32C-101 •
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company
Burlington, Massachusetts NCCI NO 40959
(800) 876 -2765
• POLICY NO. =C 5000037012010
• PRIOR NO. C 5000037012009
ITEM
1. The Insurejd Paul E Brissette dba Brissette Masonry
Mailing Addres4: P 0 Box 234 South Hadley MA 01075
(No. Street Town or City County State Zip Code
® Individual i❑ Partnership ❑ Corporation ❑ Other FEIN 04- 3157779
Other workplac es not shown above:
i 6/26/2010 06/26/2011
2. The policy period is from° to 12:01 a.m. standard time at the Insured's mailing address.
3. A. Worker& Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here;
MA
B. Empb)ers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of our liabilityunder Part Two are: Bodily Injury by Accident $ 100 , 00 0 each accident
Bodily Injury by Disease $ 5 0 0 , 0 0 0 policy limit
Bodily Injury by Disease $ __ 10 0 , 00 0 each employee
C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A
D. This policy includes these endorsements and schedules: SEE SCHEDULE
4, The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per $100 Estimated
Total Annual of Annual
No. Remuneration Rem Jrwagon Premium
INTRA 393327
SEE EXTENSION OF INFORMATION PAGE
Minimum prey ilum $ 500.00 Total Estimated Annual Premium S 3,382.00
As indicated, Interim adjustments of premium shall be made: Deposit Premium $ 900.00
❑ Annually' ❑ Semi Annually ® Quarterly ❑ Monthly
MA Assessment Chg.
$3,036.20 x 7.2000% $219.00
This policy, inouding all endorsements, Is hereby countersigned by 06/10/2010
1 Authorized Signature Date
GOV (}OV KIND PLACING CLAIM NAME SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Boston Insurance Brokerage Inc
MA 5022 23 507 _ 24 Federal Street 4th Floor
WC 00 00 01 A (11-88) Boston, MA 02110
Includes copyrighted material of the National Counal on Compensation Insurance,
used with its permission.
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, act as their own constructign supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires 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.
lithe 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
iermits in conjunction 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
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to - me.
Date
Address of work
location
•
. . :
The Commonwealth of Massachusetts
_,....—....= Department of Industrial Acidents . ,
i s = ,...4-=-.....
f1
t4L Office of Ini • .
e.a 5
600 Washington Street
Boston, NIA 02111
www.mass.gov/dia
, . •
,:.
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information . Please Print Legiblv • '
.-.:.
Name (BusinesS/Orgardiationfindivirinal):
.., ,
• • Address:
City/State/Zip: - Phone.#: -
Are you an employer? Check the appropriate'box: • •
6 Type O pioject , (req ): /
1.0 I am a employer with 4. 0 I am a general contractor and I
. ew co on
employees (fall and/or part-time). have hired the sub-contractors
listed on theattached sheet. 7. 0 Remodeling
2..0 1 am a Sole proprietor or partner-
These sub-contractors have .8. Q Deiriolition
ship andhave no employees
working for me m any capacity ti.axylo..3T.L7414-PsillaYe Workers' 9 . ..-=,T •
[No workers' comp. insurance .
required4 .- • . 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3. 0 I am a homeowner doing all work officers haire4xereised their .
/ 11.0 Pluntbing repairs or additions
•
myself [No workers' comp. - right of exemption per MGL 1--1 • .
12.LI Roof repairs .
insurance requirectj t ' • c 152, §1(4), and We have no •
employees: [No workers' 13"1-3 Other r
! .
' . . comp. insurance reqUited.l.
*Any applicant that checks box #1 must also fill out the section Moil/showing their compensation policy information:
t Homeowncra who submit this afradaVitiackatini they are doing ail work and then hire outside ctm1raCtors must submit anew affidavit indicating such.
:Contractors that check this box must attached an ackakmal sheet showing the nom of the sub contractors and state whether orrtotthoset =ides have
employees. If the sub-contraCtorshaie employeed, they mint provige their works ' comp policy number.
.1 am an employer that isproviding workers' compensation insurance for my einplOyees. Below L s the policy gad jobsite
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 mintier andCapiration date).
Failure to secure coverage as retiiiiidinictei Settibil25A 152 can lead to the iin of "criraing penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of; 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 ta‘.0ffice of
EieitrialionS for iiiiirIiiee' adVeraze verification. _ _ - - _ . _ ,.... ;--,,..•..--.... -,—.._,.........,._
_ Ilia herebysertifil under the pains penalties olpedray tkaithe infonnatiOn providiiisiboveLlitnie.rindioriPct
. . .
Signatire: ' . ' . Date; • - ,
--
Phone #:
, • .. . . • .
. _ .
• - OffiCial use only. Do not write in this aria, to be cortipleted by city or toWn offici a 1
Permit/License #
City or Town .
Issuing Authority (circle one):
". '
--.
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector
6. Other .
Contact Person: '
Phone #:
• -
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder ad F% 6P- /7 / /
License Number
O1 1-- HCO I N Ate - 69478 blcdY14 0/07f ,RA . //
Expira ' n Date
7crA,& C cio 6- 3a -ydae
Signature Telephone
Lteallste a lofne ltripro rtibiri ;ri i re" _ eiZilarler . x 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 ❑
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
d
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [l Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other,�j]
Brief cription of Proposed , � ��
Work e-h it IC.l r. hl nWi WOC �- 1..1...,14t, -,ru, op (,CJ( [:i1 f / ' 6,5 N
1
Alteration of existing bedroom _ Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a :C�te ro r and r r$:alddlt of to ti (hoi su 'c` rlpt to th+ oHowtnn:
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
l -0 2. t- CI Ot t ' ` " , as Owner of the subject
property
hereby authorize /� /1 / "
to act on my behalf, in all matters relative to work authorize this building permit application.
s i 2s 1 �t
Signat of Owner Date
I, , as Owner /Authorized
Agen ereby declare that the statement - • • • ermation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Si• I -d under the pains and penalties of perju .
Signature of Owner /Agent Date
4 N
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Inc. ple „ .. ”
Existing Proposed Required • - . , f rA
;7
This column to be filled m .., , •
Building Department r "v F ' ..,/
Lot Size_ ,.
Frontage 1 1 1 1
Setbacks Front F-1 i 1 1
Side L:1 ..__J R' _ ., L:1 1 R:' ._, _-
Rear t
3
Building Height j = i`
i--
Bldg. Square Footage %"' 1 4
Open Space Footage , % :
(Lot area minus bldg & paved ! i a
parking)
# of Parking Spaces i "�
Fill: . ._m ._a,w _ ... .. . ,_b - ._
(volume & Location) i ----- -
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book Page and /or Document #.
B. Does the site contain a brook, body of water or wetlands? NO Q 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 Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• mot• ��
2 's of Northampton
ding Department
1 Main Street.
d , A • Room 100 $ ,m
Northampton, MA 01060 ,
phone 413- 587 -1240 Fax 413- 587 -1272 4
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
G.ON2 6 Jf ", Ma Lot Unit
Zone Overlay= District
EImSt District CB. District__
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
ale Gw Name (Print) Current Mailing Address•
l3 6q Z15' 4'
Telephone
Signature
2.2 Authorized Agent•
s E) SY 14660H,, aD)c aati 59ctkii
Name Print) / Current Mailing Address:
...�� ) CLj13)
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item `' / Estimated Cost (Dollars) to be Official Use Only
�� 4IYY114 ,� i �/ 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) Check Number
This Section For Official Use Only
Rate
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
36 CONZ ST BP- 2011 -0999
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 101 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: chimney rebuild BUILDING PERMIT
Permit # BP- 2011 -0999
Project # JS- 2011- 001626
Est. Cost: $2000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL E BRISSETTE 15711
Lot Size(sq. ft.): 12414.60 Owner: CLARK GORDON E & JANET F & LAURIE E CLARK
Zoning: URC(100)/ Applicant: PAUL E BRISSETTE
AT: 36 CONZ ST
Applicant Address: Phone: Insurance:
P 0 BOX 234 (413) 532 -4630
SOUTH HADLEYMA01075 ISSUED ON: 6/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REB U I LD CHIMNEY
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 6/2/2011 0:00:00 $50.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner