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36-191 • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations `; 600 Washington Street Boston, MA 02111 www.ntass.gov /dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Annlicant Information Please Print Legibly Name (Business/Organization/Individual): /1) eat_ HO M - I PR.DV Address: 1 `'M & 1k. lq t City /State /Zip: C 1 I I 4 a i '� ' r Phone #: 3- 8 G 3-- cQ t ) Are y,ui an employer? Check the appropriate box: Type of project (required): 1. 1 am a employer with $ 4. ❑ I am a general con rector and I 6. ❑ New construction employees (full and/or part time).# have hired the 2.0 I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sum have 8. 0 Demolition workin for me in employees and have workers' g any capacity- 4. ❑ Building addition [No workers' comp. insuranceP- insurance•i required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing ail work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 oof repairs insurance s ] t c. 152, §1(4), and we have no employees. [No workers' 13. Other w r i comp. insurance required-] _ ( t r u,l& INN *Any applicant that checks box # 1 must also fill out the section below showing their workers' coition policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contsu tors must submit a new at vit indicating such. [ Contractors that check this box attached en additional sheet showing the name of the su - 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' co cation insurance for my employees. Below is the policy and jobsite information. Insurance Company Name: 9Utir'fcL Policy # or Self - ins. Lic. #: q6[io' L /'70 Expiration Date: / /Ai 169 Job Site Address: t o (.L r t -4 vac p ., City/State/zip: (7 n t e. M A- 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 impnsonme t, 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. 13e 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 certify under the pains quid penalties of perjury that Ike information provided above is true and correct Signature: Date: Phone #: 4A 3 B 6 3- a i a T Official use onl}c Do not write in this arm to be completed by city or town ofciial City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3 Cityffown Clerk 4. Electrical Inspector 5. Phumbing Inspector 6.Other Contact Person: Phone #: a SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : J a (r S F l i t s q (t)_0(1 ' �2 ` License Number i V.. v 04 V n t /i 1\ I''\/ © 15 1 i 0 11L I?OI Address ) Expiration Date Signature Telephone 9. Regis red Home Improvement Contractor; Not Applicable ❑ Regis S € I L L S 1 - L 4.DC Company Name Registration Number 1 \ —(_ _ 646*At --- M P y2 o v-e l -t,e rv`r 4( .. ) ) l Address �Q /� Expiration Date (y '��11J�. Q I YT Telepho �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 I3 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 heishe 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. Ryerson 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 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 m 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 O 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 Q DONT KNOW 0 YES Q 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 NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all agplicable) 2t-' $ New House ❑ Addition El Replacement Windows Atteration(s) Roofing ❑ Or Doors 0 Accessory Bldg. El Demolition El New Signs [0] Decks [p Siding [D] Other [D] Brief Description of Proposed Work: ��l n (� ( ■ S u ' C Alteration of existing bedroom Yes --- 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 . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, ,� 1 e ? H t CA l.. L- A l- c) , as Owner of the subject prope he z..yauth•rize to a• , o , •ehalf, in it ela ve to work authorized by this building permit licatio 0f /.... \— �e I s f . ® 61 igna • re of • , Date 1, iCL?S e (1 t % 1 ( AL_ _ J Ni 'Pie_ 0Y-e me 4 - 1 - , as Owner/Authorized Agent hereby declare that the statlements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Sign d under the pains and penalties of perjury. _� rues el\LS Print Name Signature of Owner/ #) Date Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability ' Northampton, MA 01060 Two Sets of Structural Plans phone 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 f 1.1 Property Address: - This section to be completed by office to • YJ ike + P. A- t Map Lot Unit - 14 0 YC r1 e e) n o i 0 (0), Zone Overlay District J Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Ownier of Record: S - t ' ►' ea_, I, I - Name (Print Current Mailing Address: 1 `� — 1 , �, �. Telephone J `1 Signature 2.2 Authorized Agent: iurn.es E 'tlIS t ) .i1e_ I 11 o f 35� Name (Print) Current Mailing Address: t 8CO3 - - te 1 . 1 2 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 t ( a- (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) t t ). . `F'' * Check Number 9 This Section For Official Use Only Building Permit Number: IIsssuued: Signature: Building Commissioner/Inspector of Buildings Date File # BP- 2010 -0432 APPLICANT'CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS /PHONE 142 BOYLE RD GILL (413) 863 -2128 PROPERTY LOCATION 824 BURTS PIT RD MAP 36 PARCEL 191 001 ZONE SR(100) / /WP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 9 40" Fee Paid Typeof Construction: ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 091207 3 sets of Plans / Plot Plan THE F O WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 Delay . -,--,•.. - 5 _ e ..,,,, 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. 4 '.. I BP- 2010 -0432 GIS #: COMMONWEALTH OF MASSACHUSETTS 36 - 191 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 -0432 Proiect # JS- 2010 - 000587 Est. Cost: $1112.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Sire(sq. ft.): 118483.20 Owner: CALLAHAN STEPHEN A & DIANA F Zoning: SR(100) / /WP Applicant: IDEAL HOME IMPROVEMENT INC AT: 824 BURTS PIT RD Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 GILLMA01354 ISSUED ON:10/23/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:ATTIC 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: FeeType: Date Paid: Amount: Building 10/23/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo