17C-058 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
�_ Office of Investigations
=cow 600 Washington Street •
,,,� Boston,MA 02111
=SV°y� . www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information 6 ,Please Print Legibly
Name(Business/Organization/Individual): I G/Lj„/`, 'g6� a
Address: 1 C(.. t 5r_
City/State/Zip: E5, �/J? Td�;
,- /14/7 Phone#: 9/3 -Cd-7 ?ad-7
Are you an employer?Check the appropriate box: Type of project(required): 1/
1.❑ I am a employer with 4. 0 I am a general contractor and I
loyees(full and/or part-time).* have hired the sub-contractors [�6. ❑New construction
2.
_301p am a sole proprietor or partner- listed on the attached sheet. 7. 'Remodeling
ship and have no employees These subTcontractors have 8. 0 Demolition .
working for me in any capacity. employees and have workers'
g Y P tY 9. ❑Building addition
[No workers' comp.insurance comp.insurance.t
required.] 5. 0 We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their i 1.❑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.❑Other __
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T
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).
4 li
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 cert• u er the poly an,penalties o per' ry that the information provided ab a is tr a and correct.
Signature: ' /1 Date:
Phone#: 773 _5 —/ , 1?.
Official use only Do not write in this area,to be completed by city or town official I
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#:
SECTIONS-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:1�� /�� Not Applicable ❑
L-_�7
Name of License Holder: /f (< /3�7C� �/fl A4'y '5753 L
License
� N mber
/a �A- 7 s�f�oV�( �9-0/0)27 / /
,
Addres
y
Expiration Date
527 - 7 27
Signature Telephone
;ti. �.s� ,..< f ��l ff RA 3 f� a d 4. w Not A PPI
icable ❑
/f/c eP
c/' 'f V /0 7
Company Name Registrat n Nuyber
/002- c7 / 117Y'&' '2/43 V
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c,152,§25C(8))
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 build permit.
Signed Affidavit Attached Yes No ❑
t,� Eq
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
III 1�s 5- 0r...^s. �c1 .t Act •� ; ceo r .)a,'4. a ti; A. a5>.w.z. "_ii , ,"a1 " ,a.-
New House Addition Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. Demolition New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Propose/D� /%C/ ,7 Cc-Aie-��/✓y/vDG� e // ade,S'
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
,..4.0,,=----,,4 r p x.t.-1 "`c'#a h`t `=r. k,'E 2x 55 1. r ? t"^.1'�2k n^ }. gb "kr �`,tr`'3 rT A .:-
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 AUTH ORIZATION-TO-BE'COPAFt.E' } WHEN
OWES AGENT OR+ONTRACTOR'AFFUEE FOR SOIWI PERMIT
I ca.-4L . W VA cr , as Owner of the subject
property
hereby a rize
to act o y behalf, in all matters relative to work authorized by this building permit application.
2? J N1.4 id 1)
Signature of Owner Date
I, /t' Z • , 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 penal'es of p rjury. o
W/C-ri,09/0 �il9A/►'l k pi
Print Nam
r t0 ‘%7//3
Sig ture of Owner/Agent Date
S3ction 4. ZONING M 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: L: R:
Rear
Building Height
Bldg.Square Footage °Io
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A Has a qaedai Permit/Variance/Rnding ever been issued for/on the site?
NO DONT KNOW YES
IF YES date issued:
IF YES Was the permit recorded at the Ragistry of Weds?
NO DONT KNOW YES
IF YES enter Hook Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES NO
IF YES, describe size, type and location:
E. WII 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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
aUL
J-7--7;.,i'.`.., City of Northampton
'1,.. ' - T Building Department
212 Main Street
juN 2 6 2.0i3 Room 100
N• hampton, MA 01060
DEPT.OF _
NORTHAMPTON, '' "' : 587-1240 Fax 413-587-1272
SUiU DING INSP CTIONS -
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELUNG
SECTION 1 SITE INf iM1T#ON - I
1.1 Property Address: a �q ��, n � " 4 ��y s
Ga. Y z+ max' a+ 3x .ax' s m Y + r -; >`�r 5
z t6 eta' ���? .� .�, '�a-�,,'k §,4r v��p ��:� es �"�xy� r '�`
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` Q2�'Nc C P"3 7 , a w r va `}r,.s a s €^�.-a� r u,{s V `t
e a e3; f, t'Cx i $.' t P 1 f £++ � .". ,. r3Y c:. rA' e"`•�
° �r #..,xx,� a7':7'1 '�'.' d 3 "x'rc.2b',Y xE '§r fi `�'1�`.Y. ��"� }
E Pt3OR!SCTON �� � G
2.1 Owner of Record:
A/ Q lrJ�..` t`to GL.�,k►...), S4, F1erc c!, 111 ia' OIO(,
Name(P ' Current Mailing Address: cf") 58 y 1? 11
Telephone 7
Sig' to
A prized Molt: / i / _ _03,
Name{P• tC/`� Current Mailing Address: a�0o2
Y/3 -6?-7 - 7 g 7
Signature Telephone
I II P - - `.€1 t 0 ��.J:._I I.L.,• I ', �.-, '
Item Esti mated Cost(Dollars)to be
Official Use O
completed by permit applicant
1. Building �: o ��
(a)Buy Permi
6
ding t Fee
2. Electrical :'(b)Estimated Total Cost of
Constrtition m 6). ^
3. Plumbing Bung Permit Fisa
4. Mechanical(HVAC)
5. Fire Protection
6. Total= 1 +2+3+4+5 `Check> umber.
Tim on For Offload ded
Date
Bullring Penttint plumber Issued.
S nature:
Budding Comml MMlns or:of s
190 CHESTNUT ST BP-2013-1249
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-058 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit# BP-2013-1249
Project# JS-2013-002058
Est.Cost: $6000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD LABOMBARD 055340
Lot Size(sq. ft.): 14897.52 Owner: WHITTIER SARAH JANE
Zoning:URA(100)/ Applicant: RICHARD LABOMBARD
AT: 190 CHESTNUT ST
Applicant Address: Phone: Insurance:
102 CLARK ST (413) 527-7427
EASTHAM PTON MA01027 ISSUED ON:6/28/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS & ENTRY
DOORS
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 6/28/2013 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner