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17A-089 The Commonwealth of Masuuhusetts --- Departm of Industrial Accidents 41 Office of Investigations 600 Washington Street Boston, MA 02111 " www.inass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumber A . 1 Beans Information Please Print I.c: ibly Name ( Bruntoniorganiurion/lndividuat): .,i r -�. > r . Crt /State/Zip: Ik r14.t.• , H4 0100 Phone #: W3 ' o?'V— ` � ?&2 Are you an employer'? Cheek the appropriate box: Type of project (required); - ❑ am a 4. I I 1.0 l am a employer with nd the contractor and 6. 0 N construction employees (full and/or part - time).• have hired tub contractors 2.0 I mat a sole proprietor or partner- listed on the attached sheet. 7. Remod =ling ship and have no employees Thcsc sub contractors have 8. 0 Demolition working for me its my capacity employees and have workers' 9. 0 Building addition [No workers' CO'. insurance tosucaau. required.) 5. Flag a corporation and its 10.0 Electrical repairs or additions 3.0 Tam a homeowner doing all work officas have eWcinCd their 11.0 Plumbing repairs or additions myseii t14lo ' cotaP. right Of exemption per MGL 12.0 Roof repairs insurance Via] 1 x.152, §1(4), and nts have no employee. [I30 washers' 13.0 Other comp. insurance required.] *my spp4cs c thaeheeics box at emit also fill eta dm section bdew:M.Ang their various' compassitiat policy mfmtmsaee. t Hauteur *Aso esrbrmt this affidavit indiea** dry are dolts in work mad is be outside ea arses mast submit a ceav affidavit bidintiaq such. 1 Ca tmetors tint cbmk dtis boa ucnt studied as additional duct showing the none tithe wbeannanas and state winsher er not those entities have employees. If the sub-mnnetoirs have anplores, they must provide their workers` temp. potierenn her. I ant an employer tkat isproviding workers' compensation Insurance for sty employees. Below is the policy and job site • inforneation. Insurance Company Name: reef' f e 5 wt 5vccuA C P - - Policy # of Self -ins. Lie. Jl: C8? $ 1 lo' g 7 . Expiration Date: 0 / 06`. O r Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (skewing the policy number and espiratioa date). Fsilnrcto grease covesuge as required under Section 25A of W3L c. 152 am lead to the imposition of criminal penalties of a fine np to $1,500.00 and/or one-year imprisonment, as von]] as clot penalties in the fa = of a STOP WORK ORDER and a fate of up to 5250.00 It day again the violator. Be advised that a eopyoft is s t moot may be forwarded to the Office of Invesli : • : ons of the D1A for' _ verification. I is hereby eat& • the p muskies efpedaty that the 1mrjorlrradomr provided above is stare and cold • $marine: A Date: L #: I f • use only. ' . not write this area la tdty or tour offlt Jst City or Town: , Perndtaietase k Issuing Authority (circle one): . i. Board of Health 2. Building Department 3. City/ own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other _ • Contact Person: • Phone a: 111.. , SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement ndows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs ED] Decks [❑ Siding [p] Other [a Brief Description of Proposed rferkti eAJJ/ 40t-JS �AD r �f �� r o X orrf r (/ u5P Alteration of existing bedroom Yes ' No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a._l# NeM► a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stones? f. Method of heating? ANA Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ► u/e as Owner of the subject property 1 hereby authorize `)� n K ( et et �{s-c to act on my beh If, " II matters relative to work authorized by this building permit application. Si of Owner Date t, ,1; i ot- LetA4- CrV , as Owner /Authorized Agent hereby declare that the stateme is and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. / 7c L Print Name 1 4 ..f►.r . /® � v Signature of Owner /Agent / Date Nib Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume it Location) A. Has a Special Permit/Variance/Findin. ever been issued for/on the site? NO 0 DONT KNOW • YES 0 IF YES, date issued:. IF YES: Was the permit recorded the Registry of Deeds? NO 0 DONT NOW 0 YES 0 . _ IF YES: enter Book Page and/or Document # _ . B. Does the site contain a br.k, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit 'een or need to be obtained from the Conservation Commission? Needs to be obta* ed 0 Obtained 0 , Date Issued: :- C. Do any signs exi on the property? YES 0 NO 0 _ . IF YES, des •be size, type and location: D. Are there ,ny proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF Y describe size, type and location: E. WiI e construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan tf -t will disturb over 1 acre? YES 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ,., City of Northampton $ 7 Buii ing Department 21 Main Street s oom 100 i rrthampton, MA 01060 phone 413 -587 -1240 Fax 413 -587 - 1272 : xi *.,f ,- .. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: section to be Pled by office 096 a+ t 4t. Mal' L Unit Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Li 44 S1-0 e (29e - o kOca Name Print) Current Mailing Address: 4 //3 - 56P '-"/ / Telephone Signature 2.2 Authorized Agent: ©l. r. Lextidf /e V Nat Name (Print) Current Current Mailing Address: k if6 ��Y Signature j Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee / 400 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number / 7O/ 5 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date s BP-2011-0399 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2011 -0399 Project # JS- 2011- 000662 Est. Cost: $10000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN LANDRY 093450 Lot Size(sq. ft.): 12458.16 Owner: THURSTON MICHAEL T II & LISA R STOWE - THURSTON Zoning: URA(100) //RI Applicant: JOHN LANDRY AT: 296 BRIDGE RD Applicant Address: Phone: Insurance: 104 NORTH ELM ST (413) 204 -9880 WC NORTHAMPTON MAO 1060 ISSUED ON:10/28/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS /DOOR 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 10/28/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner