31A-022 The Commonwealth of Massachusetts
Department of Industrwl Accidents
• Office of Investigations s
- 600 'Washington Street
Boston, MA 02111
= www mass.govldia
Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
A > • licant Information Please Print L • ab
! Di it • -
Name ( Business /Organization/Individual):
_. -
Address: ' Williamsburg, .MA 010%
•
City /State/Zip: Phone #: ul 13 .
Are you an employer? Check the appropriate box. of eet required).
I :a sacral contaactoi and I NoJ ( )
1. [eh am a employer with " . '� 4: ❑ am g 6. 0 New'
ew constru
employees (full and/or part-time) * have hard the sub contractors
2. ❑. I am a listed on.theattached sheet 7. ❑
. _ _ propr��z�ar- Ever . - = -- -
ship and have no employees
These sub - contractors have $ ❑Demolition
worlds for me in employees and have workers '
g any c�acity. ui
- 9 Q B ilding add Tian
[No workers'. comp. insurance � =__ — _
. -- -
] 5. ❑ We are a-cor poration an d- 10.0 Electrical repairs or additions
_ d-
offioeisha a exercised theri 11. Plumbing 3. ❑ I am a.homeownex doing 81114:r-cat : � ❑ �ing repairs or additions
_ ; . myself [No .workers'-wnmp - _rigbl- a otp GL.._ _ :.... 12.0 Reef repairs
insurance required.] t c. 152, § 1(4); and we have no
employees. [No workers' 13.❑ Other
comp. insttranc a regtised ]
*Any applicant that decks box #1 mist also fill out the section below - sbovvi ng iheifiioilfeilrotiinpetisition policy won.
t Homeowners vile, 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 our the subcontractors and state whether ornot those entities have
employees. If the sub-contactors have employers, they ,must provide their waikes''eomp.policy=ober. .
I am an employer drat is providing workers '+compensation insurance for my employees Below is the polity and job site
information. /�
Insurance Company Name: A SSOC A . eM l 1E.rLS
Policy # or Self -ins. Lie. #- j 10 Q ` rT 0 i w ( l Expiration Date: 12.- b ! Z—
Job Site Address: ° 7 iZI WW N �� % City/State/Zip: i /r- Aj‘/6"c 1�
Attach a copy of the workerrs' compensation polity declarxhon page (showing the policy number and expiration date).
Failure to secure coverage as. required Section 25A MGL7c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 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::Sriolator....B.eadvised that a copy..of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification. -
I do hereby certify under the pains and enalties ofperjury that the inforiitionprovided above is trice and correct.
T . .
- -- Sic.:
tare. � / / r� r . - _ a ate: .. ..... -_ �. _ ___ .... _. .
Phone #: �/ 3 ?-G $ - � 3��- �:,_ ... _ :_.--_
-__
Official use only. Do not write in this area, to be completed by city or town official
City or Town; Permitcese #�
= -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 ❑
l
Name of License Holder : \ 7 l v , - Q _ i t /'9
License Number
z 5 < -/;
Address / Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
GOUGEON LOS ze
Company NaniA6 t StIvpt Registration Numb r
%V iU r e , •� MA . 1096 � Z �
Address Expiratio Date
Telephone Z
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 ❑
11. - Home Owner Exemption
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 n r(ossess 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 la on which he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attack<1 or detached structures accessory to such use and/ or farm
structures. A person who constructs more than one in a two - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Buildin$,0Ticial, on a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed der the building permit.
As acting Construction Supervisor r presence on the job site will be required from time to time, during and upon
completion of the work for which is permit is issued.
Also be advised that with referce to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries n esulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform w for you under this permit.
The undersigned " omeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton dinances, 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 ❑ Addition ❑ Replacement L ows Alteration(s) Roofing El Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [0] Other [0]
Brief Description of Proposed
Work: prep �19.G E 3 toiitlavL3 eun(.lt% Trz. tNi i S<lM D/ kt &Z / DA/Ali
Alteration of existing bedroom Yes K_ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _ ik No
Plans Attached Roll - Sheet N/A
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family v 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
v► (. N OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/ -' 1
I, , as Owner of the subject
property n ,�, y
hereby authorize I$41 665 Lt Ge---- -
to act on my behal in all matters r ative to work authorized by this building permit a licat n.
Signature of Owner ' Date l
I, J01fl 6 1 - 6 1 6 - 4 4 76 - , as Ow er /Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of ge
and belief.
Signed under the pains and penalties of perjury.
J s c -6 ,'==--
Print Name
Signature of Owne Agent Date
CW,WC5
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete,lnfolmation
w
Existing Proposed Required by Zbning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO C DONT KNOW YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Regis ry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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 a
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.
Department use only
EGE D Ci 1, of Northampton Status of Perm
R`` p
q Bu ding Department Curb Cut/Driveway Permit
�N • A 20t2 2 Main Street Sewer /Septic Availability
Room 100 WaterNVell Availability
GFBV��INGINSm firth. mpton, MA 01060 Two Sets of Structural Plans
cE N -I� .: - 87 -1240 Fax 413 587 - 1272 Plot/Site Plans
Other Specify
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
94 2 4iJ 1 , (� S . Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
/ I C/1"-( A-,, CV Z4 �r i, S-
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
‘1,41446S LI ff -t 2 6 1 / 72 1 5 3 � iii i GG011 tr2~=
Name (Print) Current Mailing Address:
cc !�/ 3 -2,6g-f31.
3
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building it 473 0 (a) Building Permit Fee
2. Electrical j 5) (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 30
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ,..5 Check Number ic0 3 3,
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
26 FRANKLIN ST BP- 2012 -0629
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A - 022 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2012 -0629
Project # JS- 2012- 001083
Est. Cost: $5600.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GOUGEON & LOCKE 001992
Lot Size(sq. ft.): 8363.52 Owner: GORRA MICHAEL E & BRIGITTE BUETTNER
Zoning: URB(100)/ Applicant: GOUGEON & LOCKE
AT: 26 FRANKLIN ST
Applicant Address: Phone: Insurance:
26 South Street (413) 268 -9323 Workers Compensation
WILLIAMSBURGMA01096 - 9726 ISSUED ON:1/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 REPLACEMENT WINDOWS &
REMOVE 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 1/5/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner