24C-044 (3) The Commonwealth of Massachusetts
01111188 Ailglii.
. Department of Industrial Accidents ,
. t Office of Investigations
.1 1 '
I. 0 =. 600 Washington Street
'''t. _ " Boston, MA 02111
0" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): EQ -f,c 2 ,9, Vc Y\ 2 \ ( \e\ Q c--\ _
Address: �'-� l, 7}- -i,
City /State /Zip: f �, r -,iairk r3, r l { (l1 A 0 Phone #: S f[ 6 S
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
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
listed on the attached sheet. 7. El Remodeling
2. ❑ I am a sole proprietor or partner -
ship and have no employees These sub - contractors have 8. ❑ Demolition
for in any capacity. employees and have workers'
working Y p tY• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its io.❑ Electrical repairs or additions
3.,I am a homeowner doing all work officers have exercised their required.] 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. ❑ 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. 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 _ hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
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. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
•r
8.1 Licensed Construction Supervisor: Not Appl ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9s., egisteredkNome;C r�o vemenrContractor-; , 7V4 Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M AL L c' 152, § 25C(6)) s ,
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 ❑
11 = Ho ne ��?.wnerc a tro
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 w/
SECTION 5.: DESCRIPTION OF 'PROPOSED WORK (check all- applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors Cif
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [[] Siding [I� Other [D]
Brief Description of Proposed (� 1 1
Work: f-in; 5 a T l� a 1 � r tea 11 S. CC�rn»i �1 b Cf
rOo - v i' del 1
Alteration of existing bedroom X Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
4iii Ne'n► Citii aria or addition:.to.,ez sti n complete the fo lo�uin`q:
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 P
I , , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, DQc /t 1 c' Q 0 S Q `'„. , 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 1 penalties of perjury.
R2.a4fic'Q a
Print Name
/bA-i/ c l/ol C // / /
Signature of Owner /Agent Date
•
f . M
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information =,
Existing Proposed Required by'2oning
This column to be filled in by ` v,, . d
Building Department
Lot Size l
A o r I ..... a
Frontage i 1 `
Setbacks Front j
Side L: R: L~ i R° 1
Rear I I
Building Height i i I i
Bldg. Square Footage 1 77 % 1 i __
Open Space Footage ( � j
(Lot area minus bldg & paved . ! _- i
parking)
# of Parking Spaces
Fill:
(volume & Location) f J ` i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW e YES 0
W 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 t Page I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES l
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 e
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
IF YES, describe size, type and location:
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 9
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• ■
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4 - a 1;1 D� _Tune t LlS � y , a „` a m 5 y
R City of Northampton Status O
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ErVE Bui!. ing Department c re,-;:c•: 6 fie- er « .4 ..
2 Main Street Sewer Sept val all r . � ,, 11%
I 2 9 2011 Room 100 1Na a A air - � p
ort ampton, MA 01060 T e ` * c tu '-' -. � s ue y
oF LWNG 4 3-5;7-1240 Fax 413-587-1272 . e i
TNAAIPTON, MA 01068 NS Qth6i lfy sY .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
n to be completed by office ` e , t
1.1 Property Address: ` Th,is sectio , ". �; a �, ,ttt�.° . , * ;. ' x ;
n u g ± tia5'^a. y , ``' ? . :. u'"r o- e �y=,,s x i 4 � `x . 1
333 D 34 � � Lod , u� t
��A ��^ ''' //04-t3 a Y k � `e+ 4 z
x ` t y M1 � a " +`max - , .. �"x*r x. „3 ` "� u s
r Z oy � r a:a4 ..�r` a , nt x "" "a'°,,,,.a A: e w c v.` :-.r -e4 �2:! � 'a i`w "',,'ia lf
a Zane . Oyerla r Disfr�ct ,
.,rEtm S t. Dis k ` °" ' CB District . n ., - " `' ` ' ,
SECTION 2 PROPERTY OWNERSHIP(AUTHORIZED AGENT
2.1 Owner of Record:
D ckN o._ A. g Q \- c ; c l,? O I Q c 33' C/o-v. S' No /' /L v- elO n /1? A 61060
Name (Print) Current Mailing Address:
"/Ii /(' Telephone S'8S— 110
Signature .
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) Buiidmg Permit Fee
2. Electrical (b) Estimated Total Cost of
/, 000 Construction from (6)
3. Plumbing a. 0 Bu Pe Fee
4. Mechanical (HVAC) 3o o
5. Fire Protection 7. 6. Total= (1 +2 +3 +4 +5) 9 � 3OCi ., •' ; °„ M °
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature
Building Commissioner /Inspector of Buildings - . Date
-K ■
File # BP- 2012 -0318
APPLICANT /CONTACT PERSON O'SHEA DANIEL J & BEATRICE H
ADDRESS/PHONE 333 ELM ST NORTHAMPTON 0 585 -1105 Q
PROPERTY LOCATION 333 ELM ST
MAP 24C PARCEL 044 001 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 6, , g g Fee Paid
Tvpeof Construction: FINISH 2ND FLR BATH & CONVERT 2 BEDROOMS TO ONE
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
INF9RMATION PRESENTED:
I/ 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
A ar y's• vela ,,,,,,, ,, , ,,---7 7, r_
":"./fr 7, - - ' , ,,g7 :-- ((-
- r f 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.
333 ELM ST BP- 2012 -0318
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 044 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 -0318
Project # JS- 2012 - 000517
Est. Cost: $9300.00
Fee: $55.80 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(so. ft.): 54450.00 Owner: O'SHEA DANIEL J & BEATRICE H
Zoning: URA(100)/ Applicant: O'SHEA DANIEL J & BEATRICE H
AT: 333 ELM ST
Applicant Address: Phone: Insurance:
333 ELM ST 0 585 0
NORTHAMPTONMAO1060 ISSUED ON:9/29/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: FINISH 2ND FLR BATH & CONVERT 2
BEDROOMS TO ONE
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 9/29/2011 0:00:00 $55.80
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner