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31B-150
Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensatin for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political .subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requifenments of this chapter have been presented to the contracting- authority:" Applicants Please .Ell out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub- contractor(s) name(s), address(es) and phone number(s) along with their certificate(s)_of , prance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or T.T.P does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensationpolicy, please call the Department at the number listed below. Self - insured companies should enter their self- insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current __. policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations - -600 Washu►gton- Sfr-eet _ Boston, MA 02111 Tel. # 617- 727 -49Q0 ext 406 or 1- 877- MASSAFE Revised 4-24-47 Fax # 617- 727 -7749 www.mass.gov/dia The Commonwealth of Massachusetts ==...=.-_—_, Department of Industrial Accidents " ' r' Office of Investigations • r . .� 600 Washington Street f +r $ te r Boston, MA 02111 . °4_�_ 6 " www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers A Information Please Print Le_ibl Name (Business /Organization/Individual): ..." t l r �lryt S cS Address: ' 7, S 7 ✓?/Z &VI C'1 c() - 1 ;Q City /State /Zip: L4_ v- .v-t3 -1-17,4} 0 0 )0 Phone #: ' > 3 - 49 - ' 2 Are you an employer? Check the appropriate box: ' Type of project (required): 1. ❑ I am a employer with 4. 0 I am a general contractor and I 6 r_-, New construction employees (full and/or part- time). the sub - contractors b! p . p * - listed on the attached e 7• _[J Remodeling =�_� Iam -a- sole.. ro rietor --or -= partner- - - _... -_:.. - sheet. . hip and have no employees These sub - contractors have g• 0 Demolition workin for me in any capacity. employees and have workers' g Y _P t3'• —. -- 9. El Building addition [No workers'. comp insurance comp ms rance —_ 10. Electrical repairs or additions required:] 5. � We are a corporation and its reP 3- D 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' 13.121 Other t t ( Ye��i �' com. ur psurauce required-] 1 Any applicant that checks box #1 must also fill out the section below showing their workers cii mpensation 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 shed 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. 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 ce under the +airs and pena.lties ofperjury that the information provided above is true and correct Si • ature: / I - Date. _ Z `� 2 1 Phone #: 4 it -- Cl c ` 4 -- .... - 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: Nct Applrcable L Nae of license Holder LC. f� 1 ► m l ►` 5 L tVYI-5 0 h G J 54 Is' Z- _ r._xS N.,rrter 2- 5 '7 ,,/VAb ti ko- ,,v --e- RA , )-R k/ e,r eif' . /Jo\ . o 1 0_ - ` //./ ) Ati Err - atior C.... 9, Raaisteted Horns imortovernent CoMraeto( tot Applicable C' Company Name Rcg;stra: on Number Address Expirat;on Date Telep o "e SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G,L. c. 152, § 25C(6)) t V.`orxcrs Cart Irsuran e aff,da.,t rr'ust be conlple -,ed an^ submitted A to th s appt;caLon. Fa.Iuro to prcro th+s affdavt'h°.l1 resu'1 n the den al c` •'e ssuarce o` tee tu.ld ng pe-mit S y ^ne A°Fda. t Alta. "ed Yes _ \ No _ ` f 11. - Home Owner Exemption 1 he sir rii ten tics T. >; . i) •'r' + " .;n;r. "-is e\reuded t., ins ludc ONner- occutt+t'd I)MrliinEs of one t 11 or tv 21 tare lics a, ,..1 r .:1 , i,,, '1 hnit "en t. an lndo..dua; Tor htrc' \;n0 (j +�C) not p nc,rss a hccn,: , pro/sided that the (miler .act-s as super.iv r. CMR 784), Sixth Edition Section Ifni-3-5.1. t)rrnition of Hur►uoNntr Pcr Est',;1 :. .a,n .t park: of land ,Y,, % \It .h he t-hc rc.ldes or intends t.'res:dc, ,n sshi h there .,- t nren trd t.■ be. a „n� or r f.n.0 :'. ut.cliinc. atta.hed or drt3.hrd ,tru.turc, :::.':. Ory t.' use and or tarn, , rn , ,)lire , .l person ah►, constructs more than one home in a two -near period shall not he considered a homeowner Sush homcnc;ner'" •h.1:1 .■brtut to the Hu shing 011ii :,l. on a farm a :t.rist_.1 :c to the Bui?dln Orti:tul, that heishe shall he responsible for all such Mork performed under the huildin2 permit. As .:ctrl (*construction Supersisor s our presinee on the Job , .aC . 0.1111 - 1/40 requ;red Tr, 711 tins;' tip t :n :i. dunny and upon .0.i, :ctu.n of the ,;0- for ,thiih this pernr,t is )sale,: Auu be aisised that ith reference to Chapter 152 1W, er, ('err ?t' and Chapter 151 (1 0 it Emp :o?.er to hr .!,sees :or :r nuru nt.t )nulling to Death 0: the \IA.. -“.husetts General 1 al.;s Annotated. sou nun he liable for rerx•n :s) . tare to p r: rnt ‘;nrk !or s. +rr under this nelr'lir 1 lie w, :rcrsi_ned • hon:tt•urarr"' .:n fie, ..nd as r-s .n, :butte for cottlpi);;r .c ;;ith the State Building ( ('lt: 01 North..-rpton Ordinal,:e,. State .;nd L(' ": "a.I !_rtwn;; 1 .,.,. and State of Mac..:,chu+rtt. General Las Annotated fllomeoiner Signature _ 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) I I New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑ r-� Or Doors E Accessory Bldg ! Demolitio l I New Signs (D) Decks [CZ) Siding I Other Eire' De•criptcn of Proposed e i IN0•: re • ti ©-- - 1.N I car bc. W (/l, ocio t S ibv 5 Aiterabon of existing bedroom Yes ° I No i ddirg new aedtoom Yes _ - No Attached Narra'r.e Rerc•.atirg unf^ sred basement __- Yes n( Na Pans Attached Ro':I - Sheet I I $a. if New house and or addition to existing housing, complete the following I a Use of bu Id! One Farr: ly To yam #y Ot"e' i b Number of rooms In each family ur t Number of Ba:nraoms c Is there a garage attached? I I I d Proposed Square `oo!age of new ccnstruct;cn 0 r y e Nur ner of stones f f,!etr.od of heat ng' f=ireplaces o• WoUdsto :.es Number of each g Energy Conservation Comp' :ance. f•fasschecX Ere•gy Con a -ce form atta•: ted h Type of construction I i. Is construct on wrrth n 100 ft of wetlancs7 Yes No. Is construction w■th n 10Q yr. floodpta'.n Yes No i Ceptn of basement o' cellar foot Delon' fir: shed grade .,'; 1 bu d;rg co -form to the Bui >d.ng and Zor ^g rrgl > °at : ,ns' ) Yes _ No I Sept: Tani. C Sewer Pr.`ate r.eil C.ty.w.ater Supply r SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT € . 1 r7 i,. i) ; tt- (..•• j •• / -! J t:'- i . as ()Are. of the sub ec• property f'.areti aUe•"'r;'.ze to act on my behaP'. ,n ail matters re'atr.e to work au` ^orzed by t'' -s bu ld ng perm appI cat cn _ __— `:/ t ;fit i.sa i•/ `f 72 l [ s are :“.re of C -.firer I ,.e I. (f' 1 S (Vt bf/Vl-S ,5 . as Omer Authorqed Agent nereby declare tnat the statements and irfom -at on on the `orego ng app' ca'ion are true and accurate to the best of my knowledge and bel ef S gned under the pans an pe^alt,es of pet,ury .V.,r;5 ® S©f`L Pr `1 a ^" °7 . z 1 2 C <,ra ,..•e n f ( . -'.-r _ pre . Section 4. ZONING A':- , `;.i•r--at''3n M -. est Be C:rr_c:ec. Pe -r t Cs) Sc i. -niec: D. To inco -pctc c - 0•r^atrc Ext■ttn: l'rop, kequirc 1 hti Zoning r:-., 'd ,:,..'L.,,,,., ,. I rr^ ,rr i Lot Size F•r„n,.: C:: Sett Front S :,ie L R 1 R lte�r But :stn, He,,:ht B)di Squarc F , •t.i c 1 t /pc Sj'.i.i Footage j 7. of l':ai,,n� Spas i F:iL (., _ , J A. Has a Special Permit/Variance /Finding ever been issues for /on the site? NO Q DONT KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? ?O a DONT KNOW Q YES 0 IF YES: enter Book Page and /or Document x B. Does the site contain a brook, body of water or wetlands? NO €j DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained a , Date Issued: C. Do any signs exist on the property? YES 0 NO 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 O IF YES. descnbe size, type and location: E ,.‘; thie co strut . n acts! r: sturb iciearng grad ng e ahem or fang) over 1 acre cr is t pa/ of a corricn Gran that .rf1 C∎s urb c.er ' acre? YES 0 NO tk IF YES then a Rte -..naTp:cn S:orm':i'ater ?. a' agernen1 Perm" from the DPW is requ+red • -- Depattnent use only RECEIVFO . City of Northampton Staass of Petrnit: 1 ■ 2 1? [----- : ; Building Department 212 Main Street Sewer/Septic Avaability Room 100 Watot/Well Availabty Northampton, MA 01060 Curb Cutgkiveway Pernik 3 2 Q il t IAR Two Sets ot Structural Mans Ek bne 413-587-1240 Fax 413-587-1272 PloUSile Plana Other Specify APPLICATION TO CONSTRUCT. ALTER, REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property This section to be completed by office Address Map Lot Unit I q -- "A- L.) P-, (A Zone Overlay District ,K) (5 t../tAA.C. 6)— i AA P • SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT Eirri St. District CB District 2.1 Owner of Record: Peter \‘ ard & Marlette SicititYn2 7tif t I- a* A. (nth:: South 44 2w. Naptc N . FL ..1 .; 1 ( 12 Nar-e ;Prr7. C .." 0 Va r Ai € S ' . 3 , _f 4. ' .1 : - i 7 l __—- ______-- /7 /-- ,- ,- --i• , , % ,._, , u, le ep . ‘ 77. - , 4 "1 / ... .,-) ,-- 2.2 Authorized Aoent: 1 ;$ 11"1. (304 S o tr. 2-5 7 ...4A6-1-2. A-0, Pr r".1 c . j va , rg ''■■ 0 ) 05 4 S3gra Tc.i.:;.*:re _ SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Es! matec Cost 'Dollars; to be Official Use Only completed by perm : applibart 1 Eithfci ig i I 00 0 (a) Building Perim! Fee 2 Electncal --- tb) Estimafed Total Cost of Cor strucben from t 3 Plumb:rg ..--- Building Permit Fee I 4 Mechamba( 4 riVAC) /113 ,s1c- 5 F re Ffrotect oi 6 Toal = (1 + 2 4 ' 3 + 4 + 51 2- / 000 Check Number This Section For Official Use Only Date Bu ld ng Permit Number: 7---Issued Si)nature . :7).,iring Comm ss .rspEctcr 0 B/'5 Date - — 19 TRUMBULL RD BP- 2012 -0827 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B - 150 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -0827 Project # JS- 2012- 001465 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KRIS THOMSON 084152 Lot Size(sq. ft.): 4922.28 Owner: STEINBERG MARLENE Zoning: URC(100)/ Applicant: KRIS THOMSON AT: 19 TRUMBULL RD Applicant Address: Phone: Insurance: 257 MONTAGUE RD (413) 549 -1027 0 LEVERETTMA01054 ISSUED ON:3/27/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAI R ROTTEN SILL 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 3/27/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner