31B-009 '` The Commonwealth of Massachusetts
Deparbnent of Industrial Accidents
Office of Investigations
i 47:4'1= I ! -' ; 600 Washington Street
,` Boston, MA 02111
`�' www mass gov /die
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/individual): /b eat._ rate-- I P•\�p OV QMLi.7
Address: P4-d, 601 k... 1 ( 2 ci .
C i t y / S t a t e / Z i p : C i I I 4 O 1 3 Phone #: 1 +3 - 8 G 3-- o � t a. S
Are y li an employer? Check the appropriate box: Type of project (required):
1. Y I am a employer with S' 4. 0 I am a general contractor and I
full and/or * have hired the sub - contractors 6. El New construction
employees ( part time).
2.0 I am a sole proprietor or partner- listed on the attached sheet ?- ❑ Remodeling
ship and have no employees These sub - contractors have 8. [] Demolition
working for me in i employees and have workers'
g any capacity. t 9. [] Building addition
[No workers' comp. insurance comp. �.
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 _❑ Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL
12.0y..00f repairs
insurance required.] t c. 152, §1(4), and we have no t _
employees. [No workers' 13. Other W heel Zai w
comp. insurance required_] (I rrSuA 't O.)
*Any applicant that checks box # I Waist also fill out the section below showing their workers' motion policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new aifidava indicating such.
kContractors 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 tun an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: The. 9 r i tc
Policy # or Self -ins. Lie. #: 966' Li Expiration Date: // // f /b ct
Job Site Address: ' ( l7 y 'fib : Cf `' \"' city/state/zip: iqU 0 .-ton f fen M '
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
foe 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.
I do h 1, • • . under the pains and penalties ofpe jury that Ike iufornwt ion provided above is true and correct.
signature: �'� Date: )(DID' j `)
Phone #.:4 1 3 _ g4.3 1 a
Official use on 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. i Not Applicable ❑
Name of License Holder : J � � S E I t i S f / ]
License Num
1 LN a, 601k V& . /0 / (v / l U
Ad I Expiration Date
. 2 4 i 3 3- aick2
si - Telephone
9. Restistered Home Improvement Contractorr, Not Applicable ❑
0. VVV2S F ►115 Pi-t,1-0
Company Name Regis 'on Number
e). Ga w i ► t\ M4 Aa a/d ��
Ad ss
� � Expi on Date
; � .�L _ Telephone � 3 e 2)° y 6
SECTION 10 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 issuance of the build/ permit.
Signed Affidavit Attached Yes No ❑
11. — Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner - occupied Dweilines 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 buildine 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, von way 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 ❑ Replacement Windows Alteration(s) Roofing Q
Or Doors 0
Accessory Bldg. 0 Demolition ❑ New Signs [0] Decks [Q Siding [a] Other [0]
Brief Description of Proposed /� , i--}l c L r s �' COI or) Work: lf^� v' t
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 .
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, " t n c r e €L - I-4 , as Owner of the subject
property
hereby authorize 1 ► -u HO -- i 1 1 (11 \re M.e. N T me S E (t t l
to act on y behalf, in all matters relative to work authorized by this building per ( JO. pplication.
X � v. In 11 >- id - 22 —0 0,
Signature of Owner Date
1 3Ci (fie. S El (LS as Owner /Authorized
Agent hereby dedare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed u der the pains and penalties of perjury.
Signed
m.e S PI it S .
P • Name
Si tun: of Owner /Agent Date /O/)
Section 4. ZONING Ail 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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding 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 Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW 1_ ^j YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO e
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
IF YES, describe size, type and Location:
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
T At
Department use only
.. City of Northampton
Status of Permit:
- Building Department curb cut/Driveway Permit
212 Main Street Sewer /Septic Availability
�� �� ��� Room 100
Fort pton, MA 01060
(; �, T Water/Weil Availability
h Two Sets of Structural Plans
on'�19 3- 581240 Fax 413 -587 -1272
Plot/Site Plans
..-, ph r nc:si i
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION I
1.1 Property Address: This section to be completed by office
i 0 ''P S ,Q.r ct Sr Map Lot Unit
0.e41Aa. m 0 - Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Signature & Telephone 4' 3 16, Goof s
2.2 Authorized Agent:
_ C rne S et 11S I `rte d/lC .- , g I ( tivg 4,
Nam T Current Mailing Address: )
Signs Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
. leted by permit applicant
1. Building it , "t G -1 (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) i 46 9 Check Number 9g/ /
#S5 *—
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings date
•
BP- 2010 -0458
GIs ; : COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0458
Project # JS- 2010 - 000631
Est. Cost: $1469.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq. ft.): 8973.36 Owner: FOX ANDREA B
Zoning: URC(100)/ Applicant: IDEAL HOME IMPROVEMENT INC
AT: 110 PROSPECT ST
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863 - 2128
GILLMA01354 ISSUED ON:10/27/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL ATTC 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:
FeeTvpe: Date Paid: Amount:
Building 10/27/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo