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17C-153 (2) LA-6qh -KAY - Zb I - f p ..6 Ji^ t a ii t .f�F-'� 4Y-� t.• ,.' it . 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." Additionally,MGL chapter 152, §25C(7)states "Neither the conunonwealth 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 certificates)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 Iine. 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 ilte 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 1 Congress.Street, Suite 100 Boston, MA 02114-2017 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts Department of IndustrialAccidents M1 Office of Investigations ' . I Congress Street, Suite 100 f 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): Address: 2Z37 City/State/Zip: 661ik) )A1'q 1 K4- 6 Phone #: 341 ' qZJ Are yo an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. E] 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. [ Remodeling ship and have no employees These suU-contractors have g, E]Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. F-] We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their I L Plumbing repairs or additions 3.❑ I am a homeowner doing all work g P myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] 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. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. r Insurance Company Name: c,(�Gr( � � Policy#or Self-ins.Lic.#: ZJq 2-0LVA, Expiration Date: 3'2).2-0/5 L �b �T- ��-r & � Job Site Address: City/State/Zip: -��� !"1 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. Ido hereby certify un r the pain andpenalties of erjury that the information provided above is true and correct. Signature: i _ Date I .. '_2 . Phone#: Offccial 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 ❑ Name of License Holder: �'l �1- � G✓ - 0"fO 7-21 License Number Z23 15 d-6"V l(4� 6t� S it-A , 6e ti &1 t, vtl F o 12-- 2-1 ICS Address Expiration Date VV 1 I>- 36 Z� Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ /0 S f6 n� Company Name Registration Number M 70W -7 _z-I -- 10 Address Expiration Date 22�j StJ FYj ►�- 1 �/l/w i 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....... No...... ❑ 11. - Home Owner Exemption The current exemption for"homeowners"was extended to include Owner-occupied Dwel ' s of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not possess icense,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 whi a/she resides or intends to reside,on which there is,or is intended to be,a one or two family dwelling,attached or de - ed structures accessory to such use and/or farm structures.A person who constructs more than one home in wo- ear period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,o a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the ildinp,permit As acting Construction Supervisor your presenc• n the job site will be required from time to time,during and upon completion of the work for which this permit i, sued. Also be advised that with reference to('ha er 152(Workers'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in ath)of the Massachusetts General Iaws Annotated,You may be liable for person(s) you hire to perform work for you er this permit. The undersigned"homeowner" Ties and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,S and Local"honing Iaws and State of Massachusetts General Iaws Amiotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aaalicable) New House Addition ❑ Replacement Windows Alterations) Roofing Or Doors D Accessory Bldg. ❑ Demolition [Ef New Signs [0] Decks [[3 Siding[0] Other[C3] Brief Description of Pr '��-rVlf7 S1 o� 1 S' �12- 'SATIf UP MI6- _rh 1 v'" S Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes r/ No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, comulete 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. ­Di mensions 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 f or 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 L, r I /01 11�0✓' ry''fP as Owner of the subject property hereby authorize to act on my behay, in all �aers relative to work authorized by this building permit application. Signature of Owner ' Date 1z" as Owner/Authorized Agent hereby declare that the stat ments and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pai yan pe nalties of perjury. /4lN7, Print Name Signature of Owner/A nt Date I IV Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information 1_;xisting Proposed Required by Zoning This column to be filled in by Building Department Lot Size -Frontage Setbacks Front Side L: R: L: Z R: Rear Building Height Bldg. Square footage °o Open Space Footage (Lot area minus bldg&paved parking) #of Parking Spaces Fill: IX (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO U DON'T KNOW Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW Y IF YES: enter Book P e and/or Document# B. Does the site contain a brook, body of water r wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the pr erty? YES NO IF YES, describe size type and location: D. Are there any pr sed changes to or additions of signs intended for the property? YES 0 NO IF YES, de ribe size, type and location: E. Will the nstruction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan that I disturb over 1 acre? YES 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability " Northampton, MA 01060 Two Sets of Structural Plans 6 t'tphon'e.' 13-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify c,7jN t 8g NSTRUCT, 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 q2- �K,014 ST, Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 1111.1 Owner of Record: 5o1h�0✓'� k��� °jZ tq 10(0 Name(Print) �r Current Mailing Add ess: `�13-S�lo -y�z3 Telephone Signature 2.2 Authorized Aaent: Name(Print) Current Mailing Address:COAJW" V4 bl-j�t 4122 ?(a Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building t b�0 (a)Building Permit Fee 2. Electrical -1 (b)Estimated Total Cost of Construction from 6 3. Plumbing C?OQ Building Permit Fee I ' 4. Mechanical (HVAC) 1 000 t 5. Fire Protection 6. Total =(1 + 2+ 3+ 4+ 5) ,_ Check Number 6 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Comm issionerllnspector of Buildings Date File#BP-2015-0737 APPLICANT/CONTACT PERSON MARK LADD ADDRESS/PHONE 223 SHELBURNE FALLS RD CONWAY01341-9701 (413)369-4294 PROPERTY LOCATION 92 HIGH ST MAP 17C PARCEL 153 001 ZONE URB(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 Tyueof Construction: REMODEL 1 ST FLR BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 040771 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9RM7tTION 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 D n y Sig re u' ing Olfi cial 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. 92 HIGH ST BP-2015-0737 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 153 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2015-0737 Project# JS-2015-001429 Est. Cost: Fee: $70.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: MARK LADD 040771 Lot Size(sq. ft.): 16335.00 Owner: KAYE SANFORD&MARY C DONOVAN zoning: URB(100)/ Applicant: MARK LADD AT. 92 HIGH ST Applicant Address: Phone: Insurance: 223 SHELBURNE FALLS RD (413) 369-4294 WC CONWAYMA01341-9701 ISSUED ON:112112015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMODEL 1 ST FLR BATH 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 1/21/2015 0:00:00 $70.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner