25C-228 The Commonwealth of Massachusetts
Department of Industrial Accidents
1 =._rM� Office of Investigations •
w. - 1�'"
600 Washington Street
-1 / Boston, M4 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information ease Print Legibly
G ' 1( •
Name ( Business /Organization/Individte: � l _,0 \ _ . / _
Address:
$�
City /State /Zip: )\ Q. - n � r Phone. I V D 5 (. ?� ` J
Are you an employer? Check the app opriate box: Type of project (required): !
1. ❑ I am a employer with 4._ 0 I am a general contractor and I 6. 0 New construction
employees (full and/or part-time).* have hired the sub- contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet. 7. ❑ Remodeling
ship and have. no P loyees These sub - contractors have. 8. ❑ Demo',on
working for me in an capacity. employees and have workers
Y • - 9. Q Budding addition
[No workers' comp: insurance comp. insurance..
required ] 5. 0 We are a corporation and its 10.❑ Electrical repairs or additions
ce s ve exezci their
I am- a-hameo-wner- tiaiag- all -work —
right of exemption per MGL . 152, § 1(4), and we have no
1� I'I g ;cp s or additions m if [No workers' comp. 12.0 Roof repairs
insurance required) t c
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.
: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 /Stafe/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 L li the violator. lle advised that a copy of this statement may be forwarded to the Office of
Investisrations of the ID • for . urancl coverage verification
I do her mir pabis , ; penalties of perjury that the information provided above, i_true- orre
. Sias , ture ► �1� � r�� ,. Date:. / r�
t) 0
-
Phone # II � _ _ .___
Official use only. Do not write in this arrea, to_be complat d by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I: Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical_ Inspector 5. Plumbing Inspector - _
6. Other r .
Contact Person: Phone #:
i • • w
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations The inspection process req_u_z_res that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour). a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
-- ---pen its- in_conjunctio to the_building.permit_issued,. and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
ma • e
I, \. i AA , ,6 ! % understand the above.
: I me ow �� /resident's si:n�re requesting exemption)
I ••11 «.11 to schedule all require, ilding inspections necessary for the building permit
is.ued o me. vv
Address of work
location
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
Registered Home improvement Contractor: .Va„ � f 3 Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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 building permit.
Signed Affidavit Attached Yes ❑ No ❑
ll .. s °Home
OwneittExemption ,
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 Zo ' g 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) n Roofing 7
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding [❑] Other [❑]
Brief Description of Proposed n
Work: ( n O / � (( c- a S
�`C 4 �l � rap / _ re/
Alteration of existing bedroom Yes N7 No Adding new bedroom Yes 1,,7 No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll - Sheet
6a If:New 1louse and or `addition to existlnq housings complete;the following':
a. Use of building : One Family OK 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
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, /it. // J OLf, C- , as Owner of the subject
property j
hereby authorize e +-'v i 1 f Y1 / �
r
to act on my behalf, in I matter relative to work au by this building permit application.
() A i-/40
Signature of Owner Date
�G't. , 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.
0.
Print Name
Signature of Owner /Agent _. Date
Section 4. ZONING All 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 __( 1 _J
Setbacks Front
Side LL—, , . ° R: i _._ _.J L: f.... - R: __.._..
Rear
....
Building Height ( f
Bldg. Square Footage `.__. ,..W.. 1 %
Open Space Footage %
(Lot area minus bldg & paved J 1
parking)
# of Parking Spaces
Fill: i
(volume & Location) ____.._.,_.__,_,_ .._ .�_ _.a . _,..._.. . __.._.._..__. __.._ a
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 411 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW #O YES
IF YES: enter Book I Page i and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q ,Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended for the property ? YES IQ 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 Q NO GO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
`",� I�epa a o 1
c s r 'r gS� sY f f
City of Northampton Status of Permit
ASV Building Department urbutllri
Yewa P,r`m �
L S 3 N.,:°1'' Y i ffI ssx , as
\ ,:. 3 212 Street , wtS }}'' A1rai7aillty
C;,
Rom 100 1 a }ernNell� vt9,btltty
Northampton, MA 01060 Tw i`S o t Plans ,- • ;
phone 413- 587 -1240 Fax 413 - 587 -1272 pot/ 1 k' r
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section be completed by office
-/s �,.� jn�1� •- q , Map L ot to Unit
' / r 4.[ / ,, Zone
� OverlayDistrict
" 7 /► 7� Elm St. ,,, triet CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
r�? ✓�e�z i , I I ccc ►� h am,' ' r.� /n s�� r_ 1- ,;
Current Mailing Address
Name (Print) � � I : v�0
/, /,{� _ _ / • " Telephone
Signature d - V - /3'/ S
Jl/
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building / C --) C) (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) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued`
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0409
APPLICANT /CONTACT PERSON SUBOCZ MATTHEW K & JILL L PLOGGER - SUBOCZ
ADDRESS/PHONE 45 WALNUT ST NORTHAMPTON (413) 584 -1349 0
PROPERTY LOCATION 45 WALNUT ST
MAP 25C PARCEL 228 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out / Q p�
Fee Paid 3 b0 `C
Typeof Construction: REPAIR FRONT PORCH & REAR STEPS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE F LO WING ACTION H AS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
Demolition Dea
J ry 2 / 261)7
Signature of Building Official '' 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.
5 WALNUT ST BP -2010 -0409
#: COMMONWEALTH OF MASSACHUSETTS
i✓Iap:Block. 25C - 228 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 -0409
Proiect # JS- 2010 - 000556
Est. Cost: $6400.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const _Class_ Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 4399.56 Owner: SUBOCZ MATTHEW K & JILL L PLOGGER - SUBOCZ
7 0pincy• Two onl/ 4nnlicflnt: SUBOCZ MATTHEW K & JILL L PLOGGER-SUBOCZ
.4T: 45 WALNUT S T
Applicant Address: Phone: Insurance:
45 WALNUT ST (413) 584 -1349 ()
NORTHAMPTONMA01060 ISSUED ON :10/19/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR FRONT PORCH & REAR STEPS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: d / 1
Footings: - 09 v
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame: �):
I p
Gas: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 8 K ( ol = g`o?
THIS PERMIT MAY BE REVOKED BY THE CITY , ' NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATI • ■ S.
Certificate of Occupancy ignature:
FeeType: Date Paid: Amount
Building 10/19/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo