32C-194 (15) 127 WILLIAMS ST BP-2019-0265
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 194 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-2019-0265
Project# JS-2019-000436
Est.Cost: $2500.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: JOHN PERRIER 105319
Lot Size(sq.ft.): 7405.20 Owner: SAWYER ANNITA&WILL
Zoning:URC(100)/ Applicant: JOHN PERRIER
AT. 127 WILLIAMS ST
Applicant Address: Phone: Insurance:
18 BROADWAY POND RD (860) 930-7794
STAFFORD SPRINGSCT06076 ISSUED ON.9/6/2018 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD R-49 CELLULOSE INSULATION IN ATTIC
FOR WEATHERIZATION
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 9/6/2018 0:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
I B G Su 'wC�
File#BP-2019-0265 N661) KN o
APPLICANT/CONTACT PERSON JOHN PERRIER To H t 1 (AI
ADDRESS/PHONE 18 BROADWAY POND RD STAFFORD SPRINGS (860)930-7794
PROPERTY LOCATION 127 WILLIAMS ST
MAP 32C PARCEL 194 001 ZONE URC(100)/
i t16►J a i`
THIS SECTION FOR OFFICIAL USE ONLY:
� ISSN
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T)Teof Construction:_ADD R-49 CELLULOSE INSULATION IN ATTIC FOR WEATHERIZATION
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 ATION PRESENTED:
oved 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
04— ZL
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.
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The Commonwealth of Massachuse JRel,f
* Board of Building Regulations and StarE C 8 4LITY
Massachusetts State Building Code, 78 . -
Buildtng Permit Application To Construct,Repair, Re JOr TRa-Rtoksit a 2011
One- or Two-Family Dwelling bb �Ji
This Section For Official Use Tny'
Building'Permit Number: — Date Applied:. G`'` '
Building Official(Print Name) Signature Date
SECTION l: SITE INFORMATION
1.1)Tr a ty Addre s: 1.2 A essors Map&Parcel Numbqcr��,
1.1a 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 11) 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnet'of R cord:
Nam e Print) ity,State,ZIP
t/i3 -moo
No,and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. O Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
To Add/Achieve R-49 Cellulose Insulation in Attic for wcatherizationLir oses
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $ �
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �Q J j ❑Paid in Full ❑ Outstanding Balance Due:
NEGH
28 Spellman rd
Please Submit Stafford Springs,Ct
Permits to: 06076
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
John Perrier 105319 12-12-2019
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) I
18 Bradway Pond rd
Type Description
No.and Street U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
Stafford Springs Ct 06076 WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
413-244-2003_ jperrier06076@yahoo.com D Demolition
Telephone Email address
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name 173021 8-27-2018
John Perrier HIC 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: 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 ..........I No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
W10-f/2018
Print Owner's Name Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I 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.
John Perrier
0 . /2018
Print Owner's or Authorized Agent's Name Electronic Signature) Date
NOTES:
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.masL og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/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 halfibaths
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"
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The Commonwealth of Massachusetts ME rrn i
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): NEW ENGLAND GREEN HOMES
Address: 18 BRADWAY POND RD
City/State/Zip: STAFFORD SPRINGS CT 06076 Phone #:413-244-2003
Are you an employer? Check the appropriate box: Type of project(required):
1.0 I am a employer with 5 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. EJ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers'
9
comp. insurance.: . ❑ Building addition
[No workers comp.insurance p•
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' 13.2 Other
comp. insurance required.]
*Any applicant that checks box#I 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.
I 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#or Self-ins.Lie. #: NEWC883979 Expiration Date: 8-1-2019
Job Site Address: IN ALL STREETS OF: City/State/Zip:WWAV L�
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 certift under the pains and a alties ofperjury that the information provided above is true and correct.
Si ature: Date: _. .77/ /
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
Contact Person: Phone#:
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NEWENGL-20
ACORO' CERTIFICATE OF LIABILITY INSURANCE DAT08E!13!2 1312018 18
THIS CERTIFICATE 19 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s).
PRODUCER QJACT
AP Intego Insurance Group,LLC Pf{pNE FAX
1601 Trepolo Rd Suite 280 A1C,No.Ext): ac No):
Waltham,MA 02451 Mbs,Sup ort 8 Inte o.corn
INSLIII AFFORDING COYCRAGG
_ INSURER A:Guard Insurance Groups** 25844
INSURED INSURER B:
NEW ENGLAND GREEN HOMES LLC INSURrR C!_
,
18 Bradway Pond Rd INSURER
Stafford Springs,CT 05075
INSURER E,:
INSURER F: I
COVERAQE6 CERTIFICATE NR: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
!NSR TYPE OF INSURANCE ADDL UBR POLICY NUMBER POLICY EFF MMIDONYM POLICY EXP L1MrrE
COMMERCUU.OENERAL LIABILRY EACH GLIPRENCE
CLAIMS-MADE F OCCUR DAMAGE TO RENTED
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PERSONAL 8 ADV INJ RY
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AUTOMOBILE LIASILIry COMBINEnOSINOLE LIMITIE& —
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OWNED SCHEDULED
AUT��Opp$ONLY ALIT
NNOppSyyyy EEpp BODILY I r nt
A�RiOSONLY AUTOSON0 ROPER AMAGE
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UMBREUALIAB OCCUR EACH OCCURRENCE
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A WORKER3COMPENSATION X PER STATUJF 0TH•
AND EMPLOYERS'LIABILITY
gr-F-114=07
AQNV�PROPRIETOAlP TNE� �ECUTIVE YIN NEWC920850 08101/2018 08101!2019 E.L.EACH AccIeENT 500.000
{M-F-114 Ino FXCLUDED7 NIA
.L.DISEASE-EA EMPLOYEJ500,000
If ves."-esvft under 500,000
DESCRIPTION CIPERAT,IO S low _ _ L.DISEASE•POLI U
DESCRIPTION OF OPERATIONS I LOCATIONS f VEHICLE*(ACORD 101,Additional Remarks ioMdule,may be attached If mon spsce Is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
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ACORD 25(2016/03) 01988-2015 ACORD CORPORATION. All rights reserved,
The ACORD name and logo are reglatered marks of ACORD
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.acoizv CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDONYYY)
�.. 08/13/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. TH13 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement e.
PRODUCER CNAME
ONT;CT Lori J Meagher
Wilcox&Reynolds L.L.C. PHONE
822 Stafford Road,PO Box 529 .860.4299387 ac a 860429-2394
Storrs-Mansitald,CT 002CS-0521 r-MA1L
Joseph A.Barrett mea her WI{COX 16 nO1ds.COm
INSURER(S)AFFORDING COVERAGE NAIC
INSURERA'Ohlo Mutual Insurance Group 10202
INSURED New ngland Green Homos LLC INSURER 8:
John Perrier
18 Bradway Pond Rd INSURER C;
Stafford Springs,CT 06076 INSURER D: _
INSURER E:
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INSURE-7 F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 13 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN R POLICY Po
TYPE OF INSURANCE POLICY NUMBER MM! LIMITS
A X I COMMERCIAL GENERAL LAmLITY EACH OGCURRUNCE t 11000,00
X cLAIMSA(ADE occuR X 5P 0028743 07114/7018 07/14M099 DAMAGE TO RWiTED
PREMISE R ce $ 100,00
X Business Owners MED EXP An one perwn) s 5,00
PERSONAL S ABV INJURY $ 1,000,00
GENLAGOREGATELIMITAPPUrSPER: I GENERAL AGGREGATE f 2,000,00
a PRO- D LOC PRODUCTS-COMP/OP AGG = 2,000,00
X POLICY JECT
OTHER: _
AUTOMOBILE LIABILITY COMBJNEDen L I I $ 1,000,00
A ANY AUTO CPP0022611 07/14/2018 07/14/2019 BODILY INJURY(Per pown) $
ARALL
ED X SAIC�HEESVLED BODILY INJURY(Per&Wdant) $
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HIREDAUT09 NON-OWNED
AUTOS
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X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 2,000,00
A EXCZES UAB CLAIMS-MADE CX 0002971 07/1412018 07/14/2019 AGGREGATE s 2,000,00
DED X RETENTIONS s
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY Y/N STA
ANY PROPMETOR/PARTNERIEXECUTIVE N 1 A E.L.EACH ACCIDENT i
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOY $
'If vea,da'alder
0 LS6RIPTION OF CP Rt.TI NS below E.L.DISEASE-POLICY LIMITS
DEacRIPTION OF OPERATIONS t LOCATIONS I VEHICLES(ACORD 101,Additional RYmar"5dudu*May be atraCrwd If mon apeoe U mgvIrad)
INSULATION CONTRACTOR
Eversource is listed as Additional Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE'.DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
®1988.2014 ACORD CORPORATION. All rights reserved,
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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Office of Consumer Affairs and Business Regulation
1000 Washington Street-Suite 710
Boston, Massachusetts 02118 "
Home Improvement Contractor Registration
' Type:. 1nd[vldtml
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JOHN PERRIER , s dim
18 BRADWAY POND ROAD `testiwr ,3a
STAFFORD SPRINGS.CT 08078 Iw
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173021 08/20020 1000 Washkgton Stmt
JOHN PERRIER k f t30atpn MA 02115 r+ C n Y
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15 BRADWAY PONDROAd:!'i C�— w h "� •' �7t; 'p +''``a• <s
STAFFORb SPRINGS,CT 08078 Und9t6BCf0181�/��+N��{{f�y}��i n O V811d}Y111 8r$f�8i<I�fA
CQMMon.-.'eajt.h of Massachusetts
Division of Professional Licensure
Board of BUtlding Regulations and Standards
'Con struct.Q11.Supervisor Soecialty
CSSL-105319 Expires: 12/12,'20 19
JOHN A PERRIER
18 BROADWAY POND ROAD
STAFFORD SPRINGS CT 06076
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Commissioner
New England Green Homes
Permit Authorization Form
I, ,Owner of the property located at:
(Owner's Name, printed)
l a•7 &,i, Ifa' Pp S ST /VntAA4L WIIZ,"1
(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)
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(Date)
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City of Northampton
,i Massachusetts
e t DEPARTMENT OP BDIbDING INSPECTIONS �`•, r
212 Main Street •Municipal Building y.y
Northampton, MA 01060
Debris Disposal Affidavit
in accordance of the provisions of MGL c 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
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
12 7 >1 111 a , �
(Please print house number and street name)
Is to be disposed of at:
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(�aw'�L&Lol �A�
(Compa6#Name and A ress)
Signature of Permit Applicant or Owner Date
If, for any reason,, the debris will not be disposed of as indicated, thE!Applicant or Ownur shall notify the
Building Department as to the location where the debris will be disposed.
City of Northampton
Massachusetts r
DEPARTMENT OF BUILDING INSPECTIONS 's
212 Main Street • Municipal Building �r 0Cti
Northampton, MA 01060
Property Address: %
Contractor r
Name:
Address:
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City, State: _
Phone: Lil Z— L
Property Owner
Name: T LL
Address: /3 7 L1)"Lai I"
City, State:
I, contractor) attest and affirm that the building I intend to
insul ave any open air(knob and tube)wiring in the spaces to be insulated and that I have
pjzked the property owner with a copy of this affidavit.
Contractor signature
Date � �//