25C-251 (40) The Commonwealth of Massachusetts
Department of Industrial Accidents
h " Office of Investigations
r:9 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): L au re y. j c " l L v 6 Y•
Address:
City/State/Zip: e - (1f J'C`° #:
� �c��(' c
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑ 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. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
/equired.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 11.0 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 13. Other
employees. [No workers' Sip
comp. insurance required.]
*Any applicant that checks box #1 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:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: 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 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 certify under the pai and penalties of perjury that the information provided above is true and correct.
Date:
[lL
Phone #: (it 3) 32o- 3b'•1 e
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 #:
SECTION 8 - CONSTRUCTION SERVICES
t
r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
` me • isfererl , 1ome_lm . r•verner ontractor. =„+` " #
a ..r . ;� � � A ��" ,. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION _ '10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G L c x152, § 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 ❑ No ❑
LE,4 o o uon
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 1083.5.1.
Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside; on which there
is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon
completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordinances, State and Local Zo ' g Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing i l
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding [ j Other [DJ
Brief Description of Proposed •
Work: ► wl t j f\ p F vu N St.
Alteration of existing bedroom Yes No Adding new f5edroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa ILN w,,house.ar d.or addition.to;existi.nq housrnq. comta eteAherfoihiwirii
a. Use of building : One Family Y Two Family Other
b. Number of rooms in each family unit: b Number of Bathrooms I
c. Is there a garage attached? ICES
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? b'$ , A - / (.b f A ntL Fireplaces or Woodstoves YGS Number of each 1'
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction U ..a.cx
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 BECOMPLETED WHEN
OWNERS AGENT OR CONTRACTORiAPPLIES FORBUILDING PERMIT
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matt s relative to work authorized by this building permit application.
9 - 2Z —J(
Si nature of Owner Date
, as Owner /Authorized
Agent hereby declare that the statements 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.
Print Name
Signature of Owner /Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Information a 4
b
Existing Proposed Required by 'Loping ;: +.'"
This column to be filldl in by
Building Department
I{ I
i •,
Lot Size
? i 1 p
Frontage
Setbacks Front j i
Side L: R: L:i . i R:3 I 1 1
Rear 1 i d
Building Height 3 a
Bldg. Square Footage i 1 % f—" 1 1
Open Space Footage
(Lot area minus bldg & paved 1 i r—
I I = i 1
parking)
i 1 i I i
# of Parking Spaces
Fill: __ _.___.___. _ __ _. __ . .___ __
(volume & Location) ' f
A. Has a Special Permit /Variance /Finding ver been issued for /on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued: I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page; and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO e DONT KNOW C YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO lr
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location: '
E. Will the construction activity disturb (clearing, grading, exc ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
.
RECEIVED Cit of Northampton S - tr i of P .
Buildin Department City Cr ® ear . errn k �'
sEp 2 3 all Room Main Street S. t.rA ep is atlat � � ,
Room 100 t►a er. e t y a'1 a bit 1 r
a v �a , g te �s , �
- ..2,- .
Northampton, MA 0 4 1 1 0 3 6 -5 0 87- -,,tit!-, cr e _ Str` c al Patts�
f4iEFT OF6UiLDIN P � 58"1 -1240 Fax 1272 F d i t $ P ' 3
NO ' `� i
k® h et "peclfx , �t »
b
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- " INFORMATION
k Thrs sectr t o be completed lay office ,
1.1 Property Address: a;'4 x � ,
� ( }'� � - N' t.^;`x}y -Pfeg A -« ' e 7 k 'fi ,,,, : .4i t ` g
Z eY ` ` - 4* . n t L vx , 9 t+t . 4 hi
rL ■ C L M �� OyerlarDistri
c / � 'r w" g Y s:.. � ;^ :e°e. .' mt, A„„�, rr a 1 s . �' x �i �
3'Etm St District . . CB District
SECTION 2 P R OP ERTY . OWNERSHIP /A AGENT
2.1 Owner of Record: r
- A�)t'e..) �1���s011 1.Z cA,twAY pit. 9�Teoce, IA-v atoG2
Name (Print) C went Mailin Add ss: 61 Ca
Te ephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 = ESTIMATED CO COSTS
Item Estimated Cost ) to Official Use Only
completed by permit (Dollars applicant be ..
1. Building °Q "(a) Building Pe :, . L'
i miitFee
x,36".
2. Electrical (b) Estim Total Cost of : ,
Constru fro (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number �
This'Section For Official Use Only
Building'; Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
a
22 FAIRWAY DR BP- 2012 -0294
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 44 - 047 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2012 -0294
Project # JS- 2012- 000477
Est. Cost: $3000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 17031.96 Owner: HICKSON LAUREN
Zoning: SR(100) //WSP II Applicant: HICKSON LAUREN
AT: 22 FAIRWAY DR
Applicant Address: Phone: Insurance:
22 FAIRWAY DR (413) 718 -6162 0
FLORENCEMA01062 ISSUED ON:9/26/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE VINYL SIDING
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 9/26/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
dab
X28
I ARADISE CITY ARTS ffjTIVAL I� x 15/ Li- 4
NORTRAMPTON, MA Gate
2 I
OCT 8,9 10 2011 NORTHAMPTON'S FINEST RESTAURANTS ! !
' Live
Festival Dining Tent Jazz
MORGAN BUILDING #2 4 Wine
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401 1403140514071409 1 413 141514171 1 419 421
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1 140014021 404 140614081410141214141 Museums 10 ( 805 80718091 811 813 817 18191 821 825 827 831 833 835 837 839
6'
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1 6' 704 1 7061708 710 712 7161718 720 7241 726 730 732 734 17361738
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12'
600 642
(1300130213041306130813101 312 1 314 13161 318 604 1606 608 610 612 618 618 620 1 624 1 626 630 63216341 636
6 ' 501
5051 507 509 511 513 517 519 5211 523 15251527 531 533 15351537
MORGAN BUILDING #1 5 0 0
1 I 50 I Silent Auction Tables
3
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OFFICE
1
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202120412061 208 210 :121412161 218 220 232 1 236 240 2441 246 248 250 252
103 110511071109 111 115111711191121 123 Exhibitor 1311 133 1 137 139 143 1145 147_149 151
REGISTRATION
1-1 1001 102 1104 106 108 110 1 114 1116 1181 120 MAIN J 132 11341136113811401 142 11441146114811501 152
EXHIBITION TENT GATE
t
10. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common
plan of development that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
This colzrmn reserved
for use by the Building
De • a.rtment
EXISTING PROPOSED
Lot Size
Frontage •
Setbacks Front
Side L R: L R: •
Rear •
Building Height •
Building Square Footage
% Open Space: (lot area
minus building & paved =
arkin..
s of Parking Spaces
# of Loading Docks
Fill:
(volume & location)
13. Certification: I hereby certify that the information contained herein is true and accurate to the best of
my knowledge. _
/ate: z 4 ... 1 AppIicant's signature Li t, �..�: 4d .
/i-o
NOTE: Issuance of a zoning permit does not relieve an appli.:. is burden to comply with all zoning
requirements and obtain all required permits from the Board of Health, Conservation Commission,
Historic and Architectural Boards, Department of Public Works and other applicable permit granting
authorities.
w:\Docume unFORMs\ori6zures:::d in_- :-.-tt rzon. ^.2 P it- 4:?oii=on- passivcdoc 8 /4/2004
FEE$ 25, 00 /tent RECEIVED :
SEP 2 6 2011
File No.
T �
Please type or print all information and return this form to the Building
Inspector's Office - 'check or money order) payable to the
City ofNor thampton
/ Name of Applicant: P!- g-ADtSE C t ri AR; rJ f ,S TI V P L
,Address: 30 - S"�LLSATP► 4 1 Ca / Telephone: 60 SI I -9 7 Z S
✓L. Owner of Property: 3 Co td'i ' oo rsvy x/vt
Address: 0 FeA /'r.) O0 Telephone: J 1- 7
3. Status of Applicant: Owner l Contract Purchaser Lessee Other (explain)
/4. Job Location: 3 C) \I ' 5 tl l r/ QtJY►
...
f.
��
Existing Use of Structure /Property:
LIST EVENT p 1)15 ( C 1'1" 1 AIL f iS j VA l--
•
6. Description of Proposed Use/Work/Project /Occupation: (Use additional sheets if necessary):
LIST DATES OF EVENT
NO OF /SIZES OF TENTS • I SX 1 c 4'0 x 27-0 tp 0)C 3
WHEN TENTS READY FOR INSPECTION 111 J+(\ CPC-*
7. Attached Plans: Sketch Plan Site Plan Engineered /Surveyed Plans
8. Has a Special Permit/Variance/Finding ever been issued for /on the site?
NO DONT KNOW V YES IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and /or Document
9.Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , date issued:
(Form Continues On Other Side)
W:1130 ---..0 sF OFu iS,": arR rE .tr- ectorzoi i rse Penn+- ?*7pii=ion- pasive.doc 8/42004
FAIR ST - FAIRGROUNDS BP- 2012 -0298
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 251 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Tents BUILDING PERMIT
Permit # BP- 2012 -0298
Project # JS- 2012 - 000485
Est. Cost:
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owner: HAMPSHIRE FRANKLIN & HAMPDEN AGRICULTURAL SOCIETY
Zoning: Applicant: Paradise City Arts Festival
AT: FAIR ST - FAIRGROUNDS
Applicant Address: Phone: Insurance:
30 INDUSTRIAL DR EAST (413) 587 -0772 0
NORTHAMPTONMA01060 ISSUED ON:9/27/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: ERECT 15 X 15, 40 X 220 & 60 X 300 TENTS
PARADISE CITY - 10/8 - 10/12/11
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 9/27/2011 0:00:00 $75.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck— Building Commissioner