17C-153 (3) Massachusetts General Laws chapter 152 requires all employers to provide worker' 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 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.
Fhe Offce of Investigations would like to thank you in advance for your cooperation and should you have any questions,
Tease do not hesitate to give us a call.
"re Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Departrient of Industrial Accidents
Office of Investigations
600 `Z'ashinaton Street
Boston, IVI�? 02111
Tel. - 617-7217—`900 exi 406 or 1-8 7 7-ti1ASS<.=E
Fax� 617-727-7749
The Commonwealth of Massachusetts
Department of Industrial Accidents
- Office of Investigations
ZZ
. :. 600 1 Yashington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AI7Alicant Information / Please Print Leizibly
Name(Business/Orzanization/Individual): � i't ���' C' r
Address: s l � /,,Z t 2.-IL X
City/State/Zip: Z= e c d,
Phone #: :,2 /0
Are you an employer? Check the appropriate box: Type of project(required):
4. I am a general contractor and I
1.Q I am a employer with U 6. ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or parmer-
listed on the attached sheet. 7. Remodeling
ship and have no'employees These sub-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.]
D. 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. ['=`o workers' comp. right of exemption per MGL 12.7 Roof repairs
insurance required.] t c. 152, §1(4), and we have no 13 ❑ Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
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 far my employees. Below is thepolicy and jab site
information.
Insurance Company Name:
Policy:or Self-ins.Lic. ;r: 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. Ii2 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
I do hereby cerr under :e pains and penalties of perjury that tine information provided above is true and correct.
S;1na ure: Date:
Phpne :
icial use only. Do not write in this area, to be completed by city or town officiaL
i
I
City or Town:
Issuing Authority(circle one):
L Board of Health 2.Building Department 3. City,Town CIerk =.Electrical Inspector 5. Plumbing Inspector
6. Other
i
Contact Person: D one
1 � 2
BATHROQM
0
B.TUQY BEDROOM
- CHIMNEY LL
( 1 ,
DN CHIMNEY
yu
-------- ---------
1 1 / 4i
1 1
�-
i
1 1 .
BEDR00M
Iij
CLOSET
I
f1y>r,+�_ /VGA✓• °�
s
R.f
' r 1v'<,SME :,�_ �^ .11f4}t'W-'�'bKN.1'.tair SS.wk^it'^-+tMlYwu!f.�iP.a.•n.:+Y 9.IfF.-wSaYi r-.xq.nyw"'t'.�'-"�nR}+rt-w.,,r{ ....
SECTION 2-CONSTRUCTION SERVICES
PA, L =ed Const.*uc*ion SuoerAsor: Nat Applicable ❑
Name of License Holder: 1? ',)
License Number
4dcress Expiration Da(e
Signature Telephone
I
1_Reuistered Home Imaravetrtent:Contractor )._, _.._ .._. _,• Not Applicable ER
:omoanv Name Registration Number 1
.ddress Exp—ir �iDt e`3 i 5
Telephone
ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT EM:G.L.c. 152,
'alters Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
the denial of the issuance of the building permit.
cned Affidavit Attached Yes....... ❑ No......
3.. Home-04i erJg�i�1€ ion
The current exemption for"homeowners"was extended to include Owner-occupied DweWnQs 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.CI-IR 780. Sitth Edition Section 103.3.5.1.
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 2 homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.icial,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 15'3 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be Iiable for person(s)
you hire to perform work for you under this permit.
The undersimed"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
i
i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoolicable)
New House Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs =1 Decks [F7 Siding[G; Other[p] I
Brief Description of Proposed
Work:
f
Aiteraticn of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Rencvatino unfinished basement Yes No
Plans Attached Roil -Sheet
sa. If New house arrc ai addition to ezistirn4-housing.:c' ' fefe thy-fattay+rina:
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 EnerCom fiance form attached?
h. Type of construction
i. Is construction within 100 ft_ of wetlands? Yes No, is construction within 100 yr. flocdplain 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 TdBE.COMPEETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR:Bt1It:DING-P1=RMIT
11,y to &11— as Owner of the subject
property
hereby authorize J�11
to act on my behalf n ail m tze ra tive to work authorized by this building permit application.
,� -� o
Signature of G r Date
i as Owner/Authorized
Agent'here eclat ",at the sta*.ements and information on the foregoing application are true and accurate, to the best cf my knowledge
and befief- I
Signed urder the pairs and penaltie cf perjury.
Print Name �
��crat_r2 of Cwner/gent ate
`
'
15ectjor4. ZONING Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
~
This column to be filledrin b�
Building Department
Lot Size
Re
Buildin.-Height
Open Space Footag
A. Has a Special Permit/Yahance/Finding ever been issued for/on the site?
NO 0 DONTKNOY _ YES 0
IF YES, date issued:
^ `
IF YES: Was the permit recorded at the Registry ufDeeds?
��
NO �� DONTKNOYY 0 YES
�
IF YES: enter Book Page and/or Document#/ �
B. Does the site contain a brook, body uf water orwetlands? NO 0 DONTKNOm/ 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tnbeobtained v~-� Obtained /~� Issued:
\_� �~/ ���~^^ ' L___-___---�
/
3 \/- /�~�
C. Doa�y�gnse�ston the prope�y? YES �~/ ^ mu �~�
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location: .
E. Will the construction activity disturb(clearing,gradingexcavation, or filling)over 1 acre or|oit part ofaconmnan plan
that will disturb over 1acre? YES � ) NO K )
�� ��
|FY�S�����N�f5���� S5��-V���K@��g�6�fPenn��omUheDPVVisrequi�d.
r
Department use only
City of Northampton Status of Permit:
Building Department Curia Cut(Dr veway Perrnit
212 Main Street Se)ver/Septic.Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of 5trudtural 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
This section to be completed by office
1.1 Property Address:
Map Lot Unit
Zone Overlay District
Elrri St District CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�A ry v 9,411;
Name(Print) f Current Mailing Address: J' ?�/_
r/ Telephone of V' /
Signature
2.2 Authorized Agent- _ Cr
Name(P ) Current Mailing Address:
Signat Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item I Estimated Cost(Dollars)to be Official:,Use Only
completed by permit apolicant
1. Building Sui7ding IPermit 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) r" < Check Number
This Section For Official:Use Onl
-Date
Building Permit Number: Issued:
Signature:
-- —-------------
Building,Commissioner/Inspector or Doings Gate
r
File#BP-2009-0246
APPLICANT/CONTACT PERSON JAMES HARRITY
ADDRESS/PHONE 515 KENNEDY RD LEEDS (413)210-5256 Q
PROPERTY LOCATION 92 HIGH ST
MAP 17C PARCEL 153 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: INSTALL REPLACEMENT WINDOWS&4 NEW CLOSETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 052260
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
Demolition Delay
LOa
Signature of Bm ding 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.
i BP-2009-0246
GIs#: COMMONWEALTH OF MASSACHUSETTS
` ) CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit# BP-2009-0246
Project# JS-2009-000319
Est.Cost: $12000.00
Fee: $72.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES HARRITY 052260
Lot Size(sq. ft.): 16335.00 Owner: KAYE SANFORD&MARY C DONOVAN
Zoning URB Applicant: JAMES HARRITY
AT. 92 HIGH ST
Applicant Address: Phone: Insurance:
515 KENNEDY RD (413) 210-5256 (�
LEEDSMA01053 ISSUED ON:91412008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & 4 NEW
CLOSETS
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 9/4/2008 0:00:00 $72.00863
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo