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24D-286 w ° The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street 4, Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): fit) 6 ( z . E L - - + G . r6.. ( - 1 1 2 - 4 - . ) Address: '?. 1 City /State /Zip: F-P-s })- ' 1t lr6N. r visa c iot1 Phone #: 4, } 152c1 �5 � Are you an employer? Cheek the appropriate box: Z 4. of project (required): 1. � I am a employer with ❑ 1 am a g eneral contractor and I employees (full and/or part- time).* have hived the sib- contractors 6 El N construction 2. Q I am a sole proprietor or partner- listed on the attached sheet. 7. 1E1 Remodeling ship and have no employees These sub - contractors have 8. Q Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp_ insurance_ $ 9. [] Building addition required.] 5. Q 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. o workers' comp. right of exemption per MGL insurance requited.] t c. 152, § 1(4), and we have no 12.0 Roof repairs employees. [No workers' 13.0 Other comp. insurance required.] * Any applicant that checks box #I 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. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: V1 NC I< PEi(<s(2- A-S hlS■) 12 -Ar•kt A at-t-L c--4 — L I f ( 1 S Policy # or Self-ins. Lic. #: t 0 Z (v 5 Expiration Date: 4 1 2 t 1 . l Job Site Address: t \0+t.— *a(Npreil City/State/Zip: 14) P�i / L i d 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. 1 do hereby certify unde e .r,;' and penalties of perjury that the information provided above is true and correct Signature: Date: 3- ' t 1 Phone #: t S 5'lei - 09-1-9 Official use only. Do not write in this area, to be completed by city or tow 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 #: , 4 • co ...,...,....„ to:7 624n/i` weitzza e.. "& f✓iar 2s'.€oP..11 . t.-. ' ' Off ice of Consumer Affairs and business Regulation �, 1 0 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Horne Improvement Contractor Registration Rerlistration: 131279 Type: Individual Expiration: 6/29/2012 Tr# 297765 SEAN JEFFORDS SEAN JEFFORDS _ __ .. __ 13 TERRACE VIEW ___... _ ____ __- EASTHAMPTON, MA 01027 -- _ ___ update Address and return curd. Mnrk reason for ch ange, Address Renewal Employment Lost Curd 1PS.CA1 Ci 50trt.0.44•C1101216 Ufticec "'rtaaiiifjct `k if4fif�i `it"sint license or registration valid for indiridul use only HOME IMPROVEMENT CONTRACTOR before the ex piration date. If found return to: �� c Registration: 131279 Type; Office o € Consumer Affairs and Business Regulation it it . ' , .+ Expiration: 8/29/2012 Individual 10 Park Plaza - Suite 5170 r ' ; Boston, NIA 02116 • SEAN JEFFORDS SEAN JEFFORDS 11 TERRACE VIEW : ;,.�r -. r;7s li '''MPTON, MA 01027 lVndersecretnry Not valid without signat _ . - 74539 SEAN R JEFFORDS ; � 13 TERRACE VIEW EASTHAMPTON, MA 01027 _ 11/28/2012 5544 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder : ' i= tk n.t — 145 c 7 License Number - tYL a nL i= : \t a� nl (V! t' 7c'tn t'� gE- O t GI., t I ' " , Address Expiration Date 4 t 2 > 52'1 c) Signature Telephone 9, Reoistered:Home itnprovemect Contractor: Not Applicable 0 ( 2_ -- / v 9 ec ,, NS; t f �v+ :f� c; / /r9 -7 C J Company Name Registration Number \1 t Oiki v k � ,.; ( L G t c, Z 7 W/2 J 2-c> / d- Address Expiration Date Ski V Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (411.G.L c. 152, § 25C(6)) 1 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 buil ding permit. Signed Affidavit Attached Yes EY No 0 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 5- DESCRIPTION OF PROPOSED WORK (check all am licable) New House Q Addition Replacement j (indoors Alteration(s) EJ Roofing Q Or Doors °� Accessory Bldg. 0 9omolition 0 New Signs [CO Decks [D Siding [D] Other [MI Brief Description of Proposed Work: 4-e.X tk.. 5 v Alteration of existing bedroom Yes no No Adding new bedroom Yes no No Attached Narrative Renovating unfinished basement Yes no No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, compete 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 Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. tloodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No 1. 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 1 , 1?c ( Elk I 1 , as Owner of the subject property hereby authorize V� C f LL-� ( .E N S T 62 t�C . t 5 t. to act on my behalf, in all matters relative to work authorized by this building permit application_ / .w.�'4 // / /g /// Signature of Owner Date —� 3 1, S`E r•-1 cl= ForL >S (�r�� s``� -tit. CD Slit() L rt , 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. SE 1 c> (L IDS Print Name Signature of Owner /A ent Date Section 4. ZONING Att Information Must Be Completed. Permit Can Be Denied Due To I omptetnft , { r, Existing Proposed Requi d by Zoning This CO mn to AO in b Buildi Depart Lot Size 10' a. Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage °c Open Space Footage i ii (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) __ t A. Has a Special Permit /Variance /Finding ever been issued for /ort the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 tF YES: enter Book Page andfor Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES 0 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 0 NO 0 IF YES. describe size, type and location: E. tail the construction activity disturb (clearing, grading, excavation, or Ming) over 1 acre or is it part of a common Oar: that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required _ __Department use enty- 1 , of Northampton Status of Permit: 13 ping Department Curb Gut/Drivemay Perl^:tit 12 Main Street Sewer#Septic AvailabiritY t Room 100 WatssiWeA ilability i '' • : mpton, MA 01060 Tyro Sets of Structural Plan s ' '` - .-7i, - .7*:::;' -- -5 ' -1240 Fax 413- 587 -1272 . Pu J to Plans — aver APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEILMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE 1NFORMATION 1 Zone Overlay District 1.1 Property Address: Thies in to comp try office { Iv UR CSC F c�1`r S�t map Lc Unit 0 o � -r1,11 � / - P -- o t Zone St District C8 District leaed SECTION 2.. PROPERTY OWNERSNrP /AUTHORSZED AGENT 2.1 Owner of Record: C0-0 ',..)1..-i-- iris Moi. -LY M i 46 Cat -e s - e:a -- . Ao,n..r'ik "-Ptoti n,4 Name print) Current Mailing Address: s / q • 1-21- • p" ti L ..� Telephone Signature 2,2 Authorized Agent: 13e Y1 e - - -1 C 7.0..,_7 c ► e 13 TE ., � vj, ,./ i EA Ti > non 1 ( A bto 21 Name ('ri �/ C urrent Mailing Address: Lt 3 5 - -054y Signature t Telephone SECTION S ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use OnIy completed by permit applicant 1 Building A 1 S e J 2 (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. Total = (1 + 2 + 3 + 4 + 5) 3 S S 2 Check Number This Section For Official Use Only__ Building Perm Number it Numbe Date 3 z,77,..._././ iioor' / Si 0 I Building Commissioner/Inspector of Buildings Date hi K� // /11 e' A'7 _ 6Yc cj(- / ie - l/ee z ` . ES- 176 CRESCENT ST BP-2011-0755 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 286 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit# BP- 2011 -0755 Project # JS- 2011- 001248 Est. Cost: $3552.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEAN JEFFORDS 074539 Lot Size(sq. ft.): 6316.20 Owner: BULL CAROLE & MARGARET MEAD Zoning: URB(100)/ Applicant: SEAN JEFFORDS AT: 176 CRESCENT ST Applicant Address: Phone: Insurance: 13 TERRACE VIEW (416) 529 -0544 WC EAST HAM PTO NMA01027 ISSUED ON:3/24/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL 8 REPLACEMENT WINDOWS - U VALUE MUST MEET STRETCH CODE REQUIREMENTS 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 3/24/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner