32C-319 (5) l's\ The Commonwealth of Massachusetts
--- Department of Industrial Accidents
w Office of Investigations
kr i 600 Washington Street
t Boston, MA 02111
4 . 0 ,
www mass.govldia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /O[gani7ation/Individual): J 0 J C 140 i (-,c n]
Address: 266 ?i.e.-4 .4--$4A. P t t.t..
City /State /Zip: S'1.t.Y B,, MA Ola ?Z -Phone #: 4 VI 3 Zq . /62-4)
Are you an employer? Check the appro riate box: Type of project (required):
1.0 I am a employer with 4. 0 I am a general contractor and 1 ,�/
_ (full and/or part-time).* have hired the sub - contractors 6. lid-
construction
2. LI I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have g. 0 Demolition
working for me in any capacity. employees and have workers'
$ 9. 0 Building addition
[No workers' comp. insurance comp. insurance. 10.0 Electrical repairs or additions
required.] 5. 0 We are a corporation and its
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] r c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #I mud also fill out the section below showing their workers' compensation policy infcmnaticm_
t Homeowners wile submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
:Contractor that check this box must attached an additional sheet showing the name of the sub- rxmtracton 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. Belong 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 certi f under the ains and penalties of perjury that the information provided above is true and correct
Signature: w Date: 6//6/2ar /o
Phone #: 4/5 2.5 - /6Zo
Official use only. Do not trite 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
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Joni c- ) Ft0 00'5aw1 f2 `i'4
License Number
266 "Pei_pi t -1, w 2 .-t S �;�-- ga�r� 9/S /2o
Address Expiration Dale
e.__ 413 2 Sq - /6 2.0
Sig re Telephone
9, Registered Home Improvement Contractor. Not Applicable ❑
JG
1 v &PSort C Pe.,J -2 - (iJ 1 LDk.2 //2472 -
Company Name Registration Number
Z E 6
Pbi- a w• Qom { i C3 J a 1/6 Ito /1
Address /, Expiration Date
4
Telephone 3 2$1.620)
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 Er No ❑
11. - Home Owner Exemption
The current exemption for `homeowners was extended to include Owner Dwellinas of one (I) 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) w°ho own a parcel of land on Nvhich 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 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, von 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 n
Or Doors 0
Accessory Bldg_ ❑ Demolition ❑ New Signs [a] Decks [[] Siding [d[ Other (El
Brief
Description of Proposed F /) _ � A ,/ r„
Work: f
Work: Op.)/ �iv( /iJ'T�arL- u l�s�4 -c.- Lt-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea. 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? 2--
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
1, , as Owner of the subject
property
hereby authorize J vrJ c-- ` kut_e 1
S e .
to act on my behalf, in all afters relative to work aiithonzed by this building permit application.
/o
Signature of Owner Date
I , d# t '40 r , PS o I , as Gwner /Authorized
Agent here ' b jeclare 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 perjury.
Print I
�i w ( �--� 6 /6 20 I o
Signa - oflnr /Agent Date
Section 4. ZONING Att Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This cohnmt to be filled in M.
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage °lo
(Lot area minus bldg & paved
t)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit/Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW er YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T 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 a YES 0
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 0 NO e
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 a
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 e -
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
lc j amity of Northampton Status of Permit:
— - -- — EtINding Department Curb CutlDrivervay Permit
212 Main Street Sewer /Seic Avaiiabitlty
2 1 8 2010 Room 100 Water/Well Availability
pton, MA 01060 Two Sets of Structural Plans
,phene:, 3-58 -1240 Fax 413 -587 -1272 Piot/Site Plans
Other Specify
APPUCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOUSH A ONE OR TWO FAMILY DWEWNG
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map 3 a Lot 3 16 Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
14•( r Qo .i14- Col / v t)i =-� F
Name (Print) t Current Mailing Address:
4l 3 2b 549
Telephone
Signature
2.2 Authorized Agent:
jOi4 c- L H.o rtices0�• 1 266P 1 } iw 201 SI Tia6 og.g D 102.
Name (Print) Current Mailing Address:
L 413 - Zsg - /620
Sig rr�atu Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS I
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Buildin /tocoo • • c.c. Building Permit Fee
2. Electrical �� (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
ova . 4P
4. Mechanical (HVAC) .5 7, Sacs • 00
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) /1Z So o r oo Check Number /� )f55
This Section For Official Use Only /
Date
Building Permit Number Issued:
Signature:
Budding Commissioner/Inspector of Buildings Date
File # BP- 2010 -1157
APPLICANT /CONTACT PERSON J C THOMPSON CARPENTER BUILDER
ADDRESS/PHONE 266 PELHAM HILL RD SHUTESBURY (413) 259 -1620
PROPERTY LOCATION 1 VENTURES FIELD RD
MAP 32C PARCEL 319 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out � ��
Fee Paid
Typeof Construction: FINISH INTERIOR 2ND APARTMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 042444
3 sets of Plans / Plot Plan
THE FOLLOWING 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
61A-4-A-j c/aa1to
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.
= BP- 2010 -1157
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 32C - 319 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 -1157
Project # JS- 2010- 001692
Est. Cost: $142500.00
Fee: $855.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: J C THOMPSON CARPENTER BUILDER 042444
Lot Size(sq. ft.): 77057.64 Owner: COY OONA MIA & BENJAMIN GILBERT JAMES
Zoning: URC(100)/ Applicant: J C THOMPSON CARPENTER BUILDER
AT: 1 VENTURES FIELD RD
Applicant Address: Phone: Insurance:
266 PELHAM HILL RD (413) 259 -1620
SHUTESBURYMA01072 ISSUED ON: 6/23/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: FINISH INTERIOR 2ND APARTMENT
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 6/23/2010 0:00:00 $855.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo