18C-049 The Commonwealth of Massachusetts
,F t Department o, f Industrial Accidents
=_;�_►� ' Office of Investigations •
600 Washington Street
• =IV= Boston, M4 02111
www.mass.gov /dia
- Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (BusinessfOrganization /individual): L 0 l 1
Address: ti 7 (JA r f-/ Et. I) S T Cl
City /State/Zip: xigi- r1II1 (t't /) 7U/ `iiJt G.1 Cf C Phone. #: 1 /73 5 � / ( S 7S
Are you an employer? Check the appropriate box: •Type of project (required):
1. ❑ I am a employer er 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 =71oyees These sub - contractors have .8. ❑ Demolition
working for me in any capacity. employees and have workers' •
9 tz1 addition
[No workers' comp. insurance 10.0 comp_ mCttranrtP #.
--
Electrical
re ed 5. ❑ We are a corporation and its repairs or additions
officers have rercised their . 11. Plumbing r
3.�I am a homeowner doing all work ffi i ❑ g epaus or additions
myself [No workers' comp. right of exemption per MGL 1/0 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 EH 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 anew affidavit indicating such.
IContiactnrs that check this box =ant attached an additional sheet showing the name of the sub contractors and state whether or not those eatities have
employees. If the sub - contractors have employees, they mustprovide their workers' comp. policy number.
lam 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 and ofMGL c. 152 can lead to the impOsition `of criminal penalties of a
fine up to $1,500.00 and/or one-year impnsonment, 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
T%estiQations of theDIA for insurance' coveraie verification
I do hereby certify under the pains arid penalties ofperjury that the informationprovided :above-irsrue_andcorrocr
.
Signature: Date:
Phone #:
Official use only Do not write in this area, to be completed by city or town
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
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
3 °Realstdre#.fdome lriigratrieii, tent "or "° - mama 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 affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes ❑ No ❑
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 buildine 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
1
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition New Signs [D] Decks [❑ Siding [0] Other [0]
Brief Description of Proposed _ , r j
Work: ,PEATP S / / j lV 2-0 X 2-L
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa:>`W i aii dI ddidoif ; °. xistitic eus fiq alai tee h sfollo a:
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 PERMIT
, 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.
L U vi) O, 4 J 'A,V J ti,13&ier
Print Name
arc- C iliftAt 5' — 1 0
Signature o Owner /Agent Date
S
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 _ ; , _.1 ..
Frontage 1
Setbacks Front 1 I I I
Side L: .1 R:L_______ L:L...._.... RA i i I
Rear E = 1 1
Building Height r" l
Bldg. Square Footage % t I I ; I
3 i
Open Space Footage %
(Lot area minus bldg &paved ? j I _ L
parking)
# of Parking Spaces • - ° '---
i
Fill: i -__.._,_ .w..__ .............�.._�..,�._. g..�.� I I
(volume & Location)
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 € Pa and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 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 ,Date Issued:
C. Do any signs exist on the property? YES ® NO Q
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: 3
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.
City of Northampton
Building Department
212 Main Street
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 Address: This section to be completed by office
r' 1 ,447fJE ID e) Map Lot Unit;
f yUi? 14 /0 Mp v—/ l�l �4. Zone overlay Distract
Elie St Dlstrlct CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
�D U >S N J, r' re r LCD ST' Nij b49PI ijV Ms1
N me (P 'rat) I ���, ; Current Mailing Address:
Telephone
ignature tr
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
2. Electrical (b) ECstimated onstruction Total Cost (6) of
from
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total= (1 +2 +3 +4 +5) Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature: 6 —
Date
l
L
Building' Commissioner/Inspector of Buildings
w 1111- - .
HATFIELD ST BP-2011-0101
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map - Block :18C - 049 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- 2011 -0101
Project # JS- 2011- 000184
Est. Cost: $500.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 40685.04 Owner: HEBERT LOUIS 0 & JOAN J
Zoning: URB(100)/ Applicant: HEBERT LOUIS 0 & JOAN J
AT: 67 HATFIELD ST
Applicant Address: Phone: Insurance:
67 HATFIELD ST
NORTHAMPTONMAO1060 ISSUED ON:8/11/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: Demolish 20x24 garage; 1901 per assessors,
beyond repair
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 8/11/2010 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner