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The Commonwealth of Massachusetts
f Department of Industrial Accidents
Office of Investigations
f .:." . }
0 600 Washington Street ti
Boston, MA 02111
r
i www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): ...._( b L2ti S 0"),
Address: 2- - 7 .___, "( Gz.i_ 4'c .--1/4_). t 1
City /State /Zip: �- (ice ✓-e t 61/4_ 0 OS' Phone #: bQ 5 6 f' 7
Are you an employer? Check the appropriate box: Type of project (required):
I. El I am a employer with 4. n I am a general contractor and I
employees (full and/or part - time).* have hired the sub- contractors 6. ❑New construction
I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
These sub - contractors have
sh and have no employees 8. ❑ Demolition
working for me in any employees and have workers'
o Y capacity. 9. ❑ Building addition
"[No workers' comp. insurance comp. insurance.
required.] 5. El We are a corporation and its lo.❑ Electrical repairs or additions
3. El I am a homeowner doing all work officers have exercised their 11.E1 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. Li 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:
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 $1,500.00 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.
Ido hereby ce fy under th , , , ins 1 and penalties of perjury that the information provided above is true and correct.
Signature: - " 3 q/ ---- Date:
�J- (25-- rr 7
Phone #: `�" � 3 � `l0 •
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 nuil/ling Department I, City/Town Clerk d_ Electrical Inspector 5, Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : (�—(' l S G S ' 34. I S Z
A (� j� n x License Number
'2-S - 2 / �-' l 0 V 5,, Q._ ✓2J ` . h,e vuQ. i ce' l 1 ✓L' l C,.. 0 o S-± 4/9/ / S
Addr- s Expiratio Date
X 13 T L B'
Signatu !='''. Telephone
"Y"a :.^�'!. MfS'�° -�„s.�.s.... , axP- ..^vt -a YR'r .°"4 °-'rcn� ' �"�"'°,., rA ' %sw '. wfta r.,..
9:: yReg�stered, Jiome`"f'm � �,����= r .e _.. �:� � �� y Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L c 152, § 25C(6)) v !, .
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 ❑
1 z-,,rz ®,wn jxe
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 0 Replacement Windows Alteration(s) Eq Roofing n
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding [D] Other [D]
Work: k: Description of Pro osed n r-e OVO L� Z��
Wor A c�� 7 r✓ Cf� -'fi5 CV �-£�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ° No
Plans Attached Roll - Sheet \
��� '°"-:«'��` °- ��',u,;^�"�`� -^.��. e� ;`. �? .''�: ,;;a �.-�x- ,�,r,��.�
6a lf. New, house.' and =orladdition to ::ezistinq hausingq :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 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
=OWNE AGENT OR. CONTRACTOR APPLI F OR,BUILDING PER
I, -it Q L.p.0 -1.3 6 -- Lo r e A Z.._ , as Owner of the subject
property I / /
hereby authorize K_ r %5 �V_ a fig 561, C6( v° 4? �(
to on m e alf, in II a sr ative to work authorized by this building per application.
Sign re of Owner Date
1, f t 5 (Att, tnvt C5 , 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.
- I S ' pvirLS6z_-
Print Name
T ;u\ _
3 , /2
Signature of Owner /Age f Date
a . 4
4
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ^•"""'"""
s •
Existing Proposed Required by 'Zoning i {
This column to be filled in by i
Building Department
Lot Size i H I
Frontage ,
Setbacks Front 1 !
Side L: R:. L ? . i R: . i 1
Rear I I
Building Height I
Bldg. Square Footage % i i r ---
Open Space Footage
(Lot area minus bldg & paved I t t 3
parking)
i I i i
# of Parking Spaces '
Fill: i
(volume & Location) € ` i I
A. Has a Special Permit /Variance /Findin• ever been issued for /on the site?
NO 0 DONT KNOW 14 YES 0
IF YES, date issued:;"
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book e' Pa I
Page; I and /or Document #i
i
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Consery Lion Commission?
Needs to be obtained Q Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 NO '
IF YES, describe size, type and location:
s
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: I !
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 'C4
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
De artmewt use:only. � r - ,1
City of Northampton Statu o, P erml �� ri
4' REr`dj \/� uilding Department #,,.., ur��� ewaeritt« s k
_ -= , - ' a.. .- ,� as
212 Main Street Sewe Sept yailabilit �;
�; / I i Room 100 �v a�p l A F uty ���� �
��� MA 01060 Two e s uct . l P a -
N rthampton, � -
oe.c ",, :
eR. ,;; ; 1 A O 1 0 6 n 1 - 587 -1240 Fax 413- 587 -1272 P � I e s � k � �
k c
Other Speci °, t r r' t,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S ECTION 1
'= SITE'iNFORMATION .
This section to be completed by office
1.1 Property Address: q � - +
<-'7---. L v l 'd I 4 Map ;� Lo& t > - m Unit" 21/t 0
t > �
,,.-Firs St .Distri :. CB D is tract r .
SECTION 2- PRO OWNERSHIP /AUTHORIZED AG
AL, • A.•' ofR •
� �'/ f 3.2 3 1 - 7 . —
Sr I(V\toy,.aZu O �� or z T µ �MdT3n )
N.Fre (Print
1 Current Mailing Address:
1 K13. 10 °I73 ' 6o�1
0 t... a• t7.r1 L-+ ° ' L Or P,. 4 `Z-, Telephone
Signature
2.2 Authorized Agent:
kr( sic)t' 5 a - 1 . 2S2i't -rte >� 12?-V4-12 'r <,� 1`�t,
Name (Print C urrent Mailin Addre C I C �.=/--,
Signature Telephone
' SECTION 3 - ESTIMATED CONSTRUCTION COSTS' -
Item Estimated Cost (Dollars) to be . Official Use Only : ,
completed by permit applicant
r (a) Building Ke rm i t Fee
1. Building f ci
2. Electrical �O O (b) E stimated Total Cost of.
_.. Construction from (6)
3. Plumbing ' dG (3C) B uildPer
i n g Permit Fee
4. Mechanical (HVAC) ! ; 1
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) -/, I Duo
� Check'Number
This Section For Official Use Only
Building Permit Numb = Date
Signature .'
Building Commis /Inspector of Buildings Date
55 MAYNARD RD BP- 2012 -0828
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 155 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 -0828
Project # JS-2012-001466
Est. Cost: $21000.00
Fee: $126.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KRIS THOMSON 084152
Lot Size(sq. ft.): 7492.32 Owner: DILORENZO JOANN GLADING & LISE GLADING DILORENZO
Zoning: URB(100)/ Applicant: KRIS THOMSON
AT: 55 MAYNARD RD
Applicant Address: Phone: Insurance:
257 MONTAGUE RD (413) 549 -1027 ()
LEVERETTMA01054 ISSUED ON:3/27/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: RENO BATH & ADD 2 CLOSETS
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 $126.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner