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DATE DRAWN:
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Information anu instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
expte s or implied, oral or written."
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 Iocal 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."
. Additionally, MGL chapter 152; §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpubhc work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting 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)..narne(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (T fi, wi n an ag •
members or partners, are not required to carry workers' compensation insurance. If an LLC or T LP 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 youbhave-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 componies 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 peimitllicense applications in any given year, need only submit one affidavit indicating current
policy information.(i fnecessary) and under "Job Site Address" the applicant should write "all locations in (city or
town)." A =copy ofaffdavit that has been officially stamped or marked by the city or town may be provided to the
applicant s= - pmoof hatuai d affidavi n file -. for --futur-e permits or- licenses. - A flew -afi day t rn* be`filled-out each
year Where home owner` r citizen`is a license or permit not related to; any business or-commercial venture .
i.e. a do license =or' Peinnt to burn leaves etc) said person is NOT required to Complete this affidavit.
The Office of Investigatrons'would Like to: thank 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
artnre zt of - hndustrtal- Accident
4ffice of Investigations
600 Washington Street
Boston, MA 02111
•
Tel. # 617 -727 -4900 ext 406 or 1-877-MASSAFE .
•
www.rass.gov /dia
,
.Th-, The Commonwealth of Massachusetts
�_ _ Department of Industrial Accidents
', -=: Office of Investigations
600 Washington Street
E.Ay MA 02111
t- www.mass.gov /dia
Workers' Compensation Insurance davit: Builders/ Contractors /Electricians/Plumb
applicant Information Please Print Leeibly
Name ( Business /Organization/Individual): 0 U • ;.,�
Address: ` j S . VA-A,/ S
City /State /Zip: Sot-144)1^14 (. ) ' Phone #: q ci, - L ca S' - 9 1 5
Are y an employer? Check the appropriate box: , Type of project (required): •
1. I �'i I am a employer with tk 4. I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees
wor These sub - contractors have g. 0 Demolition
king for me in any capacity. employees and have workers' D
Y P �'S' S. � Building addition
[No workers' co comp. insurance.:
CN comp.
required.] • 5. [] e are a corporation and its 10.[] Electrical repairs or additions
3. ❑ I am a homeowner doing all work
myself [No workers' comp.
officers have exercised their 11: Q Plumbing repairs or additions
right of exemption per MGM 12.0 Roof repairs
insurance required t c. 152, § 1(4), and we have no
•
employees. [No workers' 13.❑ Other
have
insurance required.] .
Any applicant that checks box #1 must also .fill out the section below showing their workers' compensation policy information.
t Ho meowners who submit this 'affidavit ind caCiug"drey are doing all work and -therrhire o side contractors must-submit anew afndavit indicating suck.
=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: A • �-- . . ,
Policy # or Self -ins. Lic. #: Expiration Date: . 1 a ( D
Job Site Address: I IL- City /State /Zip: e fr i .._-
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure as covera g e. ems' on 2
r ed under Section. ofMGL c °= 152-can leadta the impositit a oif c initial ienalkies af-
. ,.. .�
fine up to $1,500.00 and/or one -year imprisonment, as well a s civil penalties`inthe 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 ofperjury that the information provided above is true and correct,
•
Signature: • Date: •
Pliant #: .
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. Electrical Inspector 5. Plumbing Inspector
6.Other -
Conta Person: Phone, #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ' Not Applicable ❑
Name of License Holder : ..e V i-\ U -. ' C No - p�.-t� -^ 1 ` 3
License Number
S . k . t & S o v - Dd cLr3 -t tQ U 1 O 1 1 1 0
Address Expiration Dat
/Ala 1 *i3 -ceps - ct 9 i'.
Signature elephone
9. Registered Home Improvement Contractor: Not Applicable ❑
S cti s (d . [ n coo c \
Company Name Registration Number
23 S. tm-Aug S .g.. ) ( / �� ( lcp
Address Expiration Date
Telephone `t\3 - 14 t2 5 l t s
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) u Roofing ❑
Or Doors CI
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [0] Other [0]
Brief Description of Proposed Sc 2 3 °4) wwzS
Work: l
1��'�✓i — Li L ��17 4VA o 9$
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes V No
Attached Narrative Renovating unfinished basement Yes v No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following: 514 ,i� wltfN
a. Use of building : One Family Two Family Other ✓ 1QK151-14 RtToktk.. C3lt
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garag- -ttached?
d. Proposed Square foo': •e of new construction. Di ensions
e. Number of stories?
f. Method of heating? Fire. .ces or Woodstoves Number of each
g. Energy Conservation Compliance. asscheck Energy Compliance form attached?
h. Type of construction NIIPV
i. Is construction within 100 ft. of wetlands? No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor • -low finished grade
k. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City : - Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , LM AJ QdS 11) 24Q. St c , as Owner of the subject
property I �
hereby authorize v 0 r � S
to act on my be :If, in all mattersr-lative to work - .thorized by this- building permit application.
7 1 2z /a
Signatur- :f • 'er Date
._.18( 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 erjury.
Print Name
ZZ U `1
Signature of Owner /- Da
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incompl -te Information
Existing Proposed Requ' • -d by Zoning
Thi olumn to be filled in by
tiding Department
Lot Size,
Frontage
Setbacks Front
Side L: R: R:
Rear
Building Height
Bldg. Square Footage
Open Space Foota.
(Lot area minus bld k ; paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW a YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW YES ()
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES g NO 0
IF YES, describe size, type and location: gyp,,,„( t.
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, exca tion, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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 rA�
Northampton, MA 01060 Two Sets of Structural s
phone 413- 587 -1240 Fax 413- 587 -1272 Plot/Site Plan `' "'
Other city ^a\
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLI H A OSE OR - rItil,FI IMILY DWELLLIING
; '
SECTION 1 - SITE INFORMATION
This section t - bi,Coi ?�rleted by office
1.1 Property Address: Q
3 8 •P 'Som-c u--c - Map ,Lot ' Unit
R ONA -C b -C Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
')E` 1 —V\H J rost.LE- E4C.f. V.e.,AS 1 ne A PC•it-
Name (Print) Current Mailing Addres
-1 I Sri ' 2 48 2 -
Telephone
Signatur
2.2 Authorized Agent:
o • S A- c..A-- 0-441 $ 3 S. IA* fir. S YC ,a-,M)
Name (Print) Current Mailing Address:
_ ■11111h. `-113
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTIO COSTS
Item Estimated Cost (Dollars) to be Official Use Only
corn. eted by permit applicant
1. Building (a) Building Permit Fee
I
2. Electrical (b) Estimated Total Cost of
c 4V) Construction from (6)
3. Plumbing Building Permit Fee
5 C7 2.0, (3
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) 4. 9I coo Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0104
APPLICANT /CONTACT PERSON SACKREY CONSTRUCTION
ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413) 665 -9995 0
PROPERTY LOCATION 378 PLEASANT ST
MAP 32C PARCEL 182 001 ZONE GB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out // n(/ �/
Fee Paid d6 / ( ild6`�
Typeof Construction:_RENOVATE INTERIOR 1 ST,2ND & 3RD FLRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included: ���,
Owner/ Statement or License 040714 / ;Fi ° 42 `v' Q
_ ���
3 sets of Plans / Plot Plan JL�/
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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
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.
-23 ,
I " A
_ , _
378 PLEASANT ST BP- 2010 -0104
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 182 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
gateau BUILDING PERMIT
Permit # BP- 2010 -0104
Project # JS- 2010- 000121
Est. Cost: $44000.00
Fee: $264.00 PERMISSION LS' HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SACKREY CONSTRUCTION 040714
Lot Size(sq. ft.): 7361.64 Owner: POSNER RICE LYNN
Zoning: GB(100)/ Applicant: SACKREY CONSTRUCTION
AT: 378 PLEi-,SANT ST
Applicant Address: Phone: Insurance:
83 SOUTH MAIN ST (413) 665 -9995 O Workers
Compensation
S U N D E RLAN DMA01375 ISSUED ON: 8/5/2009 0:00:00
T() PERFORM THE FOLLOWING WORK: RENOVATE INTERIOR 1 ST,2ND & 3RD FLRS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
inspector of Phunbing Inspector of Wiring D.P.W. Building Inspector
Underground: - Service: Meier:
Footings:
Rough3' „ ( Rough: House # Foundation:
Driveway Final:
Final: (f O Fina1: `` //,,,.
Rough Frame: C/\ -7' 0474
Gas: Fire Departmen Fireplace /Chimney:
Rough: Oil: ti Ilia Insulation:
Final: Smoke• o Final: OK A Li /0 2/03 Lery "
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupan -_! Signaturc;.�_.__...
FeeType: Date Paid: Amount:
Building 8/5/2009 0:00:00 $264.00
212 Main S rt , ;1, Pi:o,,e (413) 587- 1240, lax: (413) 587 -1272
I:?aii 1:n; -.4: t::::__ Patillo