17A-226 Stk:I` a sac- �VIIMIWII rvG 4l41i Vf AEI 18.3011411.-M4.30114.3 ` Department of Industrial Accidents
iv/ Office of Investigations
_; n= 600 Washington Street
• Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business / Organization /Individual): rc \(`k L ` * e C
Address: \ \O'1 ¶'C' O h �'� . � � k.t` 0 \ C3-
City/State/Zip: Na k_e \c;\. Phone #: V )3) 5 s 6 a
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part - time).* have hired the sub- contractors
2. ❑ I am a solepropnetor or partner-
listed on the attached on t 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs
insurance required.] t 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp. policy information.
1 am an employer that is providing workers' compensation insurance for my employees Belo* is the policy and job site
information.
Insurance Company Name: t E C VD i S CC) -
Policy # or Self -ins. Lic. Q._ saqc--,y( Expiration Date: r " 1 c
Job Site Address: ' 11 Y k \-- ckk e City/State/Zip: 0 Oct v e_ `P
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
fi neup_to .$1,500.00 and/orone - 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 certifi under the pains and penalties of perjury that the information provided above is true and correct
Signature: 6)0 Date: j _'lC�
Phone #: (1 v 0
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. Othcr
Contact Person: Phone #:
AFFADAVIT .
•
Home Improvement Contractor Law
Supplement to Permit Application - _
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only Name of City / Town
Permit No: 1 ce
Date:
Note: 142 A, requires than the " reconstruction, alteration, renovation, repair, modernization, conversion
improvement, removal, or demolition, or the construction of an addition to any pre - existing owner occupied
building containing at least one but not more than four dwelling unit(s), or to structures which are adjacent
to such residence or building" be done by registered contractors, with certain eons, along with other
requirements. ,
«1 ,
Type of Work iNct )la* IC\ Est Cost '� C �
Address of Work: \ b C' '
Owner's Name: _ ' k P 1 -X-\ c -e
Date of Permit / Application
I hereby certify that
Registration is not required for the following reason(s):
Work is excluded by law
. Job under S1000.00
Building not owner- occupied
Owner pulling own pernut
)( Other (Specify- ):` -
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEAL&IG WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME EMPROVEMEN WORK 1)0 NOT HAVE ACCESS
TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER
MGL C. - 142 A.
Signed under the penalites of perjury:
I hereby apply for a y ermit as the agent of the owners:
Date: U Contr 1 L stratior iSc33lc
OR
Not withstanding the above notice, I hereby apply- for a permit as the owner of the above property:
Date: Owner:
Property Address: 1 \ I \ 4 * --() -- - -
Contractor
Name: Th3\r\a lj . l ∎t ?
Address: X 1 V
f
City, State: 1-,10`10 �.
Phone: -1S.6. &-
Property Owner \(� p
Name: I'^� r C� kO\A, `L
Address: 4 �� , \ (\ L--Cl.
City, State:
1, Ad ' 14< attest and affirm that the building I intend
to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavit.
Contractor signature
Date
1
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) \e, "11b
i ce . ) \ \ aP C License Number Expiration Date
Name of CSL- Holder -
nnO List CSL Type (see ►)
) a
Address TYpe Description
U Unrestricted (up to 35,000 Cu. Ft.)
R Restricted ldt2 Family Dui elling
M Masonry Only
^ RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Instattation
D Residential Demolition
5.2 Registered Horneinwrovcontractor (HIC)
�r) .'kn 1 10 V 5 5 \°
IBC Comyany A ffiCR (b t�0 Y � e Nei, 3ry Nome
Address `.S J CS - -- Expiration
Signature Telephone
SECTION 6: 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 Issuanye Pthe building permit
Signed Affidavit Attached? Yes No ❑
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, J ` `t �'A�� 1(0� — , as Owner of the subject property hereby
authorize '' iC \ @ ( to act on my behalf, in all matters
relative to work authorized by this building permit application
qkr Air
Signatrue of G' Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
L ' � � � \ P , as Owner or Authorized Agent hereby declare -
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of pet%u y)
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will net have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.85, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. FL) (including garage, finished basement/attics, decks or porch)
Gross living area (Sq. FL) Habitable wont count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halflbaths
Type of heating system Number of decks/ porches
Type of cooling system Enclosed OPen
i
•
2 20�� e Commonwealth of Massachusetts
• w, AP� Bard of Building Regulations and Standards FOR
Mas use State Building Code, 780 CMR, 7 edition MUNICIPALITY
,- : LING INSPECTIONS USE
,;i,,_ LL _. • .. ation To Construct, Repair, Renovate Or Demolish a Revised January
One- or Two - Family Dwelling 1, 2008
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: i 1.2 Assessors Map & Parcel Numbers
11°x— < Ick 1.0,.. ,1
1.1a Is this an accepted street? yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' o Record:
S\--ec y mck\ 0 "f\ 'Q._ \ \ '''`1 - \ \ C‘ LANA.- ..")"' ( It).
cevkce
Name j • t) Address for Service: 1,�
* ✓ i/ .1. _ _/ 1 J / _ AP ' V13 l _ I
Signature c Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building, Owner -Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work SQ %C....L bX4 C 1 e (4 C.. >A \ is
T3^.C"1tt\\ 9" cr)) G /,. sip
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All F
Suppression) Total
o a Check No VV tr Amoun • Cash Amount:
6. Total Project Cost: $(.4 1 Syy3 ❑ Paid in Full ❑ Outstanding Balance Due:
Adoodav- door
File # BP- 2012 -0863
APPLICANT /CONTACT PERSON DONALD PELLETIER
ADDRESS /PHONE 1107 MAIN ST HOLYOKE (413) 538 -6002
PROPERTY LOCATION 117 LAKE ST
MAP 17A PARCEL 226 001 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 Lit,07 .. mob—'
Fee Paid
Typeof Construction: INSULATE WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 101876
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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
� l olition •
��
Signature of Buildi, _4f'icial 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.
117 LAKE ST BP- 2012 -0863
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 226 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 -0863
Project # JS- 2012 - 001517
Est. Cost: $4500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 20865.24 Owner: MALONE PATRICK M & SHERYL A
Zoning: URB(100)/ Applicant: DONALD PELLETIER
AT: 117 LAKE ST
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON:4/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSULATE WALLS
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 4/5/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner