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31B-237 (4)
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If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 Not valid without signature James LeBeau S/Z by PO Box 503 Goshen, MA 01 :u I& ( Vvct N V- V0,C. cam ` .. At' � elta Tv\.S ; p©1i`c � gtt2Y3cd, i3 The Commonwealth of Massachusetts Department of Industrial Accidents W Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual)Jaff1Q$ LQBB9u PO BOX 503 Address: GOMM MA 01031 City/State p: Phone 3 26F- Are yo n employer? Check the appropriate box: 4. am a general contractor and I Type of project (required): 1. I am a employer with 41 11t g employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.: 9. E] Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.[:] Other 1Gr /Gti 1�CQr7t employees. [No workers' 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. 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 L Policy#or Self-ins. Lic. #: Expiration Date: q1Job Site Address: T7 L City/State/Zip: n 4 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration te . 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. l do hereby certif under th,pains and penalties of perjury that the information provided a ove is true and correct. Si atur . r Dater 2 Phone 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#: LBUSI y4P_ & LeBEAU BUILDING CONSTRUCTION JOBS C% �C3 ,'c_ LOA leA- * * SHEET NO. OF ,'NEgiCA GQ'-4 (413) 268-3380 CALCULATED BY DATE MA Lic. #005304/103839 James LeBeau CHECKED BY DATE PO Box 503 Goshen, MA 01032 SCALE �eC o��'�►r� �r�-e:�r ��a� u.aGr.4 �i-�rK e. } nAl �,a C N►v 3 _ klol`i u>►►� j o �0�` BSI Veri�`�C i 2 o 20" D PRODUCT 207 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aualicable) New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other[ Brief Descri on of Proposed �f Work: pmmJ�? /G� tee/P .S�»P yMs�Y'o.� 11Q191FLp 4Jj i lD�B�i71�'I'r�e �'!%'intC/Ic �/L marse flU Alteration of existing bedroom Yes No Adding new bedroom Yes 4,"— No Attached Narrative Renovating unfinished basement Yes i No Plans Attached Roll -Sheet T,-k"XP,1' 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. 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 OWNS S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on al relative to work authorized by this building permit applicati n. Si ature of ow9Kr Date a" I I, ✓ TLI, C- as Owner/Authorized Agent her6by d& that the stateme is an in ormation on the fore oing pplic tion are true and accurate, to the best of my knowledge and belief. Signed unOe5the pains and p rName, s of erjury. Pint ' / Signature o wner/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 t ao Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Findin ever been issued for/on the site? NO ® DON'T KNOW YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DON'T KNOW ® YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO OX 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,exc on, 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. Department use only it City of Northampton Status of Permit: building Department Curb Cut/Driveway Permit MAY r 212 Main Street Sewer/Septic Availability 2 2��4 Room 100 Water/Well Availability Electric, Plumbing&Ga Ins cY N hampton, MA 01060 Two Sets of Structural Plans Nor":hampton, m V? 587-1240 Fax 413-587-1272 Plot/Site Plans Other Speci APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH ONE OR TWO F MILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office f 9 Cali Ste, Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: r/ Name(Print) Current Mailing Ad ress: ire 1.00e Telephone Signatu 2.2 Authorized Agent: Na Pn t) Current Mailing Address: Z// S' ature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (�r, oe, (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=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2014-1234 APPLICANT/CONTACT PERSON JAMES LEBEAU ADDRESS/PHONE P O BOX 128 WILLIAMSBURG (413)268-3380 Q PROPERTY LOCATION 49 GOTHIC ST MAP 31B PARCEL 237 001 ZONE CB(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 Ty_peof Construction: REPAIR FOUNDATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 005304 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: __k/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 olition 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. 49 GOTHIC ST BP-2014-1234 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 3 1 B-237 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2014-1234 Project# JS-2014-002077 Est. Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JAMES LEBEAU 005304 Lot Size(sq. ft.): 7753.68 Owner: WHALEN PETER J Zoning: CB(100)/ Applicant: JAMES LEBEAU AT. 49 GOTHIC ST Applicant Address: Phone: Insurance: P O BOX 128 (413) 268-3380 () WC WILLIAMSBURGMA01096 ISSUED ON.512712014 0:00:00 TO PERFORM THE FOLLOWING WORK.REPAIR FOUNDATION 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 5/27/2014 0:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner