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17A-236 . .\ The Commonwealth of Massachusetts Department of Industrial Accidents W y — Office of Investigations 600 Washinaton Street ��' I ts C la Boston, M4 02111 d w ww.mass gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly • Name ( Business /Organization/Individual): Jo /7 // - /& / /e Address: :4 -, n D ,z- /n e,-R City /State /Zip: 4 c- - 2--i0 /if, - Phone .#: ' /() ? /. 3/co Are you an employer? Check the appropriate box: Type of project (required): /' 4. I a a general contractor and I 1. I am a employer with / t t 6. ❑ New construction employees (full and/or part time).* have hired the sub - contractors 2. 1111 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship -anal have. no. loyees These sub - contractors have. 8. 0 Demolition working for me in any capacity. employees andhave workers' ct 9. Q Budding addition [No workers' comp. insurance comap..l;lsmance. required.] 5. [] We are a corporation and its 10.0 Electrical repairs or additions 3. I am - a- homeowner-doing -all -work _ o cer_s_have rcised their ____ _ 11-. J - 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 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. ZContractors that check this box must attached an aMitional 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. Iam an employer that is providing workers' compensation insurance for my employees Below Ls the policy and job site information. Insurance Company Name: / ii 4 --2 /Pc -+sy� is 7) -) Policy # or Self-ins. Lic. #: i-J G C re o .rd d ©/L 63 ° 2 Expiration Date: y/3A D Job Site Address 2 2 1 - - . 6 j 1 ---2 ' *. " " -67-- ( City /State /Zip: 0 r' 6 L � ' Attach a copy of the workers' compensation policy declaration page (showing the policy nu and expiration date). Failure to secure coverage • g as required under Section 25A of MGL c, 152 can lead to the imposition of criminal penalties of a fine up to $1 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. l'.e 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 pains and penalties of perjury that the information provided _above_is true.audcorrect ___ __ Signature: Date; Phone #: Official use wily t o not write iii this area, to be completed by city or town offciaL 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 r . Contact Person: Phone #: p SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : J co" /t' 11- '2- (N 2—( / " s (4„/ / License Number c� ✓�D ZI) c�` C /fi' 7 IL' / 7 f &'1 Address Expiration Date �L c 4 7 1 (3 2--(� / 9 e Signature Telephone ��L--. // 9: Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone _ 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 1f;] No ❑ 11:... Home OWner`E/emptio _The_current_exemption for "horneow_rters "mss 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 . ort ampton - r finance to ai'retrOza i_ - - . 6 . - s 'reneral1Laws- Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [:1 Addition ❑ /Replacement Window Alteration(s) ❑ Roofing n Or Doors IN Accessory Bldg. ❑ Demolition El Neiv"SiyiislIn Decks [[] Siding [El] Other [El Brief Description of Proposed G. c ( - e 7 - ( D C 13,3 /12- //2'121/1/4 —&? srri .t Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a ifr(VeVil'. hotise "arid or addition to existing housing, compete the following: 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 . 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, i, /l f Y / 7 7 > , as Owner of the subject property hereby authorize C'' // /-/ I C " "i -a 1.--oe L -/ to act on my behalf, in all matters relative to work authorized by this building permit application. -÷71Z---1,7-- /" Signature of Owner Date I ` r lfy,.l . f - T c t +- $/ G-, , 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. // 2 c .s SIG.( Print Name z. „J., Signature of Owner •ent i 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____. Frontage Setbacks Front Side Rear Building Height Bldg. Square Footage x i % -` Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces ' - - - - -- Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 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 Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW (3 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 0 IF YES, describe size, type and location: — — - TY. °kre tFe any proposed change or a Itions o ' signs in enaed'for the . property ? YES I NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb {clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Qepariment,pse only City of Northampton Status of Permi# Department g p C urb C Buildin utlDnveway Peimrf 212 Main Street SewerfS Availability Room 100 Wa {erlWeti A�labilrty ' w Northampton, MA 01060 TWO Sets of Structural' Plans ;'« phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans =, < _- 4tf'rer Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION A 1.1 Property Address: This section to be completed !WOO _7 G > 1 Map / s ' ' Unit F— L_l i2 L.--_-,s3 ( c D^-�1 /t- T Zone Overla P i �, U� / - /Cv A'1-- y Ehit St District / dB i efistrict O SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 5� 2.1 Owner of Record: Name (Print) 1 Current Mailing Address: yt er 74 �- - c , i- '-- 'r 71,-,--2,-.- � /"..----"' -''° Telephone Signature 2.2 Authorized Agent: i'Y'e T.-� L __) JC (1'J `. _ I Q•_: / :.--35/ --J s' co ,) ',.^. I v Cc' C..e41 e /c Name (Print) Current Mailing Address: i ft 9 "'7--- - - -'- 1 -- - -- Ce (-{(3 -- .)-- if 3 i T c Signature i) 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 2. Electrical (b) Estimated! Total Cost of Construction from (6) 3. Plumbing -- Building Permit Fee • 4. Mechanical (IVAC) -- 5. Fire Protection 3 + ( 4 + 5) 4 " G} 0 Check Number IR( ' � 6. Total .. _ � _._. __ . This Section ForOffiCla se O nly _- Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date I • BP- 2010 -0317 GIS #: COMMONWEALTH OF MASSACHUSETTS 11,6 - 2Mir 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 -0317 Project # JS- 2010 - 000421 Est. Cost: $4000.00 Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN ZIEMINSKI 017889 Lot Size(sq. ft.): 11761.20 Owner: MATHERS THOMAS M & KATHLEEN D Zoning: URB(100)/ Applicant: JOHN ZIEMINSKI AT: 77 LAKE ST Applicant Address: Phone: Insurance: 8 WOODRIDGE CIRC (413) 247 -9014 Workers Compensation HATFIELDMA01038 ISSUED ON:9/23/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS /DOORS POST THIS CARD SO IT IS VISIBLE FROM TILE 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 9/23/2009 0:00:01 $70.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo t 77 LAKE ST BP-2010-0317 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 236 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 -0317 Project # JS- 2010- 000421 Est. Cost: $4000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN ZIEMINSKI 017889 Lot Size(sq. ft): 11761.20 Owner: MATHERS THOMAS M & KATHLEEN D Zoning: URB(100)i Applicant: JOHN ZIEMINSKI AT: 77 LAKE ST Applicant Address: Phone: Insurance: 8 WOODRIDGE CIRC (413) 247 -9014 Workers Compensation HATFIELDMA01038 ISSUED ON :9/23/2009 0 :00 :00 TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOWS /DOORS 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: D)K moo ed `4, 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 ' aid: Amount: Building 9/23/2009 0 :00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo