32A-218 (2) Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation foftheir employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
1 An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required." t
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall"
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented taxhe coniracting_authority." - - - -- = —
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub - contractor(s) name(s), address(es) and p one number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self - insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. •
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city'or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affiidavit..:.. . .
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1- 877 - MASSAFE
Revised 11 -22 -06 Fax # 617 -727 -7749
wwwmass.gov /dia
1.
. r The Commonwealth of Massachusetts
Department of Industrial Accidents. •
I c ( Office of Investigations
600 Washington Street
Boston, MA 02111
.: www.massgov /dia • •
-Workers' Compensation Insurance Affidavit Builders/ Contractors /Electricians/Plumbers
Applicant Information • Please Print Legibly
Name ( Business /Organization/Individual): k a) C
Address: 2;2- M 4 j IJ s
City /State/Zip:� S! V1 pc 01653 Phone. #: /-{ / 3 2:2- -1 - '1 " il
Are o an employer? .Check the appropriate box
Y u Type of project (required):.
1. ❑ I am a employer with 4•. ❑ I am a general contractor and I
e_pjoyees (full and/or part-time).*
have hired the sub- contractors Cs ❑ New construction
2. I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no e.^ Ioyees These sub - contractors have .8. ❑ Demolition
working mployees and have workers'
g for me in any capacity. aci t3'• # . 9: ❑ Budding addition
[No workers' comp. insurance comp. insurance. 10.0 Electrical repairs or additions
required.] 5. ❑ We are a corporation and its reP
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
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/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 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 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 hereby certify under the pains -and penalties of perjury that the information provided above is true and correct
i!" . tore: Alos■ • Date: .3
•
Phone #: ( 3 - 5 g • . ..T)
Official use only. Do not write in this area, to be completed by city or town official
City or Town: #
Issuing Authority (circle one):
.'1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
ii Contact Person Phone #: I
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
� Not Applicable
V ❑
Name of License Holder : ,ti N
License Number
Ad `�� - A Sq. LIbs A- otvC3 - 7o00
d / Expiration Date
4 I — 22. -- ( - 4
Signature Telephone 4/ � 2-0
9. Registered Home Improvement Contractor: Not Applicable ❑
5 A-S A/ - /,2 9 1 /
Company Name Registration Nanber
Address Expiration —0— O '3
�dat
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 ❑
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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing 0
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [m Becks [q Siding D] Other [01
•
Brief Description of Propose
Work: ( 2 L % O v ( ) C - s - 1e(J)'rug4vveso S W ( - L5AIc.?o GG(L.(Wt.. pLVt►'�b wkLL •
OPLI C-la ■/� i D -t tc'R -- - 141- 4C- A 'TVb 15 w rZ v1'I i
Alteration of existing bedroom Yes )( No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes X 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 AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, Pg f 2 /cL) ��� , 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 penalt - j rjury.
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:
Rear
Building Height
Bldg. Square Footage 'o
Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a pec'. Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit reco ded at the Registry of Deeds?
NO 0 DON KNOW ® YE •
IF YES: enter Book Pa: - and /or Document #
B. Does the site contain a brook, body of wa - .r wetlands? NO 0 DONT KNOW ® YES
IF YES, has a permit been or need to .e obtai -d from the Conservation Commission?
Needs to be obtained ® Obtained , Date Issued:
C. Do any signs exist on the pr' lefty? YES ® ' 0
IF YES, describe size ype and location:
D. Are there any prop •sed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, • -s be 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
. Department use only
RECEIVED , City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
j 2 4 201 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
DEPT. OF BUILDING INSPECTIONS Northampton, MA 01060 Two Sets of Structural Plans
NORTw1MPTON,MAO1t nnpR13- 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 Co PrA Nc_ocCc- S / Map Lot Unit
N 0 2 ii-k ik W Td N 1 14 Pv 6' ob 0 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
1 L l--- di OIJ A-Li> SO KJ 5 e O(2rtvz 72 e' (D/2 .
Name (Print) Current Mailing Address:
4)0 ti.t.L / OZ06i
Signature
Telephone 8 Z _ 9 2 9 6- 2—
2.2 Authorized Agent:
I C t..1) A- ,2 2.7,3 kkt U sT, L-t E 15 ( 0$0
N •nt) Current Mailing Address:
s --______ b il3 — Zzf - - -L i' I ° �
Signatu � Telephone /
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 06 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing ' ' /� 0 Building Permit Fee
4. Mechanical (HVAC) V "55
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Liq 0 b U ➢ Check Number l'i '
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature �''" 6 f
Building Commissioner /Inspector of Buildings Date
0
16 HANCOCK ST BP- 2011 -1092
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 218 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -1092
Project # JS- 2011- 001758
Est. Cost: $4406.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KAREN CARTER 070008
Lot Size(sq. ft.): 4486.68 Owner: PIETRA LORENA ZURITA DELLA
Zoning: URC(100)/ Applicant: KAREN CARTER
AT: 16 HANCOCK ST
Applicant Address: Phone: Insurance:
223 Main Street (413) 221 -7419 ()
LeedsMA01053 ISSUED ON:6/23/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE TUB & REPAIR WALL
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