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The Commonwealth of Massachusetts
Department of Industrial Accidents
=.— 'i Office of 1'nvesdgations
600 Washington Street
°f = Boston, MA 02111
WO www mass.govfdia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print ',eighty
Business/OrganizationName: ERN/9( 57 F ,9fer j! S t!1' i�C .
Address: y S /2t y 57
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City /State/Zip: /347zwnpb 5.7 fYt a/337 Phone #: 1/3 - 6 73 /
Are you an employer? Check the appropriate box: Business Type (required):
1. El I am a employer with • employees (full and/ 5. ❑ Retail
or part - time).* 6. ❑ Restaurant /Bar/Eating Establishment
2. ❑ I am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. [] Non- profit
3.0 We are a corporation and its officers have exercised 9. ❑ Entertainment
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their right of exemption per c. 152, § 1(4), and we have 10. ❑ Manufacturing
no employees. [No workers' comp. insurance required) **
11. El Health Care
4. ❑ We are a non - profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
"If tho corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an
organization should cheek box #l.
I am an employer that is providing workers' compensation insurance for my employees Below is the policy information.
Insurance Company Name: PEC/tLES3 /14 cliery'Ic1 � ,
Insurer's Address: `-i O - goX So 7 K —iJ 711 03 Y • 1` \
City/State/Zip: 4
Policy # or Self -ins. Lic. # wC 8/4 .C4 y Expiration Date: 1-1-1
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 lend to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investi l , tions of the DIA for insurance coverage verification.
I do hereby c 'fit, under the ' nd penalties ofperjury that the information provided above is true and correct
Signature: ,�%. I � Gt 44k_ Date: V^ G —1/
Phone #: tit 6 ti ( - ?3 /)
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. Licensing Board 5. Selectmen's Office
6, Other
Contact Person: Phone #: -
www.mass.gov /dia
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ( Not Applicable ❑
Name of License Holder : 00741.S � ifJ 4 � ce- q 0 /
License Number
q5 /7 tS J — 60e,r9 y/ dlo3 j /-6 &/L
Address Expiration Date
i3 - 9a /
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
6EP/4 ,J ,ZT 5 T NJ FAR rn F 3 ,5V L)I / 6 0 5 ea
Company Name Registration Number
17,8 ? lvciC 3i - ✓ Err 3Thr) tY ai3
V Z Address Expirati ate
Telephone q/3 - q 3
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 Bl No ❑
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
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Ti
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [D] Other (
Brief Description of Proposed
Work: / tf 5 7R L L- '7 L t-L E. r S i'V L
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 budding : 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
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, YI/L'"X1t tiel O to 0 271 , as Owner of the subject
property
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hereby authorize 6 L: ✓z N � 2 5'7-o 7 5'� N 6�i4 rrn r�ZS S L / }7 /
to act on my behalf, in all matters relative to work authorized by this building permit applic tion.
•/ •!
•
Date
, 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.
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
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 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW ® YES Q
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 ® NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® 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 ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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Department use only
' tyy of Northampton V Status of Permit:
B sing Department Curb Cut/Driveway Permit
• Main Street Sewer /Septic Availability
bom 100 Water/Well Availability
, s * ampton, MA 01060 Two Sets of Structural Plans
ne 413 587 - 1240 Fax 413 587 - 1272 Plot/Site Plans
•
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 to be completed by office
` 1 0 c 0 0 1 5 etc.. Map Lot Unit
Vlocst nc e , Y A, Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
(US/WU 6 ' . SA -40\m `Z.c.ciu )Or r u . VI r ote hl 14 0/6
Name (Print Current Mailing Address:._
� r2 G ! V, c> S
Tele phone
Signature
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 (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) % S 00 Check Number '30 �S
This Section For Official Use Only
Building ermit Number:
Date
g Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
202 BROOKSIDE CIR • BP- 2011 -0891
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 115 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2011 -0891
Project # JS- 2011- 001449
Est. Cost: $1800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BERNARDSTON FARMERS SUPPLY 99401
Lot Size(sq. ft.): 15376.68 Owner: ZADWORNY STEPHEN & WENDY
Zoning: URA(100) //WSP II Applicant: ZADWORNY STEPHEN & WENDY
AT: 202 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
202 BROOKSIDE CIRC (413) 522 -2125 () WC
FLORENCEMA01062 ISSUED ON:5/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL WOOD PELLET STOVE
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 5/2/2011 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner