18C-139 The Commonwealth of Massachusetts
'-- Department of Industrial Accidents
rip ..- 4 Office of Investigations •
_, h i Er 600 Washington Street
' Boston, MA 02111
www.mass.gov /dia •
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A • • licant information Please Print Legibly
Name (Business/Org. r - . u I • .Yy . .
Address: t)t l ; •
City /State/Zip: 6 0/1S . Phone. #: Y/3 3V
Are you an employer? Check the appropriate box: Type of project (required): 1
1. ❑ I am a ....foyer with 4. ❑ I am a general contractor and I
6. ❑ New construction
* have hired the sub- contractors— — —
- . — .: (full and/or parf -1.* - -- -
2. si I am a sole proprietor or partQer- listed on the attached sheet. 7. ❑ Remodeling
— slop and have no employees These sub- contractors- have — .8. ❑ Demolition
• working for me in any capacity. employees and have workers'
$ 9 ❑ Molding addition
[No workers' comp. insurance comp. r
required.] 5. ❑ We are a corporation 1 0. and its ❑ Electrical repairs or additions
officers have exercised their 11.0 P1 ing repairs or additions
3. ❑ I am a homeowner doing all work
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.[] Other
- comp. insurance requited.]
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 indic sting they are doing all work and then hire outside contractors must submit a new affidavit indicatatg such.
ZContractors 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. policynumber.
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 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
Investieations of the DIA for insurance coverage verification
I do. hereby certify under the • and penolein of perjury that the information provided above is true and correct
SiJa :tore:' - . Date:
Phone #: `'3 3 _ •
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: .• Permit/Licensee #
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other r •
I Contact Person: Phone #: II
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable- 0
Name of License Holder : / /,iyJo7A
c-E. /
License Number
/ yr v &A 1Rci 1 Iv ( LE_ -eC S 111/ Ps c20
Address Expire ifon Date
3_ 337_ Prod
ature Telephone
Ti{f i ;`� "e � Not Applicable ❑
-7 the 71 L Gt Cs2
Company Name Registration Number
fi aX 1 le e_15 /1,uA- oyes /,q / c>20
Address Expiration Date
Telephoney (f— 387 7,Ce
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G L. ;15 , § 25C(6))
Workers Compensation Insurance affidavit must completed and submitted with this, application. Failure to provide this affidavit will result
in the denial of the issuance of the building p
Signed Affidavit Attached Yes No ❑
/11;;;,' '1'44 Yo•Ati4P1PAY
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
SECTION 5- DESCRIPTION': OF PROPOSED WORK (check all applicable)
New House 0 Addition ❑ Replacement Windows Alteration(s) E Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [El Siding [❑] Other [❑j
Brief Description of Proposed
Work: r► j V�S(n ' roar
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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. Wilfbuilding conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION TO E COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLI OR BUILD! MIT
I, r Y—" M i , as Owner of the subject
property
- 1 ,
here- authorize [i Lad
to .,� •n my 'eh- f,:14471atte relative to work authorized by this building permit ap lication.
iot t[ Opt[
Signature of Owner_ Date
I/ / . '"'— , as Owner /Authorized
Agent hereby dec r e 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.
-4910 ). 3
Print Name
/0/,
ign o ner /A Date
4 Q
a
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ,
~ Nr
Existing Proposed Required by Zoning ng -. x ' ,
This column to be filled in by
Building Department sk '
' Lot Size 1 1 f 1 1 v
Frontage f
Setbacks Front = 1 1 1
Side L:i i
1 R: i L:1 R:i i EI..`�_! 1-1
Rear 1 1 =1 1
Building Height = 1 1
Bldg. Square Footage 1 1 1% 1 1 11 f 1
_Open Space Footage %° €
(Lot area minus bldg & paved f 1 1 i = 1 1
parking)
# of Parking Spaces 3
1 i
Fill: 1
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:1 I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pagel 1 and /or Document # i '
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location: j
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location: 1
E. WIII 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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
%\ City of Northampton
• p� r 1 . Building Department j
212 Main Street
�jt'� °■`� Room 100
Northampton, MA 01060.
phone 413 -587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION ..
1.1 Property Addres This section to be completed
s: by office
a
/
,�Nlap�� �z � y � a Lot lJnif
-Zone iVr13,`
iritStistrlct :. CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
.4 T92� e lf}-
8 j 2 te t aemt
Name (Print) fi Current Mailing Address:
Telephone �C-�„I,_ L
Signature •J
2.2 Authorized Agent:
>' ,.9fz.t J. 1. ;� P o book 1 y Lej 1///i c;i0
},
Name (Print) Current Mailing Address:
7/) 3 S' �G
— Sig - .ture Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building /.3 dt-2Q' (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) /3 �
`� Check Number � 1
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings; - Date
i' �
91 BLACKBERRY LN BP- 2012 -0396
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C - 139 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0396
Project # JS- 2012 - 000636
Est. Cost: $13000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sq. ft.): 10715.76 Owner: KHADEMI PATRICIA
Zoning: URB(100)/ Applicant: TIMOTHY J LUCE
AT: 91 BLACKBERRY LN
Applicant Address: Phone: Insurance:
P 0 BOX 14 (413) 387 -9800
LEEDSMA01053 ISSUED ON:10/19/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 10/19/20110:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner