17A-152 (3) Information and 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,
express 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 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." , r.
Additions Tly, 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 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) name(s), address(es) and phone 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 affidavit. .. _ _
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. 4 617- 727 -4900 ext 406 or I -877 -I tASSAFE
Revised 11-22-06
Fax 4 617-727-7749
www.mass_govldia
The Commonwealth of Massachusetts
..�. Department of Industrial Accidents
Office of Investigations 600 Washington Street
1. Boston, M4 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/IndividuaI): 9601 Zlic(11, --b
Address: - 70 n0
City /State /Zip: UorTAar11 [1 A Up4v Phone .#
Are you an employer? Check the appropriate box: Type of project (required): - ..
1. I am a employer with 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 eloyees These sub - contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers'
co insurance.$ 9. 0 Building addition
No workers' comp. insurance �•
d
re aire 5. [� We are a corporation and its 10.0 Electrical repairs or additions
required.] have exercised their 11. Plumbing repairs n T am a homeowner doing all work h id hi
❑ g airs or additions P
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. lithe 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 51,500.00 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 ce ., under the pains a dpenalties of perjury that the information provided above is true and correct
IV
Signature: j ► 44 ' - . Date: Vqd.-J)3
_
Phone #: 1. 1/ — 57S- Sr .
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
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : c4 +/ Z acc 1 iv, (S 7- 135b
License Number
Cit2r, (tP• I1 A /31/ao)3
Addres, / Expiration ate
. ' ft P 1 - 11 3 - 50- 3c1r ■
Sig -t A - Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
160 9
Company Name Registration Number
t poly
Address Expiration [[5sate
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 X 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 1083.5.1.
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 ❑ Replacemen endows Alteration(s) El Roofing ❑
Or Doors I
Accessory Bldg. ❑ Demolition ❑ New Signs ID] Decks [0 Siding I❑] Other [Ei
Brief Description of Proposed nn e /,
Work: RQptctc� 3 -r x - T CaA4VA''; 14.4 33 r' X S1 el, er, Sf <r Cz -4lt 4 L iv' I ,a W
Alteration of existing bedroom Yes V" No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes 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. i 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
1, ' B a n e wart i L t; I: Sf S *%- ■ , as Owner of the subject
property /�
hereby authorize E tip` "' / Si , 7jc. cit ; n u
to act on my behalf, ti all matters relative to work authorized by this building permit application.
�` Et r 1, IS 3/24/2-411) i nature of Owner Da
1, `Q Ue,h 2u,c,11 ;Ko , 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 perjury.
S Zt,cC. ( ;),q
Print ; f i
A • J - &raw ' 3 2,O1
Signature of Oww r /Agent Date
...mirk
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: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
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 YES O
IF YES: enter Book age and /or Document #
B. Does the site contain a brook, b of ater/•r wetl. ds? NO O DONT KNOW O YES O
IF YES, has a permit been or ee be obtained fr• the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
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? YEE O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
_._ -- ,City of Northampton Status of Permit:
E�'- '� ' 9 Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
NIPA 2 20 )3 Room 100 Water/Well Availability
' orthampton, MA 01060 Two Sets of Structural Plans
CEP/OFauawJNGINS 4 3- 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
NORTHAMPTON MA 01060 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
S L./ Fu r I r i.s P0,4 Map Lot Unit
` Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: � row Fa
SAnt I` r•
Evcu1S . �, SA- -t..� � t( 1 O t y Lc,
Name (Print) Current Mailing Address:
a.+.�t�nra.rin C \\' t.�-� Telephei Li- p! _3
rgnature
2.2 Authorized Agent: r /y { /
5 4 t ZUC�, ho 7O Cl /.e4So r�i1�,� / /�/or4k4 +, ti A
Name; t) Current Mailing Address:
r / .
Ain. 1�.. 5 7 5- aaS(
Signature / Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building if 1 " + (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
A ilyie Construction from (6)
3. Plumbing Building Permit Fee
h an-F
4. Mechanical (HVAC)
5. Fire Protection ewe
6. Total= (1 +2 +3 +4 +5) 403 — Check Number /o 3 9 # 35
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
54 FOX FARMS RD BP- 2013 -0882
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 152 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: REPLACEMENT DOOR BUILDING PERMIT
Permit # BP- 2013 -0882
Project # JS- 2013- 001515
Est. Cost: $800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEVEN ZUCCHINO 021356
Lot Size(sq. ft.): 15681.60 Owner: STENSON ERIK L & JANE R EVANS
Zoning: URA(100)/ Applicant: STEVEN ZUCCHINO
AT: 54 FOX FARMS RD
Applicant Address: Phone: Insurance:
70 Gleason Road (413) 584 -3878
NORTHAMPTONMA01060 ISSUED ON:3/29/2013 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE EXTERIOR DOOR
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 3/29/2013 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner