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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