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38B-046 The Commonwealth of Massachusetts Department of Industrial Accidents '' 1 '' Office of Investigations �, 600 Washington Street .. Is `� Boston, MA 02111 r .-- . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /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. n I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. E] New construction listed on the attached sheet. 7. E Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. 111 Demolition working for me in any capacity. employees and have workers' 9. Fl Building addition [No workers' comp. insurance comp. insurance. required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3. 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. ❑ 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 d hereby certi under the pains and penalties of perjury that the information provided above is true and correct. ignature: 1', eL— Date: 1( 7 aZ / o / / 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. R„ildina Department 3, City/Town Clerk 4. Electrical Inspector 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 97 eats ered.,Heine Improvement Contractor ; "'Yrw, _ : v „xi Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- WORKERS', COMPENSATION INSURANCE AFFIDAVIT (M G L c 1 5 2, §`,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 ❑ t ; , i 1 a` itr wner:� t e rnpt ion 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 rthampton Ordinances, Site and Local Zoning . s and State f Massachusetts General Laws Annotated. c H omeowner Signature LtAka,.Iii I 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) w New House ❑ Addition ❑ Replacemen indows Alteration(s) n Roofing n Or Doors ®` Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [0] Other [0] Brief Descriptio f Pr osed ' Work: e r tt I Sh bI Q. re,� r1P.u� j1� IbY 1JI�yn L P S "5 f Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet a If.Newi. ouse.andor addition.to existing,hous complete the follow.i`nq: 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 F OR BUILDING PRM EIT ,. , 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 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. kft e6 Aa 5 e;E6 L Pri t ame s i� II 101 c)( Date /Agent � � SSignature pf O /Ag V NSCaie-kos G( + r Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete formation b Existing Proposed Required by•/,nin ` {t This column to , fille in by . .... a Building Depa.. ent ! Lot Size ! �' . Frontage Setbacks Front Side L:: R: L:. R:' I Rear Building Height ; i Bldg. Square Footage : 1 1 ! % i i Open Space Footage % 1 ' i (Lot area minus bldg & paved i parking) 6 r 3 # of Parking Spaces s Fill: �_ _. __ _ ._.. .._ _ _ ...n _..__ . (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO YL, DON'T KNOW 0 YES 0 IF YES, date issued: ! 1 IF YES: Was the permit recorded at the Registry of Deeds? NO (0 DONT KNOW 0 YES 0 IF YES: enter Book ' i i Page; I and /or Document #1 I F B. Does the site contain a brook, body of water or wetlands? NO 6 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: g. C. Do any signs exist on the property? YES 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 r 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. s w G .= l3epan.mea�tue_n4y r,'" �� City of No rthampton St tus ofP �z n #S � ka Building Depa rtment c ur b u r�v errnat ��. 4 . Z 212 Main Str Sewer ua a bi � , , , fi g~ _� Roo 10 U ater . el Avarl�' ,�t, E NO o Northampton, MA 01060 To Se of5trtrct tans 1 " o B �� °N phone 413- 587 -1 Fax 41 587 -1272 P I © le [a,7 - , a ;?r :�� ' �-; "� - - `��"kr�`" -$�: -mss '. i- ss a � f. a' O er�5pel#y �h R_ a O n g, ., APPL ICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLI A O N E OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This sec t i on to be completed by office 1.1 Property Address: hk 5 ,IV ap L o t ' ' ' l]m t e rn: �, ' t u s � '�'' =�' "a ..�sx � � � ,,,��a � � . ' 'Z " h Overlay Drstrrct -- r .mot k . Elm St Chstnct ti� v r" C District- _ _. -, S 2 PROPERTY O WN E RSHIP /AUT HORIZED AG d .1 2.1 Owner of Record: , I je,�Q,l Z 5Dili �f Nye (Pnnt Current Mailing A rs _ cf.-19 ` Teleph ne Signature 2.2 Authorized Agen Name (Print) Current Mailing Address: Signature Telephone SECTION 3 : ESTIMATED CT Item Estimated C Cost (Dollars) t o be Offic U , i ' completed by p ermit applicant 1. Building -to() (a) Building Permit "Fee 2. Electrical t ( b ) ' E st tmated Tota Cost of C o on frm (B) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) C heck: Number This Section For O ffici al Use o nIy 9 Date Buildm Permit!.Number Issued " Signatur ... Bu Commissioner /Inspector of Buildings Date • 124 SOUTH ST BP- 2012 -0439 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B - 046 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT DOOR BUILDING PERMIT Permit # BP- 2012 -0439 Project # JS- 2012 - 000711 Est. Cost: $1200.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 5575.68 Owner: STRIEBEL MARGARET A Zoning: URB(100)/ Applicant: STRIEBEL MARGARET A AT: 124 SOUTH ST Applicant Address: Phone: Insurance: 124 SOUTH ST (413) 687 -4137 0 NORTHAMPTONMA01060 ISSUED ON:11/2/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: INSTALL REPLACEMENT DOOR 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 11/2/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner