42-074 The Commonwealth of Massachusetts
, Department of Industrial Accidents '
'.- ;;=, Office 6f Investigations
. 600 Washington Street
Y ..qy
Boston, MA 02111
,.- www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /EIectricians/Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): _
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ 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
ship and have no employees These sub - contractors have 8. ❑ 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 10.0 Electrical repairs or additions
3. tiLi I am a homeowner doing- all work officers have exercised their 11. fl Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ 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.
t 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 is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: _
Policy # or Self -ins. Lie. #: 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, 506:00 and /or onE= year-imprisonment, - as welfas civil penalties -in --the form of a STOP WORK ORDER and a fine
of up to $250.00 a .. . gainst the violat. advised that a copy of this statement may be forwarded to the Office of
Investigations . 10IA for insurance co -,Loe verification.
I do her' .y ce fy undefr hepain and penalti ,.perjury that the information provided abuv. is true at d COIF Cf.
Sir • . ture: / / _ ..e 4 ). � D ate: _ my.
Phone - : ,
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 Rear-r- d- a-HeaIth ?. Rtifi 'nj Department 3. City /Tuwu Cierk__4._ElectricaIInspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9 .- Reuistered.HomeImprovement Contractor _, ,,.. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (MG.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 ❑
4 �
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 -ofthe- work€ or - 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" c 'fies and assumes res isibility for compliance with the State Building Code, City of
Northampton Ordinances, Stat- . d Loc9.l -Zo Laws a� :. to of Massachusetts General -LawsAnnotated.
C Jl/
Homeowner Signature �► ANie
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement dows Alteration(s) n Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [/Other [DI
Brief D ti n of p Pro osed l ^ �t �✓�
Work: V
0 L ` 4 li.p.tr 4 t '' ,ime) 'Door
Alteration of existing bedroom Yes � No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Ye No ee
Plans Attached Roll - Sheet !v 71i#7
6a. If, New house an or addition existing housing, complete; the. following: 5 C - ,m i
a. Use of building : One Family' , Two Family Other
- S .-- D R
b. Number of rooms in each family units, 5 Number of Bathrooms
c. Is there a garage attached? HID ....... —...� 7
_
d. Proposed Square footage of new construction. "-------„- Dimensions /
e. Number of stories? .�
f. Method of heating? 0 \\ Firepl_ - or400dstoves IV o Number of each l
g. Energy Conservation C . ante. Masscheck Energy COMplikice form attached?
h. Type of construction
i. Is construction within 100 ft. of wetland . Yes ! No. Is construction within 100 yr. floodplain Yes No
�ti
j. Depth of basement or • - Ila ' .. r below finished grade
k. Will building co 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, C ' CkC , ? r5 , as Owner of the subject
property
- hereb authori -ze . `C 1 � eho 1
to - ' o my behalf, in all :tters relative to ork authorized by • ding p it application.
r
Ir. Tr 7. 2� � Date
I, , as Owner /Authorized
Agent hereby declare 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 penalties of perjury.
Print Name
Signature of Owner /Agent Date
r
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:
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Findin ever been issued for /on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Re stry of Deeds?
NO 0 DONT KNOW 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 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Da 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 I NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex vation, 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.
Departm gse :only
City of Northampton t rf it:� � K
Building Department f 0 ftE 4 ,0r r F ah 0f
212 Main Street urer S iIabthty 4 ` . g ` F
Room 100 Wate yari tkt
40 '
Northampton, MA 01060 Two bets ofSterctur :,-,'-'.'.10'4:\\'',,,,:'\'''',-;"''
phone 413- 587 -1240 Fax 413- 587 -1272 I? ottSite f?fans, Se
ti1e '' a m
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEM • AH AcO OR TIAIO DWELLING
2
SECTION 1 - SITE INFORMATION ���
This section to be c,phipleted by office
1.1 Property Address: <
97-
G leto c ._. c�� / r Map t4t ( Unit
\OCe V " ` r'1 b Zone \ Ve District
y
"Etm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2. Owner of Record:
'-s- ; ' MC r` _- f 2 9. ? GI e re c 'R(c) F 1or't
Na' - Prim, air Maili ddfess: WI
Al .4 _ .AI , i elephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
S 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated- Cost - (Dollars) -to -be Official Use Only
completed by pemiit applicant
1. Building /57)0 f/'C)V*' 1):,Y' ����C' _ 50 .-(a) Building Permit Fee
t t7r �
t S' t 010 SV►r. keS
2. Electrical (b) Estimated Total Cost, of
lS ® � - Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 5 00
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
.. .. _,. --- .. - - This Section "F
o� Offiicai tlse "Only
Date Issue
Building Permit Number: Issued:
Signature : - 7 e f / Y
Building Commissioner /Inspector of Buildings Date
...............
•. r
BP-2010-0015
GIS #: COMMONWEALTH OF MASSACHUSETTS
fitimatitkva. ' 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- 2010 -0015
Project # JS- 2010- 000023
Est. Cost: $1500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 4486.68 Owner: ODGERS MARY C & CRAIG W
Zoning: SR(100) //WSP II Applicant: ODGERS MARY C & CRAIG W
AT: 97 GLENDALE RD
Applicant Address: Phone: Insurance:
97 GLENDALE RD (413) 585 -0935 0
FLORENCEMA01062 ISSUED ON: 7/7/2009 0:00:00
TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT DOOR /SIDING
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 7/7/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo