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23A-174 r • • . , 7 The Commonwealth of Massachusetts �, _ Department of Industrial Accidents I = f Office of Investigations to, a S 4 " Investigations - rr_ + 7 ❑ 600 Washington Street 3� =f� x Boston, ALI 02111 ;. www mass gov /dia -Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers Applicant Information ` r Please Print Legibly Name (Bus nes V-. . " r/5 ;‘,.. ( i , t 5C. i\ Address: : . J-4: - It ,C (e, . `- -) /0 ty f y City /State/Zip: - Phone. #: 4l — S �(- )ii) 4. Are you an employer? Check the appropriate box: . Type of project (required): / 1.0 I am a employer er with 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have hired the sub- contractors I ani a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no, eloyees These sub - contractors have. .8. 0 Demolition working for me m any capacity ea�Ioyees and have workers' 9 - Bud ton [No workers' comp. insurance -. co iesu a t Q - -� r 5. � We are a corporation and its 10.0 Electrical repairs or additions officers have their . 11. - Plumbing r 3.0 I am a homeowner doing ill work ❑ mg epairs or additions myself [No workers' comp. right of exemption per MGL 12:0. Roof repairs insurance required.] t c. 152, § 1(4), and we have no r employees: [No workers' . 13.(1 Other yt'( r- lei,t..•a.,, coml% insurance reclaim :4J • 'Any applicant that checks box #.1 must. also fill out the section below showing heir woria rs' compensation policy information: • t Homeowners who submit this affidavit.indicating they are doing all work and then hire outside contractors roust submit anew 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 lithe sub-contractors have employees, they mustprovide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob site information. • Insurance Company Name: . Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: • City/State/Zip: - Attach a copy of the workers' compensation policy declaration page the policy n umber. and expiration date). Failure to secure coverage as required 25A: ofMGL c. 152 can lead to the iiiiposition of'cnniinal 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 $250.00 a day against the violator Be advised 'that a copy of this statement maybe forwarded : to the O.$'ce of Investigations of thelIA for insurance coverae verification: I do hereb ce ' er und the r, .y - .fY under Pai and penalties o. fPerJury that the cn,�ormation�rovided�avE cr �icE aaLrvrre� Signature: - ----,> �. Date: { , ((M Phone #: - . Official use only Do not write in this area, to be completed by city or tow 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. PIumbing Inspector 6. Other Contact Person: Phone #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : V- k 'le; I N Oil t j E. i\ 9: 5 ?— License Number L,-; ? tt (,, ar ■) E V--t\ 1 OS, Vic. - _i'i(A . I i Address r Expiration Date Si ' gle tune Telephone 9 :RRect teredaom iii.gro leme tt`iContiacWr aiill Not Applicable ❑ Company Name Registration u ber Address Expiration Dat Telephone yA) )6)1 — 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 ❑ tai 4%0er t The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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 SECTION 5- DESCRIPTION. OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors E _ Accessory Bldg. ❑ Demolition ❑ New Signs ED] Decks [E 1 Siding [D] Other [g1 1 Brief Description of Proposed I z I ' ,,,, t; ` . L.14 (..tx V` t, ■ t'( It Work: Is 4 � ,1k S-ok_5‘40l'atcti3OYk Y-e— PA,cti Alteration of existing bedroom Yes o / No Adding new bedroom Yes < No Attached Narrative ■ Renovating unfinished basement Yes _____,... o' Plans Attached Roll - Sheet y� �y tS c 6 'tlfE Ot k 6 C. - dtti re i fffi ,p e ,. fi / -i iMila M. 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 ,)r l Ai Ih e_14 1244 • '‘'. 07\ , as Owner of the subject property hereby authorize to act on bea in all u - •ers rel- •' to work authorized by this building permit application. (if kl /I I Ar hiure • _ , Date I ' a - , as Owner /Authorized Agent hereb • eclare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and p alties of perjury. V_ ► v' s 62 Print Name f `i�� _ I Signature of Ow - nt 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 i d .i F Frontage l (_ Setbacks Front = [ R L. Side L: 1 R:i -_ _ ' L: : R:1 Rear = I-1 ' i Building Height 1 E___ Bldg. Square Footage = I 1 % r m i LI 4 Open Space Footage ; % (Lot area minus bldg & paved 1 1 1 1 l e .mi Lam.. parking) # of Parking Spaces (volume & Location) L `_ - A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES 0 ffi I IF YES, date issued:; t IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book j I Pagel and /or Document it B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0 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 0 NO CIA IF YES, describe size, type and location: € I D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO ,, IF YES, describe size, type and location: I J 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 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. - .o . g am ; City of Northampton - RECEIVED Building Department k • LSEP . 1 11111 212 Main Street =� '..,, Room 100 e6 • rthampton, MA 01060 • R ' phon 3 41c-587-1240 Fax 413 - 587 -1272 ` �� L OF & LDl i0 N TICNI{ . - i �.u... u•., .. „ 'Y APPLICATION TO CONSTRUCT, 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 6 ; 9 i n t 4-t-' Map Lot Unit Zone Overlay Drstrh t f (ate, c,,_ __,t -c._- © / 0 0 Z.— Elm St. Di `..: 'CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ::: ? - e Current Mailing Address: — 4 1 4 Li 2.2 Authorized Agent: Name (Print) Current Mailing Address: L._2, --v ._ ,tom - 0 / 5 4 Signature Telephone L' 49 — 1 0 'Z 7 SECTION 3 - ESTIMATED CONSTRUCTION COSTS J 1 Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ©� O - (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) s ^ 0O o Check Number f This Section For Official Use Only (f Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date . • File # BP- 2012 -0255 APPLICANT /CONTACT PERSON KRIS THOMSON ADDRESS /PHONE 257 MONTAGUE RD LEVERETT (413) 549 -1027 () PROPERTY LOCATION 36 PINE ST MAP 23A PARCEL 174 001 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 i Fee Paid / et6 1 66-- Typeof Construction: REPAIR 15' OF SILL & FOUNDATION - BRICK ABOVE GRADE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 084152 3 sets of Plans / Plot Plan THE FOLLOWING 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 Demo,;hn Delay __ 4111(0011.1° f— 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. v 36 PINE ST BP- 2012 -0255 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 174 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- 2012 -0255 Project # JS- 2012- 000400 Est. Cost: $5000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KRIS THOMSON 084152 Lot Size(so. ft.): 5183.64 Owner: ROTTIGAN MATTHEW Zoning: URB(100)/ Applicant: KRIS THOMSON AT: 36 PINE ST Applicant Address: Phone: Insurance: 257 MONTAGUE RD (413) 549 -1027 Q LEVERETTMA01054 ISSUED ON:9/16/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REPAIR 15' OF SILL & FOUNDATION - BRICK ABOVE GRADE 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 9/16/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner