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The Commonwealth of Massachusetts
Department of Industrial Accidents
z —'-'1 —....--:1=--.----.. ►� Office of Investigations
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_ 600 Washington Street
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Boston, MA 02111
�� www.mass.gov/dia
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• -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):. . Ai ` , " _ _ • ;, 1 1 i 'zt ,
Address: < ;S l (■ nil 1 1 4
City /State/Zip: A e 4 1 . , : U,: - . 060 Phone. #: (43 ' 9,00
Are you an employer? Check the appropriate box: . Type of project (required): /
1.0 I am a employer with 4.. 0 I am a general contractor and I 6. 0 New construction
employees (full and/or part-time).* have hired the sub- contractors
2.. ❑ I am a sole proprietor �r partner- listed on the attached sheet 7. 0 Remodelin g
ship and have no euloyees These sub - contractors have. 8. ❑ Demolition
working for me in any capacity employees and have workers' 9 Q Building °addition
[No workers' comp. insurance comp inctrranr P
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
officers havexercised their . 11.0 Plumbing repairs or additions
3.0 I am a homeowner doing all work
e1£ o workers' comp. right o exemption MGL per
myself [N mp. hf 12.0. Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No o workers' 13.0 Other - 02-iiii e v' `ji
• comp- insurance required. }. (.E.4 'LA., 5
`Any applicant-that checks box #1 must also fill out the section below showing their workers'. compensation policy information.
t Homeowners who submit this affida. it.indicarimg they are doing all work and than 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 .Sectron`25A'ofIGIGL`c. 152 can lead to the imposition ofcrimina1 penalties of a
fine up to $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator Be advised' that a copy of this statement may be forwarded to the Office >of
Investisations of the Da for insurance coverage verification _ .. _...:.
I do hereby terra un ,, - th�rns d penalties f per1ury that the infornur#ion provuledsrbove ' e orr - -- . _ .
Si • . • tore: : Irlia 'iie �' z Date: )/ / * Z d . ,
Phone it: 13r'> . 1: 6( • . 9.96h • •
Of, facial use only. Do not write in this area, to be completed by city or town of iciaL
•
City or Town: Permit/License # ___ ...
Issuing Authority (circle ones):
.'I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other , .
Contact Person: Phone #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 3.4 +: , 6u I Ic y
License Number
' l ZOb 1 1 ' " 76 f I
Address Expiration Date
7Jl�jl� ( s � r ' a 1 a-
Signature 1 Telephone
COl:A/20 (
ik" iris L
9. f episteied ImDroverner[t ctor ' • 4,1.. a. „,,. 4474 ' Not Applicable ❑
T 6 I Itt 3 J 1(� 1
Company Name Registration Number
tdd1Jr J iA)O 4 p (h �i &Z J Mt 1 ,---, .-• ' 5 IJ��
Address /J �{ Expiration Date
9 7 ( U L,Jt ( ,�S' 4 Telephone ' q3
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 XL No ❑
1 -i - om ,,• er E xempti on '
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 [J Addition E] Replacementjdows Alteration(s) ED Roofing
Or Doors III,1
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [I] Siding [D] Other [D]
Brief Description of Proposed
Work: S eepc me A.( LLA ea'? -1` 1 in
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. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTFIORIZATION - 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
1, g S 1k , as Owner /Authorized
Agent hereby declare that the statements and in 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 N e " „r
des$ / Z” r /1 / `� 2 0 /
nature of of Owner /Agent Date
s
• '4,
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 1 ? ' I
Setbacks Front ( I i __ I
Side L . R:j L:; I R:,.
Rear
Building Height ? 1
1 1 i
Bldg. Square Footage
r ( I 1 % i
Open Space Footage %
(Lot area minus bldg &paved _ .—......—
parking)
# of Parking Spaces
Fill: 1 ;
(volume & Location) i 1
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
i
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
1 Page and /or Document ft,
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 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES (2) NO Q
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
P • �
,16407-1prli Art;
City of Northampton
Building Department 8 _ a ,
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
Map Lot Unit
1 '' ff '
)( ()�J Zone Overlay District
i" r I "' — - t s �` (I ( ) Eirn St: District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Anent: fi - C7114111►
3 � = �� ► �
Name,E'R i nt � ' Current Mailing Address: /
Signatur / j Telephone d
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building C i (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
-ff
6. Total= (1 +2 +3 +4 +5) Check Number /3a/
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
r 1
a
12 ALLISON ST BP- 2011 -0425
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C -121 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 -0425
Project # JS- 2011- 000694
Est. Cost: $1790.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT BUSHEY JR 057011
Lot Size(sq. ft.): 10018.80 Owner: HORTON RICHARD & NICOLE
Zoning: URB(100)/ Applicant: ROBERT BUSHEY JR
AT: 12 ALLISON ST
Applicant Address: Phone: Insurance:
351 WALNUT ST EXT (413) 786 -9900 0
AGAWAMMA01001 ISSUED ON:11/4/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 11/4/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner