17A-203 The Commonwealth oflMlassachusetts
Department of Industrial Ae dents
Office of Investigations
t 600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I'seaie Frwt r e-ibly
Name(Business/Organization/Individual):
Address: }�c�--
City/State/Zip: t��t 11 '�. `� Phone-#: �// 3 - 3 a/ ,
[2. re u an employer?Check the appropriate bog: Type of project(required):
I am a e Io er with 4. ❑ I am a general contractor and I
mP Y 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors❑ I am a sole proprietor or partner- Iisted 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' 9 ❑Building addition
[No workers' comp.insurance comp.insurance.$
required.] 5. ❑ We are a corporation and its IO_❑ElectricaI repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 I.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.[]R f repairs
insurance required.]t c. 152,e 1(4),and or have no
employees.[No workers' 13. Oth er �
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 anew affidavit indicating such.
tContractors 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.M NC—J4)'v)0- Q N y'14o U - 09, -
Expiration ate:
Job Site Address: �Q�/�� CityiState!Zip:` r�,f'L(��
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.
I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct.
Si na re: '` Date: 4-241'
Phone#: � 3 3 j d
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: PermitlLicense#
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#:
City of Northampton
l� Massachusetts
a;
DEPARTMENT OF BUILDING INSPECTIONS 9`• .�'
212 Main Street • Municipal Building
Northampton, MA 01060
Property Address: �Q , °" r ��
Contractor
Name:
Address:
City, State:
Phone:
Property Owner
Name: l Gt
Address:
City, State: �a wi
c.
I, !1'1�I� T � I`� (contractor) attest and affirm that the building I intend to
insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor s' nature
Date
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work:
The debris will be transported by:
The debris will be received by:
Building permit number:
Name of Permit Applicant
N� �
7
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction u ervisor: r Not Applicable ❑
Name of License Holder: - �� Y��� J f Idd 7
License Number
LILA 6" /6 to//(,
r ss I Al Expiration Date
--- - ei� �
S nature Telephone
9 Realstered Home Imarovement Contractor: Not Applicable ❑
Company Name . Registration Number
r(4, r&u�c 7
Address Expiration Date
Telephone9 IJ
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 buildingpermit.
Signed Affidavit Attached Yes....... No...... ❑
11. -Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied DwOlings 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 o a parcel of land on which he resides or intends to reside,on which there
is,or is intended to be,a one or two family dwellin , ttached or detac structures accessory to such use and/or farm
structures.A person who constructs more than one ho in a tw -year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the builArn mit,
As acting Construction Supervisor your presence o e job site wi be required from time to time,during and upon
completion of the work for which this permit is is d.
Also be advised that with reference to Chapte 2(Workers'Compensati and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in De of the Massachusetts General ws Annotated,you may be liable for person(s)
you hire to perform work for you under is 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[S
v
Brief Descriptio�of P posed� tlk� I r f Q S i G 5"5 1 – J�/ '' y--
Work: L-2 40 - � '� t_i Xx,Gc G�i1St 5 Iir�S � - 001 V2.�}S ; �7 i yP/n h(a:�1�t
Alteration of existing bedroom Yes ,,"— No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes /No
Plans Attached Roll -Sheet
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
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�I R ✓�'C�� 1�j7 as Owner of the subject
property f
hereby authorize
to act on my half, in tters elative to work authorized by this building permit appligatign.
Signature of Owner Date
J(Z n C C /,' > as Owne orized .%
eni ereby declare that the statements and information on the foregoing application are true and accurate,to the best of�ge
and belief.
Signed under the pains an"e akties of perjury.
e%, -
Pri e _
:::�z _
Si nature of O er/Agent'i 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 Q DONT KNOW Is YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW 0 YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q 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 0
IF YES, describe size, type and location:
E. Will 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 O NO
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 Cuuwvewey Permit
212 Main Street SmAwlseptic Avaflabitty
Room 100 WaterlWelt Availability
5�o
eb Q�o� Northampton, MA 01060 T%wa Sets of Structural Prins
<� 16, $ one 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify_-_-____-__
�6�rTION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
m
SECTION -SITE INFORMATION
1.1 Property Address: This section to be completed by office
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
a '-n 0
Nam Print,) Current Mailing Address:
Telephone
Signature l
2.2 Authorized A ent:
Na t) Current Mailing Address:
Signat a Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building J, -"' (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
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2015-1216
APPLICANT/CONTACT PERSON IDEAL HOME IMPROVEMENT INC
ADDRESS/PHONE 142 BOYLE RD GILL01354(413) 863-2128
PROPERTY LOCATION 23 POWELL ST
MAP 17A PARCEL 203 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiny Permit Filled out
Fee Paid
Typeof Construction:_INSTALL ATTIC INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildinpz Plans Included:
Owner/Statement or License 091207
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
_A proved 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
on Delay
AgRffrurBlifding 6fflcial 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.
23 POWELL ST BP-2015-1216
GIS#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 17A-203 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-2015-1216
Project# JS-2015-002298
Est. Cost: $3043.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq ft.): 18251.64 Owner: O'LOUGHLIN CAOLAN
Zoning: URB(100)/ Applicant• IDEAL HOME IMPROVEMENT INC
AT. 23 POWELL ST
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863-2128 WC
GILLMA01354 ISSUED ON.61512015 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL ATTIC INSULATION
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 6/5/2015 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner