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17A-239 v ' - . . . The Commonwealth of Massachusetts • ..v4.-----= Department of Industrial Accidents Office ofinvestigations 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): 944/ 4- AA ik ft Address: Liar 4,16 2E11/C , - City/State/Zip: Fu e bA$ .e ilk Ici . Phone #: 91 - J./ C7 - & -.,-- 0 d / . - Are you an employer? Check the appropriate box: • 6 Type of project (required): I 1.0 I am a employer with • 4• 0 I am a general contractor and I have hired the sub-contractors loyees (full and/or part-time).* listed on the attached sheet. 7. WRemodeling 2. Olarri. a sole proprietor or partner- ship and have n.o employees These sub-contractors have 8 1 ' working for me in any capacity. employees and have workers 9. D Buildin,g addition [No workers' comp. insurance - cor insurance- . required.] 5 Li We are a corporation and its 10.0 Electrical repairs or additions 3. [ I am-a-homeowner-doing-all-work _offic_e_m_havaxercised_teir__ ; 11.0-Plumbing repairs or additions • myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs • insurance required.] t • c. 152, §1(4), and we have no employees. No workers' 13.0 Other _ comp. insurance required.] • *Any applicant that checics box #1 must also fill out the section below showing their workers' compensation policy inforrnatiom t Homeowners who submit this affidaVitindicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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 worIcers comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site ircf_o_rmation. _ 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 covera.ge 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 a a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. rie advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. • I do here i erti& the' e , , • , , d penalties of perjury that the information provided.aboveis_trueund-correct.____ I - -4' ■ tare INPAIAVirdrAldi i a - — , - Phone #: - Official use only. Do not write in this area, tobe dbliipieted by cityor toivirarIciaL 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 #: i SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : Vitt V M A±I E -Sc N CS 8 G 1 0 License N ber t t 0 1 7/ c la ti Address Expiratio Date 0 >e Eeve_ m. S' ature I t Telephone -POr.-k. YuI� ` f t a r .��7 9' Reuister Kotnorhbiuoefm" ten Co c` a c . „ kg , ; ° 4 Not Applicable ❑ Companv Name Registration Number Address Expiration Date 4 fD c E✓U C e /2E) 4' / 0 3 Telephone `fly -a i 9 - d SECTION 10- 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 ❑ No ❑ 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 108.3.5.1. 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 ttl Ott amp Off •rianc =5, a e , -•_ • -_ •. 1. • - rat - Laws - Annotated. � „ .� • r - •.: , Homeowner Signature • 1 , s SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Wir(dows Alteration(s) 0 Roofing ❑ Or Doors Fd' Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0] Brief Descri lion of Propos A Work: r a Fr. 0 o a I INS v LAI 7 9 Si E w W r tN A 4N S ( FQo n7` pat e /k Alteration of existing bedroom Yes f No Adding new bedroom Yes (.7 No Attached Narrative Renovating unfinished basement Yes `' No Plans Attached Roll - Sheet a. ti dSi;. IE k ,6Emdsbwfa [i1111 6agrf 1�, R1 et t fi: 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 stories? f. Method of heating? 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 1, Cg /Ill ah c itn d b , as Owner of the subject property hereby authorize 'PA-UL 444-ffps0'Iti to act on m ehalf, in all matters relative to work authorized by this building permit application. _ A.-.1 .— g Signature of Owner Date 1, 964 LI 1 M as TES L 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. PA ✓ c- AA il -}-( S a ei P ' t Name ^/\ ■:TfA 43/. 1 _ 7 - I D Signature of Owner /Agent Date , 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 . i 1 1 . .......,..1 Frontage I — Setbacks Front I 1 I 1 f 1 , ,-,, 1 -- Side L:i , R:i, _1 L::__! R:1_ , 1 , rn . , t i 1 Rear -- Building Height , -- , i L.... . Bldg. Square Footage 1 ,----- % f i L L._ 1 __ Open Space Footage % i 1 i---i f 1 (Lot aroa minus bldg & paved L--; — ,% parking) -%--,--%--- # of Parking Spaces 1___1 . . Fill: 1 i i 1 (volume & Location) A. Has a Special Permit/Variance/Findin ever been issued for/on the site? NO 0 DONT KNOW � YES 0 t 1 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book i I Page! 1 and/or Document #. . I B. Does the site contain a brook, body of water or wetlands? NO 0( DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Dat Issued: C. Do any signs exist on the property? YES 0 NO _ IF YES, describe size, type and location: : -- D - .' - 11 AFe - 11 h - efe - t 1 - Eijii5 - iiiiia – clia - rigaTodriaatioinis o sigfirfrifelide ? 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. -- - • If City of Northampton , ,� Building Department • 4 212 Main Street r 10j\ � , Room 100 I w �� - lorthampton, MA 01060 6 0 . phone 4'13- Fax 413-587-1272 '� APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: G ! E 5 -f - Map Lot Unit ( " n h I6 Zone Overlay District -Pc °R -A/ c-c M 4 _ 0 I oC „EimSt : District CB District SECTION 2 , PROPERTY OWNERSHIP /AUTHORIZED; AGENT 2.1 Owner of Record: Name (Prirllt Cu ent Maiing Address: na it I CIA. Aho/it_toW S 1 , ice S ! ' d4-104 I� A 0 10(;1_. T ph on 21 `� p r _ Signature ' J ` j3 5 -- C1 2.2 Authorized Agent: payc. rn44- i Eso AI 'i 6 8 F ,2 6 Na e (Print) Current Mailing Address: � y r 3 .- d I 1 — Fs6 tS Sig lure Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ISM 0 6 O (a) Building Permit Fee 2. Electrical 3 q d 0 , eS jf (b) Estimated Total Cost of Construction from (f) 1 , 3. Plumbing Building Permit Femme} 4. Mechanical (HVAC) clp 5 U 4 ) ° 5. Fire Protection A (r 6 Total = (1 + 2 + 3 + 4 + 5) �j 1 Check Number L1i'� This Section For Official Use On Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0882 APPLICANT /CONTACT PERSON PAUL D MATTESON ADDRESS/PHONE 408 FLORENCE RD FLORENCE (413) 219 -8506 PROPERTY LOCATION 61 LAKE ST MAP 17A PARCEL 239 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid / g- )*'6 j G ' 6v-iv di/3. 90 Tvpeof Construction: DRYWALL /INSULATE,REPLACEMENT WINDOWS/DOOR ENTIRE 2ND FLR New Construction Non Structural interior renovations Addition to Existing 601/6 b Accessory Structure q ( „ 0 Building Plans Included: 1 1 Owner/ Statement or License 86090 3 sets of Plans / Plot Plan 114(411- I N STALL- S r/! F a € ' E c d RS 2- ? Fl-ect2 -- THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON Pt& Ct Fi f 6)0f5 INFQRMATION 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 1. Lt) 16 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. • 6 4 "4 BP- 2010 -0882 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- 2010 -0882 Project # JS- 2010- 001304 Est. Cost: $18900.00 Fee: $113.40 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL D MATTESON 86090 Lot Size(sq. ft.): 24001.56 Owner: ANDREWS GILLIAN Zoning: URB(100)/ Applicant: PAUL D MATTESON AT: 61 LAKE ST Applicant Address: Phone: Insurance: 408 FLORENCE RD (413) 219 -8506 FLORENCEMA01062 ISSUED ON:4/12/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: DRYWALL /INSULATE,REPLACEMENT WINDOWS /DOOR ENTIRE 2ND FLR -must install smoke det on 2nd fir per current codes 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 $113.40 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 61 LAKE ST BP- 2010 -0882 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 239 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- 2010 -0882 Project # JS- 2010- 001304 Est. Cost: $18900.00 Fee: $113.40 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL D MATTESON 86090 Lot Size(sq. ft.): 24001.56 Owner: ANDREWS GILLIAN Zoning: URB(100)/ Applicant: PAUL D MATTESON AT: 61 LAKE ST Applicant Address: Phone: Insurance: 408 FLORENCE RD (413) 219 -8506 FLORENCEMA01062 ISSUED ON :4/12/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: DRYWALL /INSULATE,REPLACEMENT WINDOWS /DOOR ENTIRE 2ND FLR -must install smoke det on 2nd flr per current codes 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: S L `� House # Foundation: /1 Driveway Final: Final: Final: 57/3//e Rough Frame: it .1 i (6 s C Gas: Fire Department Fireplace /Chimney: • I Rough: Oil: Insulation: 0 k ' ( 1E f o Lo Final: Smoke: Final: F; ,+Ul AG CK S I 131 (0 Lo ( S THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 0 11'4446.0 A. 4 Certificate of Occupancy S t 3 10 A f Signature: YU Feel e: l ate Paid: Amount: Building $113.40 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo