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— 3 , The Commonwealtn of Massachusetts
=1 Department of Industrial Accidents
(xi -- I Office we
3= 600 Wash / ington sUgatinns Street
I 1 � ,;.' Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
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name:
location:
city phone #
0 I am a homeowner performing all work myself.
El I am a sole proprietor and have no one working in any capacity
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a I am an employer providing workers' compensation for my employees working on this job.
r
company name: Saloomey Construction, Inc
P.0 Box 1203
address:
Westfield, Ma 01086 :: P (413)``269 4360.'
City: Alea North America Insurance Co Wel04-9789
insurance co. policy #
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0 I am a sole proprietor, general contractor, or homeowner (circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city: phone #:
insurance co. olic #
P y
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company name:
address:
city: phone #:
insurance co. • policy
attach 9ddro0 ifirettil - • / ;A t '' , _ ,, _ — ✓ �; =? a , v g7 F ,, ;rr,.. "*rl µ -?, -, . ;ru .. » 1 0 tT
Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and /or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of $100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Siana re .' - -t -'''�°a: r 1 ter Date
Print name �� * v Phone # 413 ) 269 -4360
.d'
E`= official use only do not write in this area to be completed by city or town official
�:. city or town: permit/license # _ Building Department 0
DLicensing Board >wa
ii
p check if immediate response is required []Selectmen's Office
['Health Department
L , contact person: phone #; ❑Other
.
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' DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building 'c
,
Northampton, MA 01060 .
e
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction sups.:: ,-sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he /she resides or intends 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
home owner."
The building department for the City of Northampton wants any person(s) who seek to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed). insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made '
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
,
The Commonwealth of Massachusetts
io Department of Industrial Accidents
_- _ Office of Investigations
-7.1 =
_ II 600 Washing
f=
ton Street
' I -` Boston, MA 02111 tir
NO v ° ° � � www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): Sot\00 m cep/ Cc s\ (u(. k, 60 I kl ;
—
Address: P.0 �Cl.ic 1 '`L -
City /State /Zip: Q�} \ °c \
1, MG, °la 1, Phone #: t- 1\ - Lin -43 (c0
Are you an employer? Check the appropriate box: Type project (required):
1. f I am a employer with 4. 0 I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. New construction
2. Ell I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub contractors have 8. Ej Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers' comp. insurance comp. insurance.:
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 12.0 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.
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: A\ Cx� , ;,, - AML((c., 1 (1 <1 :Vii (\le_ C 0
Policy # or Self-ins. Lic. #: \'f L t C;a1i cn r'` Expiration Date: I U - 1 " (Y7
Job Site Address: Zc C+ ?G t cict A City /State /Zip: 1,1/41),-4,..0100:! 4C1. Ol1Q :c1
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 ertify �.., 1 Date: • ' T'
under hepains a , 1 e , alties of perjury that the information provided ' bove is true and correct.
Signa �' /` ,l/ '
_
Phone #: (ui3 ( .09 - 1-1, - t
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
8.1 Licensed Construction Supervisor: Not Applicable 0
C
Name of License Holder : � �'; C . ` ( ) L/ 10W', C.� �C
f Licens Number
Pt), plo IZa Got iV.e1( Act )«),h( 11 -c a
Address Expiration Date
Signature Telephone
9. Registered Horne irripi oveinent Contractor . , _ n , _ . _ 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 ❑ No ❑
11_ Honct6Dwiler-Exeitti3tioli
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
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition 71 Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [O] Other [O]
Brief Description of Pr posed
Work:06054(u r ' } 7 IH 1'Y1jse LXi ko.44 - cek.nAG - 1%0.1) n4.A 2nd Clo r a.-ht 3 5e'454r1 `e,!. t'■
Alteration of existing bedroom Yes A No Adding new bedroom Yes K No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll - Sheet
sa .if New ° I OUSe hdditio to. e*rstinci- h com
ouslnq, phete the-follow ng:
a. Use of building : One Family ^ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms 3
c. Is there a garage attached? Yf
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? 2_
f. Method of heating? flc\u f3gS ire laces r Woodstoves 3 Number of each I
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction 2.XL
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 % 'S001
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
2- IAt r Sci\v,o t, , LL` , as Owner of the subject
property J
hereby authorize 2. \e 7 St-A° C clrl t∎/ 04 SCA000^Nt' Cu =li4ftic \∎t n
to act on my behalf, in all matters relative to wc4 k authorized by this building p application.
OF. - C ?'
e 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 Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size _
Frontage
Setbacks Front
Side L w __ R: -W. L:_. R:_
Rear
Building Height
Bldg. Square Footage %
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill: — __w
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T 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 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: l'
C. Do any signs exist on the property? YES 0 NO j35
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb (cle ing, grading,excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
�,a Department us only
•
' _. .rr u' ,�. i r E 2''4'm �+ 2 t -:-rte x ii4iM t . r r
•
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City of Northampton tatustaf
- wilding Department Curb CutlDvewayPermtt
' ' ,! `2�2 Main Street Sewer /Septic A vailability ��
\i Room 100 VVateriWel
�, � No MA 01060 T wo Sets o f Stru ctural Plans
r L - ho X 413 -5 7 -1'2 Fax 413- 587 - 127 2 PlotlSite Plans
Other Spe
APPLttATIOp4
Td CO�4 UC T, _ AiLTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 INFORMATION _ _
1.1 Property Address: T his section to be completed by office
{ "i aisc �i'�lc� M ap f Lot �.. Unit
�% 11 1U". t'`''u b` ' ` Zone O v e rla y Q
. Elm St. Distr - CB Disfrict "
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
1_,L (( '' y� Address: , i I I, i{ Al /' C)1, r` J
Name (Print) J Current ailing dress: A Telephone
gnature
12.02 3
2.2 Authorized Agent:
Name (Print) Current Mailing A
.. •.nat e Telephone
SECTION 3 ESTIMATED CONST U C N;COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ' �- C (a) Building Permit Fee
2. Electrical .' -� (b) Estimated Total Cost of
�i t✓ (' tom' Construction from (6)
3. Plumbing Q • Building Permit Fee
i
4. Mechanical (HVAC)
5. Fire Protection (_$ 0 6. Total = (1 + 2 + 3 + 4 + 5) Z ?� Z \ ^1 Check mber , ��7
013 �f� of
L
This Section For'OfFicial Use Nu Only
Building Permit Number. Date
://L61A4') Issued:
Signature:
Building Commissioner /Inspector o Buildings Date
File # BP- 2008 -0146
APPLICANT /CONTACT PERSON SALOOMEY CONSTRUCTION
ADDRESS /PHONE P 0 BOX 1203 WESTFIELD (413) 269 -4360
PROPERTY LOCATION 8 MARK WARNER DR - 20 BRIDGE RD
MAP 16B PARCEL 001 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Fille ou
Fee Paid ,T) OlU✓
Typeof Construction: CONSTRUCT 2 STORY SFH W /ATT GARAGE FINISHED 2ND FLR & 3 SEASON
PORCH - STYLE D
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 018780 ��pQ� d�
3 sets of Plans / Plot Plan :�
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Commis •
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.
r 4 The Commonwealth of Massachusetts , t � •
City of Northampton
j
Tem I ora Certi icate o Occu • anc
In accordance with 780 CMR, Section 5120.3 (The Seventh Edition of the Massachusetts State Building Code, Single and Two Family Dwellings)
this Temporary Certificate of Occupancy is issued to the premise or structure or part thereof as herein identified.
Identify Name of Building of Space Within I Certificate No.
Issued to 20 Bridge Road, #8 Mark Warner Drive
BP- 2008 -0146
Identify property address including street number, name, city or town and county Certificate
Located at Expiration
20 Bridge Road, #8 Mark Warner Drive
Northampton, Hampshire, Massachusetts June 13, 2008
Use Group Residential Single Family
Classification(s)
This Temporary Certificate of Occupancy is hereby issued by the undersigned to certify that the premise, structure or portion thereof as herein specified has been
inspected for general fire and life safety features. This certificate shall allow for the temporary use as herein described and in conformance with any and all conditions
as identified below. It shall be posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate, failure to comply with
conditions or, tampering with the contents of the certificate is strictly prohibited.
Conditions of Temporary (90 Day) Certificate of Occupancy, pending final grade and final electrical inspection approval
Temporary Use
Name of Municipal Louis Hasbrouck Date of Map /Plot:
13n ild ink Ofl icial Inspection 03/14/08
Signature of Municipal Date of
✓ Issuance 03/14/08
Building Official t �;_ c , L .�.:�, � �j L,� -t,�,
N
* � , The Commonwealth of Massachusetts rg ,
iio
City of Northampton , 0.-.r-
4.,.:-.
Certificate of Occupancy
In accordance with 780 CMR, Section 5120.3 (The Seventh Edition of the Massachusetts State Building Code, Single and Two Family Dwellings)
this Certificate of Occupancy is issued to the premise or structure or part thereof as herein identified.
Identify Name of Building of Space Within I Certificate No.
Issued to 20 Bridge Road, #8 Mark Warner Drive BP 2008 - 0146
Identify property address including street number, name, city or town and county Certificate
Located at Expiration
20 Bridge Road, #8 Mark Warner Drive
Northampton, Hampshire, Massachusetts
Use Group Residential Single Family
Classification(s)
This Temporary Certificate of Occupancy is hereby issued by the undersigned to certify that the premise, structure or portion thereof as herein specified has been
inspected for general fire and life safety features. This certificate shall allow for the temporary use as herein described and in conformance with any and all conditions
as identified below. It shall be posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate, failure to comply with
conditions or, tampering with the contents of the certificate is strictly prohibited.
Conditions of Safety and Structural Systems must be maintained
Temporary Use
Name of Municipal Louis Hasbrouck Date of Map /Plot:
Building Official Inspection 06/17/08
Signature of Municipal Date
Building Official Issuance 06/17/08 16B -001
/17/08
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8 MARK. WARNER DR - 20 BRIDGE RD B P- 2008 -0146
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16B - 001 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- 2008 -0146
Project # JS- 2008 - 000226
Est. Cost: $223271.00
Fee: $1340.05 PERMISSION IS HEREBY GRANTED TO:
Const. Class: 5B Contractor: License:
Use Gro R4 SALOOMEY CONSTRUCTION 018780
^• ,,,,,.,. n, LI.C'
Zoning: URA Applicant: SALOOMEY CONSTRUCT!ON
AT: 8 MARK WARNER DR - 20 BRIDGE RD
Applicant Address: Phone: Insurance:
P 0 BOX 1203 (413) 269 -4360 Workers
Compensation
WESTFIELDMA01086 ISSUED ON:8/20/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 2 STORY SFH W /ATT GARAGE
FINISHED 2ND FLR & 3 SEASON PORCH - STYLE D
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: > � 1 Meter: O r f 3
Footings: Of `
8 ` Rough: F Hou se # F
Rough: ., 1 '0
� g �' -,�. -� �`r' - � 7 101167
Driveway Final: Q
Final: - 3 -43 Final: iep4 3 /13/0v
�'pi 6;1-44 Rough Framer
a - c-�
/b � 1 } ya d
b : "'�+ gy p.. ' _ .-� n
Rough• Oil: InsulatRon: �
dK l— f 7 -a?
Final: _13 ,..05Kk Smoke: Final: (Ni pep.) Z.(,ECrr tcr't 5(6.
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy 1 - ^ ( Signature:
FeeTvpe: ate Paid: Amount:
Building 8/20/2007 0:00:00 $1340.0517017
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo