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16A-012 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations =s= �. ��. 0 600 Washington Street �... Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): f ` AI Z. el Address: 4 15 O S o°� City /State /Zip: e- e d s /22 0/C53 Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. n 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 These sub - contractors have ship and have no employees 8. n Demolition working for me in any capacity. employees and have workers' g Y P h' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.t required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3,1K I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs 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 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. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1 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 is providing workers' compensation insurance for my employees. Below is the policy and job 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 (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 and nalties of perjury that the information provided above is true and correct. Signature: c Date: 7 — 7 ^ / / Phone #: �i` _ 7116'.=2- Official 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. B of Health 2. B DPpartmPnt 3. city/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other • Contact Person: Phone #: • I SECTION 8 - CONSTRUCTION SERVICES a 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Hold License Number Address Expiration Date Signature Tetephone N N S Registered lome improvement , Contractor. :: J rirt. -Atiteek!,`,4„MlItt.i,, Not Applicable ❑ Company Name 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 = 'davit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes ❑ No ❑ tk- ` ° • °0 =me *.me 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 1083.5.1. 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 Ai. A ..-z 1 r • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) ■, New House ❑ Addition ❑ Replacement Windows Alteration(s) t l Roofing f Or Doors ED Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [D Siding [Dj Other [0] Brief Description of Proposed RE Q E -- b ach C r t (2S Work - N i Alteration of existing bedroom Yes k' o Adding new bedroom Yes �No Attached Narrative Renovating unfinished basement Yes 'o Plans Attached Roll - Sheet ffi a.,0 _ ewe house addition.t .ho nq co mtilete ihe7follovuinq: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit Number of Bathrooms /�1 c. Is there a garage attached? r ,r d. Proposed Square footage of new construction. Dimensions e. Number of sto r`'" f. Method of heating? Firepla : or Woodstoves Number of each ' g. Energy Conservation Compliance. M. scheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Y- No. Is construc I. • , ithin 100 yr. floodplain Yes No j. Depth of basement or cellar floor below this - • grade k. Will building conform to the Building . -. Zoning regulations? Yes No . I. Septic Tank City Se , -r Private well City water Supply -: SECTION 7a, OWNERAUTHORIZATION, ,TOPE COMPLETED WHEN OWNERS AGENT OR CONTRACTORAPPLIES, - FOR BUILDING PERMIT , r I, ,..-- Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this buil.'- •:ermit application. Signature of Owner Date I, o EV fF ` o q �` at Ag ent hereby declare that the sgtements and information on the foregoing application are true and accurate, to the est of my knowledge and belief. Signed under the pains and penalties of perjury. D© /i i d e o f eif Print Name ,-c. .a Signature of Owner /Agent Date '—ii 4 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information . y Existing Proposed Required, by',Zoning % This column to °be filled in by .^ Building Department Lot Size Frontage _ Setbacks Front i i i Side L:' R:' L i R:l I ! { Rear # 7-1 Building Height ? i l Bldg. Square Footage ? i i % 1 1 i- Open Space Footage olo (Lot area minus bldg & paved 4 j i 4 ` , parking) 4 { I # of Parking Spaces Fill: v__.�.._ _.._ .__. _.w._ t i _. w.. ____. _ 4 ___,__ =, (volume & Location) i t A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:;: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book ! I Page` { and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained. 0 Obtained , Date Issued: C. Do any signs exist on the property? YES 0 NO 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, grading, excavation, or filling) over 1 acre or is it part of a common plan that will'disturb over 1 acre? YES 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Fax 413 -587 -1272 r e J Departmeat'use on . of orthampton S f e r m i t s ue ‚3u'I.in. • Department � R ' �ay y ‘11,'-',... :x D � guewa � mitt SEP .. atilt 2 2 ain Street S e u ep t AVaitabili ' "3,30 Ro • m 100 Wale IWellA�iatiaiiili °_ 4Z ,` DE ; ;... mp•.n, MA 01060 - 24 § wta � ctciral ea 240 �P loi/tt 0143, othe pe cify. , , , ( i n„ 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: ' , w - , 'v ? o- a 4 v �'� ^3 3 c P :.. ?. re , x e +, , .03.;, x r. V /1 / N� L M'ap , lLot - , Unit'., ' , G d S Zone " 4 Overlay District x. h s ;Elm St ct : " =' ,..r; CB.District -` . SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT' 2.1 Owner of Record: fl ©N /tGd -¢ Qebbr, d oy -er'S' /3®c //& Le-ed-r 0/c53 Name (Print) Current Mailing Address: �e4 7z-/ o.2 Telephone nature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3: ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only , completed by permit applicant - 1. Building (a) Building Permit Fee 3 ©UG _ 0e , 2. Electrical (b),Estimated Total Cost of "io .., Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) , 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) Check Number ThisSection For Official Use Only - ...: Date . Building Permit. Number: . - Si Building Commissio /Inspector of Buildings Date • File # BP- 2012 -0247 APPLICANT /CONTACT PERSON ROGERS DONALD & DEBBRA ADDRESS /PHONE 450 SPRING ST LEEDS 0 584 -7462 0 PROPERTY LOCATION 450 SPRING ST MAP 16A PARCEL 012 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out `1��� Fee Paid I Typeof Construction: REROOF & PORCH REPAIRS 1TH I J CX 1ST11't f-06i'F1aTJ, New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION 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 / Ybg tl Signa 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. _____ 450 SPRING ST BP -2012 -0247 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 16A - 012 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 -0247 Project # JS- 2012- 000386 Est. Cost: $3000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 36154.80 Owner: ROGERS DONALD & DEBBRA Zoning: URA(100)/ Applicant: ROGERS DONALD & DEBBRA AT: 450 SPRING ST Applicant Address: Phone: Insurance: 450 SPRING ST () 584 -7462 () LEEDSMAO1053 ISSUED ON:9/15/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:REROOF & PORCH REPAIRS (SAME FOOTPRINT) 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 9/15/20110:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner