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036-315 (3) ; . , . The Commonwealth of Massachusetts aik Mr It U 1 I . . Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly ' N :Same (Business.organilation'Individual) : i 0 Address: , ,,,..- -- -,- \ City/State/Zip: 'cAt_i ,, t \I I i4 ) q i , , _, Phone#: ' i - 3 _ .),,i ' Are you an employer? Check the appropriate box: Type of project (required): 1. K I am an employer with 0 4. I am a general contractor and 1 6. New construction employees (full and'or part time).* have hired the sub-contractors , 2. I am a sole proprietor or partner- lised on the attached sheet. Remodeling ship and have no employees These sub-contractors have 1 S. Demolition working for Inc in any capacit employees and have workers' 9. Building addition [No workers' comp. insurance insurance . + comp. insuran. .1 required] 5. We are a corporation and its 10. Electrical repairs or additions I am a homeowner doing all work officers have exercised their I I. Plumbing repairs or additions myself No workers comp. right of exemption perm MU.. insurance required] + c. 152, § 1(4), and we have no 12. Roof repairs ' employees. [no workers' 13.,e. Other comp, insurance required.] I L. : *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. ttlomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have em , they must .rovide their workers' corn.. . olicv number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ,7 insurance Company Name. i l'-Nt. v ct. i.`""q ' C ( P -olicy g or Self-ins. Lic. tr': (..__, 11 U:)C, ,l2n 3 Hlt ,7 Expiration Date: 2/ L / , -)el , Job Sue Address: City/State/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 152 can lead 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 5250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify unj4er the pai s and penalties of perjury that the information provided above is true and correct. ----- Siullailire: Date. '''')/ I-4 / t ,-, Print Nanw: 11, ,- <,.)., --, c,_! , , 7 , .v---.L.. , 0,-,f,_ <,•=..., i v Phone 4. ,' „.-.),_) - 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 Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #: Property Address: '+- J (O 1 , � „- ..,..c.k. I i-Vi a , Contractor Name: m -3 4 s t �r 5 ) .. / 1.1(_ Address: )f) 4i lit City, State: 1441,t .c. MIA 6 ( 6' Phone: L- 11 3 3)- 3 ► It Property Owner Name: \,, . iJ Address: �_ 1 City, State: - =e- ,ti, I, " — - _ (contractor) attest and affirm that the building 1 intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature 4,/k---- g . Date —1 ZOO Z Z_'ZTLBSCTt Vid LZ:TT OTOZ%CI 60 { 1 ': 10 SECTION 8 - CONSTRUCTION SERVICES «1 l 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 4.-- net. 4. a 5 "off A. • fj /t.✓ q ace/ 0 f , p 44i License Number t j Z'Z SL.s J.'? r, ate 'Prise. er/G 42 I Address // ExpiratD si,f_„0.2,_91e, ,i, ,, Signature Telephone 9. Real tared Home Improvement Contractor: Not Applicable ❑ a t ,a , 1-1-6 ��si d 9 Company Na wk Registration Number '/ 7 for/4'A S/ % /yu,ka ANAL ,01,92!0 1t i L ' ; Addr Expirati n D e 1,' Y/L Telephon (U1;),3LL - 5 i I ( f !gym 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 K No ❑ ,, fi ' 11. - Home Owner Exemption 1 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 ual ervisor. CMR 780, Sixth Edition Section 108.3.5.1. Fi. 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 I ." 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. i As acting Construction Supervisor your presence on the job site will be required from time to time during and upon If completion of the work for which ti' permit is issued. r Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to E .' Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) '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 1 1 Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature It if a' : iI i: , i ii , SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (Q Siding [0] Other [[ Brief Description o Proposed R {9 `" Work: biro. i.. • '\ _ I o illi c- • t S's-r- ..f isi R L i . Alteration of existing bedroom Yes _ / No Adding new bedroom Yes 2< No Attached Narrative Renovating unfinished basement Yes 'C. No Plans Attached Roll - Sheet 'I sa. 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 €1I;r c. Is there a garage attached? II d. Proposed Square footage of new construction. Dimensions e. Number of stories? !I r f. Method of heating? Fireplaces or Woodstoves Number of each i ; 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 i j. Depth of basement or cellar floor below finished grade `s I i 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 1 1 I, a t-R-($(M as Owner of the subject I i , ii property „, i , hereby authorize �1 ^ �� t n ,S5M - S - � to act on my behalf, in all matters / ativeto work authorized by this building permit application. I, �, C yr. ✓' 4/”. ' '{ 4 2" "6 ` 'L...... 5 / (l 1 i i t Signature ofAwner < ' Date ,I , 1, I / t l/- d-fc3S w-e•3 , as Owner /Authorized I Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge `, 1 and belief.'' I4 Signed it ) �under the pains and penalties �of perjury. fill � ( gS�SD `'° Print Name Iii i ii ''/3/1 (i 'i ti Signature of Owner /Agent Date ' x it 0 ii • 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 tilled in by Building Department • Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage • Open Space Footage 'o (Lot area minus bldg & pared parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Fin 'n 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 Q 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 YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO t IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES V NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. L Department use only City of Northampton Rom* • 1 1 Building 212 Main Department /Septic AvalirMlny Room 100 el A ± N° v - W` Northampton, MA 01060 Two of dal lotrime °F� y phone 413 - 587 -1240 Fax 413 - 587 -1272 PIMISItePUMS OtlywSpedly 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 SS U&,c4j+4V LA 1 C Map Lot Unit + Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Nam (Print) ' Current Mailing Address: C 4, 13\ 5-(e 9 -t)373 6 . 2w Telephone Signature j 2.2 Authorized Agent: Name (P i ) Current Mailing Address: bitt3) 3) — 311V Signs ure Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only ompleted by permit applicant 1. Building 0 is , 00 (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) 7 0 Check Number ( t a 5 — 1 A This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -1081 APPLICANT /CONTACT PERSON ENERGIA LLC ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111 PROPERTY LOCATION 185 CARDINAL WAY MAP 36 PARCEL 315 001 ZONE SR(100) //WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out / j Fee Paid Typeof Construction: ADD ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 92540 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF O MATION 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 ,.� De mo 'tion I elay 7 'dr e o :uil ing 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. 185 CARDINAL WAY BP- 2011 -1081 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36 - 315 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP-2011-1081 Project # JS- 2011- 001743 Est. Cost: $840.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ENERGIA LLC 92540 Lot Size(sq. ft.): 17946.72 Owner: PIERSON ORVILLE D & JUDY Z Zoning: SR(100) //WSP II Applicant: ENERGIA LLC AT: 185 CARDINAL WAY Applicant Address: Phone: Insurance: 242 SUFFOLK ST (413) 322 -3111 WC HOLYOKEMA01040 ISSUED ON:6/23/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD 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 6/23/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner