29-025 22 BIRCH HILL RD BP-2019-0490
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block:29-025 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-2019-0490
Project# JS-2019-000794
Est.Cost: $3800.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sg. ft.): 14505.48 Owner: NUTTELMAN CAROLYN S
Zoning: Applicant: JOHN PERRIER
AT. 22 BIRCH HILL RD
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:10/24/2018 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULAT ION IN ATTIC
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:
Feelype: Date Paid: Amount:
Building 10/24/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
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> ETIfi— MUNICIPALITY
i: Massachusetts State Building Code, 780 CMR
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82 USE
z 0 Iding Permit Application To Construct, Repair, Renovate Or Demolish aev e a 11
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>Cn One- or Two-Family Dwelling
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1.1 Property Address: 1,2 Assessors Map Sc Parcel Numberll_�
I;-
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a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1A 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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone'. Outside Flood Zone? Municipal 0 On site disposal system 0
Clwck if yesO
SECTION 2: -PRO`Pk'1R
2.1 Cof C r
Name(Print) City,State,ZIP
kok A411 0 -IM-911-D-
No.and Sir-,et Telephone Email Address
MW
New Construction0 Existing Building 0 Owner-Occupied 0 Repairsisr==ion(s) 11 Addition ❑
Demolition 0 Accessory Bldg. 13 Number of Units Other 0 Specify: ....
Brief Description of Proposed Work 2:
To Add/Achieve R-49 Cellulose Insulation in Attic for weatherization purposes
S
,SE,,C!FION 4:,EisxmMl)COAT
Estimated Costs:
Item Off
(Labor and Materials
1. Building rmat lee $ Inti�oate04 d
0 staji-&(
gWz4p12hcaon
2. Electrical
, -
0 Total Project Cost C �
- (Item-,16),--x-pti ler-
X.
3. Plumbing loi2 Other ee,
4. Mechanical (1-NAC) S List:
5, Mechanical (Fire
TotatA
7.. Z
Su ression) Q1 I tri0
untr
0p-,
1 �'
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6, Total Project Cost: $ 31� Opaid Balance Due:
irl
NEGH
28 Spellman rd
Please Submit Stafford Springs,Ct
06076
5.1 Construction Supervisor Lieense,(CSL)
John Perrier 105319 12.12-2019
Name of CSL Holder License Number Expiration Date
18$radway Pond rd
List CSL Type(see below) I
y
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No.and Street U Unrestricted Build----u to 35 00o cu.ft.
R Restricted l&2 Famil Dwem
Ci Gown,State,ZIP M Mason
RC Roofing Covering
Stafford Springs Ct 06076 WS Window and Siding
SF Solid Fuel Burning Appliances
413-244-2003_ jperrier06076@yahoo.com I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(11IC)
HIC Company Name or HIC Registrant Name 3021 8-27-2018
7�1
John Perrier
C Registration Number Expiration Date
No.and Street jperrier06O76@yahoo.com
18 Bradway Pond rd
Email address
Stafford Springs,Ct.06076
Cit /Town,State,ZIP Telephone 413-244-2003
SECTION 6._WO#ZK>MRS' GOIv>4P1N��7` QI`t II1` � r&
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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 ❑
EC�TON OWNE
7aR AUTH0X2tZA��IN�OBkdP�)uA WH1irl`i
1,as Owner of the subject property,hereby authorize New England Green Homes to act on my behalf, in all matters
relative to work authorized by this building permit application.
10 /l0 /2018
Print Owner's Name Electronic Signature) Date
SCION 7 ;.1Q 'iY srt OR;AU '# Rlll , OfJ � '
1
By entering my name below, I hereby attest under the pains and penalties ofperjury ihai all of the info,nation
contained in this application is true and accurate to the best of my knowledge and understanding.
John Perrier
10 & /2018
Print Owner's or Authorized A ent's Name Electronic Signature) Date
1. 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 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.aov!oca Information on the Construction Supervisor License can be found at www.mass. og y/dps
2. Whenl floea(sq, ft.)substantial work is planned,provide the information below:
Totaor ar (including garage, finished basement/attics,decks or porch)
Gross living area(sq. fl.) 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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, AfA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/OrganizatiorAndividual): NEW ENGLAND GREEN HOMES
Address: 18 BRADWAY POND RD
City/State/Zip:^STAFFORD SPRINGS CT 06076 Phone#:413-2442003
Are you an employer? Check the appropriate box: Type of project(required):
1.21 1 am a employer with 5 4. ❑ I am a general contractor and.I
v r rr * have hired the sub-contractors 6. ❑ New construction
employees(full and/or pa-,-timc).
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. C Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9 ❑ Building addition
[No workers' comp, insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no INSULATION
employees. [No workers' 13.n,/ Other
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Job site
information.
Insurance Company Name: AP INTEGO
Policy 4 or Self-ins. Lie. #: NEWC883979 Expiration Date: 8-1-2019
Job Site Address: IN ALL STREETS OF: City/State/Zip: M
fi-
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL 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 insurance coverage verification.
I do hereby certify under the sins and petlaftles o er'ur that the in ormadon provided above is true and correct.
Si mature: _ __ _ . _ ...__ _. _ _�_....___
llate
Phone#: 413-244-2003
Official use only. Do not write in this area, to be completed by city or town official.
City or Town; __ Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector
6. Other
„__ Phone#
14E'WENl31n20 ���� •
..-� CERTIFICATE OF LIABILITY INSURAN.CE Iops
THIS CERTIFIC`A'TE I3 ISSUED,ASA MATTER OF INFORmATf01� ONLY 4NC-CONFEl;S;QJQOH S UPON THS C� IGATE.I�`KFIt#
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1 000Washington Street-Suite 710
Boston, Massachusetts 02116
Home Improvement Godtractor Registration.yn '`
Type. .irxtividwdj'.
JOHN PERRIER V�j:4G ytm J Fi6pIsU8 � 173021 •?.+C * r�r
16 BRAOWAY POND ROAD
STAFFORD SPRINGS,OT 08078
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JOHN A PERRIER
18 BROADWAY POND ROAD
STAFFORD SPRINGS CT 06076
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Commissioner
i\jew Engiand Green Homes
Permit Authorization Form
I, n n S • Ny-4f�) Yn4L41 ,Owner of the property located at:
(Owner's Name, printed)
(Property Street Address) (City/Town)
herby authorize New England Green homes to act on my behalf and obtain a building permit to
perform insulation and/or weatherization work on my property.
(Owners Signature)
/ 010113
(Date)
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City of Northampton
Massachusetts
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eze Main Street °Mmni"ipnz au^zuIng
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in accordance of the provisions iaiona mf MGL n 40. S54. I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
ofinaproperly licensed solid waste disposal facility, nsdafinadbyW1GLc111. O15OA.
The debris from construction work being performed at:
(Please pri nd street name)
\mtobadisposed ¢fat:
(Please print name and location of facility)
Orwill bmdisposed of\nadumpeteronsite rented orleased from:
;(Company Name: dre
7z ss)
If, for any nemnon, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.