32A-083 The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.tnass.gov/dia
Workers' Compensation Insurance Affidavit: Buil ders/Contractors/Electricians/Plumbers
Annlieant Information Please Print Legibly
Name(13usincss/organizatiorvindividual);New England Green homes
Address.- 5 P(I.l Vyi
F2Ci /State/Zi :Stafford, CT 06076 Phone!1:860.-930-7794
Are you so employer?Check the appropriate box:
Type of project(required):
I,[� 1 am a employer with 4 4. [3 !am a general contractor and!
employees(full and/or pan-time).'" have hired the sub-contractors 6. C] New construction
2.❑ 1 am a sole proprietor or painter- listed on the attached sheet, 7. ❑Remodeling
and have no employees These sub-contractors have g, [] Demolition
working for me in any capacity. employees and have workers'
[No workersI comp.insurance comp, insurance. 9. [J Building addition
required.) 5. (� We are a corporation and its 10.❑Electrical repairs or additions
3.❑ 1 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.)r c, 152,g 1(4),arnl we havc no c
empluyees.[No workers' 13.[X Other J
comp. insurance required.
'Any applicant that chocks box N I must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this a!'lidev it hidicating they are doing all wor6 kind then him vutsido contracwsY must submit a new affidavit indicating such.
;Contractors that chock this box must attached an additional sheet showing the name ol'thc sub-contractors and swo whether or not those entities have
emplayees. lfthe sub-contactors have employees,they must provide their workers'comp policy number.
-
I am an teriployu shut is pravlding workers'compensarian Insurance for my employess Below is the polky and job sits
tnjarrnwlon.
Insurance Company Name:lntego
Polio H or Self-ins.Lic.N:NewC42499
y Expiration Date:_��,w.
Job Site Address:All Steets In City/State/Zip:
Attach a Copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties ofa
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
(nvG4tig4tiOnS Of the DIA for inaurancet uuveragea voririicatiun.
1 do hereb y cerfifH under the alns ties
den o er un•that the in ormarlon provided above is true and correcx
Ph
/ pat
o ( o
t,ftlal use only. Do not write In this area,to be Conwieted by city or town oJJ7etait
City or Town: ^Permit/Utense 0
Issuing Authority(circle one):
1.BOtird Of ttealsb 2. Building Department 3.CitylTuwu C1rrk J. Fhevtrical inspector K. Plumbing Inspector
6,otber
Conuct Person: Phone :
_J
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
TO t4N Toro License Number Expiration Date
Name of CSL Holder �-'—`-
�rC�4L.I� 7 If������ List CSL Type(see below)
No.and Street l� t Type Description
_3P5•� ° R Rnestriteted2 Family Dwolt n5,0U0 cu.ft
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SIT Solid Fuel Burning Appliances
�-- �� V� `}Cv�fq m I Insulation
Telephone Email address D Demolition
5.2 Registered Houle Improvement Contractor(HIC) '�3 4 2..
bktq Q HIC Registration Number Expinitlon
HI tqm --v —At4en Hit
Reentrant e� � .�����
Noand Stree � p
Ernaff dress
—city/Town,state, IP Telc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.4 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 ...........0 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 �1�{- �,�� ; �t(LCY1 �
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) 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 understanding. ``
N ! .�
P gent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nonregistered in the Home Improvement Contractor(HIC)Program),will Ltot 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.eov/oca information on the Construction Supervisor License can be found at www.mass,gpv/dos
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 Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
r Y ,
5
--- r'S i The Commonwealth of Massachusetts
�ecttic C,G i:i n ,n FOR
Board of Building Regulations and Standards
Nor:.... MUNICIPALITY
Massachusetts State Building Code,7$0 CMR 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
1 roper�;Address: 1.2 Assessors Map&Parcel Numbers
CSjyal p _
I.to 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 R) Frontage(R)
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,J54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private 17 Zone: Outside Flood Zone? Municipal 13 On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP`
2.1 caner'of Record, 1 Z IP y �f ()/() W
Name Pri City.Sta
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) O 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other O Specify:
Brief Description of Proposed Work
4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1.Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard CityfFown Application Fee
2.Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) S List: _....._.
5.Mechanical (Fire $ Total All Fees:S
Suppression)
/- /1 Check No.wCheck Amount: Cash Amount:
6.Total Project Cost: $ /��U� f/V ❑Paid in Full C]Outstanding Balance Due:
NEGH
M I t 28 Spellman Rd.
Staffcrd Springs,CT 06076
File#BP-2016-0230
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 50 GRAVES AVE
MAP 32A PARCEL 083 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid /09; Lee,
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
INF RMATION 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
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.
50 GRAVES AVE BP-2016-0230
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)
Category: INSULATION BUILDING PERMIT
Permit# BP-2016-0230
Project# JS-2016-000386
Est. Cost: $1816.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Lot Size(sg. ft.): 4356.00 Owner: ARRY JACQUE
Zoning: URC(100)/ Applicant. JOHN PERRIER
AT. 50 GRAVES AVE
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