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17A-113 (4) M Commonwealth of Massachuseft .Department of Industrial Accfdents Dffrce Of investigations 600 WashhgWn Street Bosft,?yfA 02111 wwis. s,grnt/Wrtn Workers' Compensation Insumnee Affidavit:BuilderslContmetomElectricbw Plumbers Annlicant W-ormati nl Please Print IA 'b2� Name(Business/t)rpatsizatiotalltadividval}: '�"� — ru►c��5.�`'r��3'!ts_t"��3 -- -- Address: City/State/Zap: j lei Phone#: Are you an employer?Check the appropriate box; of project 1.91`1 am a 1 with a o 4. ❑I am a general contractor and I 6. e construction tTeQ ) employees(full andkr part time).* have hurl the sub-contractors 6. D New doling 2.7 I am a sole proprietor or partner listed on the attached sheet fi. Remodeling ship and have no employees These sub-contractors have 8. rl Demolition working for me in any capacity. employees and have workers 9. []Building addition [No workers'comp.i3ts mmee ",omp.insurance.` required.] 5. [] Vie area corporation audits 10.❑Elecmical repairs or acklitions 3.0 I are a homeowner doing all work of cers have exercised their I l.❑Plumbing repairs or additions o workers'cum right of exemption per MGIJ myself.� p• 12.Q hoof repairs insurance required.] c.152,§1(4),and we have no 13 employees.[No workers j insurance re*dred.3 'Any applioaas that chec a.box pa ast also fill out the section below showing their wodm'=vwu6oapdicyW=ufim t Homtaw=who submit this ate wd=ftg they am drag all watt and then has amide acmes oast subunit a saw affidavit in&=64 such. tCwtracw that check this"boot gnat a nobed an additi"shit showing the T—of the sub-coatram s and state wbedw er not!hose ruatm have =Vloycm If the sub c mQact;us have cmployets,fy mou provide their wmk='coop.policy mmtber. I urn an engWgtr that is provdd q worken'conqmMadeft/hrsurrrnce jbr Xry engaloyem Blow h thepo&7 aid jolt site Insurance Company;dame: [��C t� ����r+e _L�"+�.��C��:° C=CJ LF Policy#or Self-iris.Lac.# S l f Expiration Date: 1 i j Zc4!j Job Site Address: 4 C IGt., r,1P.- A . Q C45tatvLip: fr 1Lk'��., Ma-0 Attach a copy of the workers'compensates policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 23A of MGL c.152 cc lead to the impodd an ofcrimi w 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 5250.00 a day against the violator. Be advised that a copy of this stadement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c der atepahrs axd penaMles©f perjn,-y that rke hife nsadm provided above is fate and Corr" Si e#: Metal use onty. Do not tor&in rims area,to be coanpteted by city or tows offldid City or Town: Permit/lUeense# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: ..: �!,.. . .r,r, ..1: .. ., � « '. SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: 1, Not Applicable ❑ Name of License Holder: ,ACS lei, twuc SK. 9 erIO License Number _ 'to CcWgc%Ae Sgk;aX=-#!dd inA a»zq 7/S'IZoA- Addr ss Expira ion bate z _ Signature Telephone 9.Reaistered Home Improvement Contractor: Not Applicable ❑ L (t,t (Wcy e 4 -" #w ((,7)t2D Company Name Registration Number E�tQ Ll &-AAyd la - Ale-w M. A:..- A cA.as'�. lit/4 1701!1 Addresses,, / , / Expiratio Date (_LCf 14k o�/ Telephoner)' SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c.152,§25C(6))771 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....... 0" 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 C r .,. ' r f � i C�.,'v� • rt, ,'7 4 • y • r. • 1 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[p] Other[ Brief Descnp ion of Prop sed Work: u�N:r �+nic..�e.�:�. -u-Y3 scc If Alteration of existing bedroom Yes_,Z No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes w-l' No Plans Attached Roll -Sheet 6a.if New house and or a diti n 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? �'f'5 d. Proposed Square footage of new construction. eN\CQ Dimensions e. Number of stories? I f. Method of heating? (;,1,e d !A4 -Aw Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. I 2eA Masscheck Energy Compliance form attached? h. Type of construction .NM,6 ,r.S L.A 4,% 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 l 4 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 I, LAI pn Nj e-Q CitnonG as Owner of the subject property 7 hereby authorize ( .Sad -4: to act on y behalf, n all matt relative t ork authorized by this building permit application. 3Fisl]�( Signatu f Owner Date I, % L��� rytStrCa.i �a14o�►tr+S- 1-44 SrO►Q as Owner/Authorized Agent hereby de c a that the drafements and information on the foregoing pplication are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Name Signature of Owner/Agent Date 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: L: 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 I DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO � DON'T KNOW 0 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained ® , Date Issued: C. Do any signs exist on the property? YES 0 NO g 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. Will the construction activity disturb(clearing,grading,exc4vation,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. v :,i r Department use only City of Northampton Status of Permit: I' Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability -j Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans 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 '� C,�CrLtC� �Ve •'��Cr9tt� Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(P hnt) Current Mailing Address: Mt!t . Telephone Signature 2.2 Authorized Agent: A%C ko�& SvV-4k4*-.S Gy- 4cr- SA. .Aa:o , C1 Name(Print) uGaSZ Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit 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=0 +2+3+4+5) cii L.p V Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1004 APPLICANT/CONTACT PERSON VICTORY ENERGY SOLUTIONS LLC ADDRESS/PHONE 1 HARTFORD SQ SUITE 206 NEW BRITAIN (877)206-4483 PROPERTY LOCATION 4 CLAIRE AVE MAP 17A PARCEL 113 001 ZONE RIO 00)/URA(100)/WSP(7)/ 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:_INSTALL ATTIC INSULATION New Construction -,,- I ( q Non Structural interior renovations TI--7W- Addition to Existing AccessoKy Structure Building Plans Included: Owner/Statement or License 93101 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOOR�ION PRESENTED: pproved 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 mol' ' e y a - V-5-1141111-5-1 Signa e of Building O icial 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. 4 CLAIRE AVE BP-2014-1004 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 113 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2014-1004 Project# JS-2014-001746 Est.Cost: $1736.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: VICTORY ENERGY SOLUTIONS LLC 93101 Lot Size(sq. ft.): 10193.04 Owner: NEWDOME LYNN R Zoning: RI(100)/URA(100,/WSP(7)/ Applicant: VICTORY ENERGY SOLUTIONS LLC AT. 4 CLAIRE AVE Applicant Address: Phone: Insurance: 1 HARTFORD SQ SUITE 206 (877) 206-4483 WC NEW BRITAINCT06052 ISSUED ON:41412014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION - final inspection required 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 4/4/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner