not registered in the Home Improvement Contractor(111C)Program), will not 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.mass,Pov/oca Information on the Construction Supervisor License can be found at wwwtmassov/dps
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____ -Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
T e Commonwealth of Massachusetts FOR
and of Building Regulations and Standards NICIPALITY
?*ssa husetts State Building Code, 780 CMR
TM ti U S E
N. .11
Not r' ng ermit Application To Construct, Repair, Renovate Or Demolish a i Revised Mar 2011
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: We Applied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address:
1.2 Assessors Map& Parcel Numbers
I a I s th i s an accepted street?yes no_ Man Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arca(sq it) Frontage(1)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G,1,c,40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
Public 11 Private❑ Check iFyesD Municipal 0 On site disposal system 1)
SECTION 2, PROPERTY OWNERSHIP'
wner of R cord•
Name(Prinn) 1 qty,State,ZIP
No.-and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Co n struction❑ Existing Building❑ Owner-Occupied epairs(s) 0 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units, Other ❑ Specify:,—.-- .......
Brief Description of Proposed Work':___.
. ............
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated ts: Official Use Only
(Labor and Materials)-
1,Building $ 1. Building Permit Fee: S.— Indicate how fee is determined:
2. Electrical $
❑ Standard City/Gown Application Fee
0 Total Project Costa(Iturn 6)x multiplier x
3. Plumbing S 2, Other Fees:
4.Mechanical (HVAC) List:
S.Mechanical (Fire S Total All Fees:
Suppression) (05 Cash Amount:
Check No. 1110-Check Arnountq--
Project Cost:st
6.Total Pro, 0 Paid in 411 0 outstanding Balance Due:_
NEGH
28 Spellman Rd.
Stafford Springs,CT 06076
File#BP-2016-0636
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 244 SOUTH ST
MAP 38B PARCEL 270 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT i
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 ION 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
m ' io ay
Sign uildi Kg Of icial 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.
244 SOUTH ST BP-2016-0636
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B -270 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-2016-0636
Project# JS-2016-001057
Est. Cost: $2189.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sq. ft.): 10018.80 Owner: LAFLEUR DARYL G&JESSICA N
Zoning. URB(100)/ Applicant: JOHN PERRIER
AT. 244 SOUTH ST
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON.1112312015 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:
FeeTy pe: Date Paid: Amount:
Building 11/23/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner