17D-049 (3) Information and Instructions
vlassachusegs General Laws chapter 152 section 25 requires all employers to provide workers compensation for their
:mployees. As quoted from the "law". an employee is defined as every person in the service of another under any
.ontract of hire, express or implied, oral or written.
kn employer is defined as an individual, partnership, association. corporation or other legal entity, or anN two or more of
he foregoing enraged in a joint enterprise. and including the legal representatives of a deceased employer, or the
eceiver or trustee of an individual . partnership. association or other legal entity. employing employees. However the
,wner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the
1welling house of another who employs persons to do maintenance . construction or repair work on such dwelling house
)r on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.
AGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or
-enewal 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.
-,dditionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
)erformance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have
)een presented to the contracting authority.
kppiicants
'lease fill in the workers' compensation affidavit completely, by checking the box that applies to Your situation and
;upplving company names, address and phone numbers as all affidavits may be submitted to the Department of
ndustrial 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
:o obtain a workers' compensation policy, please call the Department at the number listed below.
,ry Mail
w
Zito or Towns
'lease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of
.he affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
:)e sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to
_lie Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank You in advance for you cooperation and should you have anv 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 InvestiSations
600 Washington Street
Boston, Ma. 02111
fax#: (617) 727-7749
phone 9: (617) 727-4900 ext. 406, 409 or 375 .
The Commonwealth of Massachusetts
Type or print legibly.
Department of Industrial Accidents
8=8 ofINNSU9211005
J'_ 600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
name:
location:
ciN
phone
f7 I am a homeowner performing all work myself.
1 am a sole proprietor and have no one working in any capacity
1 am an employer providing workers' compensation for my employees working on this job.
companvname �iI/�/^s/ 7if'Gf O✓t5�` '�,/'�/
address: /170 O xselx I6
city L°LCr/Er- 74 wet phone#: -422 — 26-3 'Z-7 '
in ura ce'c .. S Sf! . l✓I '7 fiev# 4L41C 70 os-" 4 oO
C I am a sole proprietor, general contractor, or homeowner(circle one) and have hired the contractors listed below who have
the following workers' compensation polices:
com anv name:
address:
city phone#:
insurance co U�o #
ciympanv name:
address-.
city: phone#:
insurance cn po(tcv#
:�tiatitiati�oasi rf sherSifaaetnss_�"'a
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51.500.00 and/or
one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
Id hereby ce under the par and penalties of perjury that the information provided above is true and correct
S isnatur
Date o —yZ/—
Pint n e ^ I_ ° 4re Phone
w official use only do not write in this area to be completed by city or town official
// --MM
city or town: ,CBE' permitAicense# Building Department
Q check if immediate response is required a
'el: ,4131534-2743 i
Fax:(4131 532.857'
' contact person: phone#-
l revifN 3105 PIA)
,CONS7RUCTIQN;SERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : �- r l L o o e-3 o 77?
License Number
/6'� ���'Ll�'•��a can ��./� . Z—/,V -- oS`
Address Expiration Date
3 4778
gja?ture Telephone
veme n .a `�, ,.._. Not Applicable ❑
Company Nam�e Registration Number
/
Address Expiration Date
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...... ❑
sa = earmpton€
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
xr a; ti d t,4 I'aia`;r4,ra;
S'ECTION5DESCRCp�7fCOFPROPOSED WORK check all a licable
:gpy4 9N.'.H'✓-+.,.-fi`k'.. 3A33 8. ;T 3 tl'ifF'K.?,se .i*..».'i+a,,., ,, a n—
a:
i
I
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: G s W
Alteration of existing bedroom Yes �o Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet A---
�If Ne ho -tidit"ions zistin""iliousin �"Iddf i 0 1 6 hb,1fol'WWIhik:
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: -7 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? 1d'�- /Qr% - Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
In. Type of construction /, �a"ze
i. Is construction within 100 ft. of wetlands? Yes moo. Is construction within 100 yr. floodplain Yes_l' o
j. Depth of basement or cellar floor below finished grade 7
k. Will building conform to the Building and Zoning regulations? ,-"Yes No .
I. Septic Tank City Sewer Private well City water Supply ✓
SECTION7a �Q 3ERA '�ORIZA710N TO BE COMPLETED WHEN
QWNl=�t5'J�GE T�Gr 1 RA6 70R"AP,,LlE$ FORB, 11-DING PERMIT
_ ZA A / as Owner of the subject property
hereby autho ' e to act on
my beh f, ' a matters re tive to k authori d by this building permit kllj�� :3
Signatur o wne Date
as Owner/A thorized ge
hereby declare that the statements and information on tht foregoing application are true and accurate, to the m
knowledge and belief.
Signed under the pains and penalties of perjury.
-J-71�) 4c->
Print Name
Sign of Owner/Agent Dat
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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 14—
Building Height 2 spa,-y
Bldg. Square Footage /X- %
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 DON'T KNOW '`/ YES
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 Y DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the property? YES 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
IF YES, describe size, type and location:
City of Northampton
Building Department C4
212 Main Streetr
Room 100
Northampton, MA 01060 eto
phone 413-587-1240 Fax 413-587-12720 flee F
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR 11 OM Ol E 1 DWELLING
1`
'
AUG 2 1 2003
SECTION 1 - SITE INFORMATION
1.1 Property Address: Th� f 'cet
Map'
/ ,/ Zone Over ay Des#rt x
x
EIm 5t. District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED'AGENT
2.1 Owner of Record:
4 S�rfww 41
Name(P 'nt) Current Mailing Addre s:
.5y�; - D oi9
y� Telephone
Signa r
2.2 Authorized Agent:
Name(Print),4— Current Mailing Address:
` -2.S'3 2 79 P
Sig t Telephone
SE t0'N3 - ESTIMATED CONSTR6C i6W6 OSTS
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 = (1 + 2 + 3 + 4 + 5) UGC Check Number "'
This Sect For Official'Use Only
Buifdi,ng Permit Number: JJ ""`. Date Issued:
s b v�'
I3�Ildingom ,lstonerll�ispector. B,u1N �ngs¢ gate .. a , .
File#BP-2004-0208
APPLICANT/CONTACT PERSON Diversified Construction Services
ADDRESS/PHONE PO Box 168 (413)253-2798
PROPERTY LOCATION 88 STRAW AVE
MAP 17D PARCEL 049 001 ZONE URB
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: CONVERT ATTIC SPACE TO STUDY&BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure �G -yr �7 GS
Building Plans Included: �„ �
Owner/Statement or License 030787
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLI( n 177,00-00J
INFORMATION PRESENTED:
Approved Additional permits required(see below) okv
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Spec: g,-y�a' Ve )O//S
Major Project: Site Plan AND/OR Speci
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Vari
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
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.
0 ot
,
Al
11A
D ,�, OF BU�ILD,NG
...........A
P-lp
IlZe