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25C-093 The Commonwealth of Massachusetts Department of Industrial Accidents '= ti , e" Office of Investigations --, ... 600 Washington Street A Boston, M4 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organza( ion/thdivida C tom• Q "" Address: 3. 2, q we---((5 City /State /Zip: t1 YC CCU. (1,f�' Phone #: ( 1 �2-° — Are ou an employer? Check the appropriate box; Type of project (required): 1. MI am a employer with 1 a 4. 0 I am a general contractor and I employees (full and/or part- time).* have hired the sub- contractors 6. 0 New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub- contractors have 8. 0 Demolition working for me in any capacity. employees and have workers' 9. D Building addition [No workers' comp. insurance comp. insurance.T 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 av employees. [No workers' 13.1A 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. TContraetors 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: ( W fr' C i f /_ t? Cgs,' E - �--YrS (,ti'Y fwd c C Policy # or Self -ins. Lic. #: l Je" C. 1 G t(' Co Expiration Date: Pt - (- c 1 2 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 51,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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 cer ' under the ' . • nd p 0 ties of perjury that the information provided also e is true and correct. Signature: , , ' Date: Phone #: g ' Official use only. Do not write in this area, to be completed by city or town offaciat City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Wealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: CO-OP ji 1 L p POWER BUILDING COMMUNITY -OWNED SUSTAINABLE ENERGY Affidavit of Waste Disposal I, Paul Schmidt, Energy Efficiency Program Director of Co -op Power certify that Co- op Power will remove all waste from the job site located at: f Ot Owner Name Street Address Town /State/Zip Waste will be disposed of at our dumpster at our facility in Hatfield, MA. Our removal service is Waste Management. r Z Paul Schmidt Date Co-op Power, 324 Wells St., Greenfield, MA 01301 or Mailing Address: Box 688, Greenfield, MA 01302 ph: 413.772.8898 or 877.266.7543, fax: 413.517.0300, info @cooppower.coop, www.cooppower.coop - Licensed Construction Supervisor: Paul Schmidt SECTION 8 - CONSTRUCTION SERVICES 24 Chestnut St. 8.1 Licensed Construction Supervisor: Hatfield, MA 01038 Name of Licerise Hold r : CS # 103635 U -, Exp. 5/20/2013 .._ .. ,/ �,� � � - 413- 772 -8898 Addres- / . j ' ' � 2 �` Home Improvement Contractor: Signat e d . ,W Telephone o -op Power Inc. / Paul Schmidt 324 Wells St. Greenfield, MA 01301 9. Re. istered Home improvement Contractor: # 165217 ,-) Exp. 1/21/ )- ' Company Nande _.- :._.::_ 413- 772 -8898 i / -- paul @cooppower.coop Address, "- - `,,, Telephone .I 3 117- 7' 1 `6 - SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affid vit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the bui ing permit. Signed Affidavit Attached Yes No ❑ 11. - Home Owner Exemption 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 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 1 r --- I 1 Frontage 1 1 Setbacks Front ( 1 1 Side L:I R:I L:1 1 R:1 Rear ( 1 ' 1 Building Height f 1 1 i Bldg. Square Footage 1 I 1 % 1 1 1 Open Space Footage (Lot area minus bldg & paved 1 parking) # of Parking Spaces 1 1 Fill: (volume & 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 at the Re stry of Deeds? NO 0 DONT KNOW YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: / C. Do any signs exist on the property? YES O NO 0/ IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O 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 O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. •i • 1LU:!. 1. .. New House 0 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [M Siding [0) Other [IDly Brief Description of Proposed Work: 1 1J { jte �} (7•' 7` , I el it• 1f t 04 S " t�> � i'r 'r? iH en/Kt. Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing( housing, complete 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 . I. Septic Tank City Sewer Private well City water Supply SECTION Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1 Pe'2(L'f Get jC'_7i2 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this budding permit application. Slgn • Owner Date t r , as Owner /Authorized Agent he by dedare that the statements and Information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pain : • • - aides of perjury.. t/ „- Print = e / 3 (i7/11/ Signature of Owner/Agent Date RED • ty of Northampton Status of Permit: B ilding Department Curb CutlDdraway Permit , � a 2012. .12 Main Street Se r/Septisa + i i — 20 ic ` - ° Room 100 Water/Well Availability ort - mpton, MA 01060 Two Sets of Structural Plans � tNSPECnoIS g �' s;� : - 17-1240 Fax 413- 587 -1272 Plat/ 4e Plans " „ "" es Outer Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1 1.1 Prggertv Addross: This section to be completed by office 3c Ik/0,414 Map Lot Unit 14044 prn t y"r' 0 (0 ( p 0 Zone Overlay District am tB. District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT ea : g - 1 2 . - - / Core— - Zis Nib Stce. d NnitkaktApiThi, MA- Name ( ) u Q _t F aLQ�Q Telephone Signature ho Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building i,l O t o (a) Building Permit Fee 2. Electrical ( (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection ' 6 7 6. Total =(1 +2 +3 +4 +5) (0 . Q0 Check Number This Section For Official Use Only Building Permit Number I Isssusu ed: Signature: Building Commissioner/inspector of Buildings Date File # BP- 2012 -0781 APPLICANT /CONTACT PERSON PAUL SCHMIDT ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739 PROPERTY LOCATION 215 NORTH ST MAP 25C PARCEL 093 001 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 8 rZ Fee Paid /a Typeof Construction: ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 103635 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I■ F RMATION 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 :-1 .1'i eay / >Z— /)Z Signa re 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. 215 NORTH ST BP- 2012 -0781 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C - 093 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2012 -0781 Project # JS- 2012- 001367 Est. Cost: $4110.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PAUL SCHMIDT 103635 Lot Size(sq. ft.): 9844.56 Owner: CARTER PERRY B Zoning: URB(100)/ Applicant: PAUL SCHMIDT AT: 215 NORTH ST Applicant Address: Phone: Insurance: 24 CHESTNUT ST (413) 247 -5739 WC HATFIELDMA01038 ISSUED ON:3/13/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:ATTIC INSULATION 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 3/13/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner