36-015 41 FOREST GLEN DR BP-2017-0097
GIS u: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-015 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACT ORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit BP-2017-0097
Project ft JS-2017-000164
Est.Cost:$2776.00
Fee:$65.00 PERMISSION IS HEREBY GRANTED TO:
Cons[.Class: Contractor: License:
Use Group: JOHN PERRIER 105319
Loot Sze(sp. ft.): 14418.36 Owner: QUIRK JOHN C
Losing: Applicant JOHN PERRIER
AT: 41 FOREST GLEN DR
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860) 930-7794 WC
STAFFORD SPRINGSCT06076 ISSUED ON:7/26/2016 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL INSULATION
POST THIS CARD SO 1T 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: 00=h 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 7/26/2016 0:00:00 $6590
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
File#BP-2017-0097
APPLICANT/CONTACT PERSON JOHN PERRIER
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS06076(860)930-7794
PROPERTY LOCATION 41 FOREST GLEN DR
MAP 36 PARCEL 015 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT �)
Fee Paid idle 4
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL 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
IN O ATION 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
I— :titian I-lay
dillii"r
S TAT. in midi g I ictal 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.
CEIV D
252446
Commonwealth of Massachusetts
p� • • uilding Regulations and Standards FOR
U•r11 °i1 ' f B
a Massachusetts State Building Code,780 CMR MUNICIPALITY
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) yyLgla�/�� Signature Date
./) 3�Etf t 1. �j,FORMATION
1.1 Property Add :{f x1.2''Asxeswrs Map&Parcel Numbers
1.1a s:his an.accepted s no Map Number Parcel Number
1.3 Zoning Information: 1.4 Pruperty Dirnecsions:
Zoning District Proposed Use Lot Area(so ft) Frontage(8)
15 Building Setbacks(n)
Front Yard T Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L o.40,(BB i.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public U Privatel2 Zona: __ Outside tlmd Zone? Municipal O On site disposal system ❑
Check if vcsC1
SECTION 2: PROPERTY OWNERSHIP'
2. Owner'of : - ord:
_ 0 . . . s }(}j ) fit - 0/002
="n" Ar y (i1r1 ) rdr-.) if, �`3.0—y76( C
No,and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied C Repairs(s) O Alteration(s) ❑ Addition U
Demolition U Accessory Bldg. U Number of Units Other O Specify:
Brief Description of Proposed Work':
To Add & Improve It-Value Insulation in home for weatberization purposes.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
nem Estimated Costs: Official Use Only
(Labor and Materials),
I.Building S I. Building Permit Fee:SIndicate how Pee is detennined:
2.ElectricalS ❑Standard City/Town Application Fee
U Total Project Cost (Item 6)x multiplier __x
3.Plumbing S 2. Other Fees: S
4.Mechanical (HVAC) S List_„_
5.Mechanical (Fire S Total All Fees:S CO 5_,�
Suppression) ,f f
Check Amount Cash Amount:
6.Total Project Cost: $ r7t ' Check Nn 32G/p Paid i Full 0 Outstanding Balance Due:
NEGB
28 Spellman rd
Please Submit Stafford Springs,Ct
Permits to: 06076
SECTION S: CONSTRUCTION SERVICES
$.1 Construction Supervisor License(CSL)
John Pettier 103319 12-12-2015
License Number Expiration Date
Name ofCSL Holder
19 Bndway Pond rd List CSL Type(ace below) I
Type Description
No.and Street —
U Ulmstrioted(Buiidrngs upm35,000 m.ft)
R Resrrtaed 1A2 Family Dwelling
Ci crownState,ZIP M Masonry
RC Roofing Covering
Stafford Springs Ct 06076 WS Window and Siding
SP Solid Fuel flaming Appliances
insulation
e60. tioie 4 iperrEmail r66076@ishaocom D Demolition
Tel-done Email address
5.2 Registered Home Improvement Contractor DOC)
HIC Company Name or RMC Registrant Name { 173021 837-2016
John Perrier HIC Regisiredon Number Expiration Date
No.and Street jperriar06076@yabooeom
IS Bradeay Peed rd Email address
Stafford Springs,Ct.06076
Ci (Town,State,ZIP Telephone S60-930-7794
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152.§.7.5C(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 No_....._..❑SECTION 7s,:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of rhe subject property,hereby authorize New England Green Homes to act on my behalf,in all matters
relative to work authorized by this building ptrmiapplication.
John Perrier/JO ,. l e�'U-t t
016
Print Owner's Name Electronic Si; arum to
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties ofperjuty that all of the information
contained in this application is true and accurate w the best of my knowledge and undemtending
Lynn Ford
F i 016
Print Owner's or Authorized A e i''s Name Electronic Slgnemrc3 Die
NOTES: 1.111111.11.111111111
I, M Owner who obtains a building permit to do hisTer own work,or an owner who hires : unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will (have ac s.s to the arbitration
program or guaranty fund under M.G.L.c, 142A.Other important information on the IHProgram can be found at
)yww.mass.gov/V9$Information on the Construction Supervisor License can be found at- u,... :.,vid r
2. When substantial work Is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basemen inks,decks or porch)
Gross living area(sq.ft.) Habitable room count_
Number of fireplaces_ Number of bedrooms
Number of bathrooms Number ofhaiffbaths
Type of heating system Number of decks/porch-
Type of cooling system Enclosed Open
3. 'Total Project Square Footage"may be substituted for"Total Project Cost"
A The Commonwealth of Massachusetts Print Form
r_`I Department aline/owlet Accidents
m ongesfsStvet,S tions
Suite
j�= 1 Congress Street,Suite 100
ni
'.. �r Boston, MA 021144017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name tBuairtessiarganixaion/Individual);New England Green Homes
Address:18 Bradway Pond rd
City/State/Zip Stenbrd Spnngs CT 06076 Phone 888836.7794
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 4 4. 0 1 am a general contractor and I S. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub-contractors have g, Q Demolition
working for me in any capacity. employees and have workers'
[No workers' comp,insurance comp.insurance.* 9. Building addition
required.] 5. 0 We are a corporation and its 10.[] Electrical repairs or additions
3.0 I am a homeowner doing ail work officers have exercised their 11.0 Plumbing repairs or additions
myself.[No workers'comp. tight of exemption per MGL 12.0 Roof repairs
insurance required.)t c. 152,§1(4),and we have no Insulation
employees.[No workers' l3.[{]Other
_ comp.insurance required.)
`Any applicant Chet Mocks box#1 must also fill out the section below showing their workers*compensation policy information.
r Hamcownon who submit this affidavit Indicating they ere doing all work and then hire outside contncton must submit a new affidavit indicating such.
k;onwaoe Mt deck this box must attached art additional sheet showing the name of thesub.,xmtrectors and state whetaerarnm those entities have
employees. tithe sub-wmacton hove employee,May must provide their workers'comp.policy number.
lam an employer Mai is providing workers'compensation Insurance for my employees. Below is the policy and jab site
Information.
insurance Company Name Intego
Policy P or Self-ins, Lic.#:NE wc634866 Expiration Date:W1/2o16
Ail Streets In t f t °' fl
Joh Site Address:_ S City/StaterZipt_ C'f.. „,Li e-,. Ud-G--
Attach a copy of the workers'compensation policy declaration page(showing tee policy numkor and expiration date).
Failure to secure coverage as required under Section 25A ofMOL c. 352 can lead to the imposition of criminal penalties eta __
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 fire
of up to$250.00 a day against the violator. Be advised that a copy ofthl$statement may be forwarded to the Ofl'ke of
Investigations of the DIA for insurance coverage verification.
I do hereb certio,uu%der the pains an mal sof perjury that the information provided aboveabis true and Correct.
$iznature') f! /7 "y � [Date/7:7 2016
Phone :413-244 24tl3
Offload use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License u
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone Pr
New England Green Homes
Permit Authorization Form
µ
"'V _ ,Owner of the property located at:
//(Owner`s Name,printed)
I --14.01- C�t.�yr�? rcc /7/1 C/C',k/�, z
(Property Street Address) (CityjTown)
herby authorize New England Green homes to act on my behalf and obtain a butd!ng permit to
perform insulation and/orrwweatherization work on my property.
A
(Owners S gnature)
(Date)