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29-423 (2) (a NOTICE NOTICE TO TO EMPLOYEES yip EMPLOYEES cc- 0 1,11 = Sv The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617 - 727 -4900 — http: / /www.mass.gov /dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: ZURICH AMERICAN INSURANCE GROUP NAME OF INSURANCE COMPANY P.0. BOX 1450 MIDDLEBORO, MA 02344 -1450 ADDRESS OF INSURANCE COMPANY ( 6ZZUB - 4354P60 - 2 - 11) 08 - 27 - 11 TO 08 - 27 - 12 POLICY NUMBER EFFECTIVE DATES BARDWELL BOWLBY & KARAM PO BOX 1700 PITTSFIELD MA 012021700 NAME OF INSURANCE AGENT ADDRESS PHONE # MEIER, DAVID DBA MEIER 108 1/2 COLUMBIA STREET ENTERPRISES DBA ADAMS STOVE o ADAMS MA 01 220 EMPLOYER ADDRESS EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE o MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of • employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the ° — injured employee. The employee may select his or her own physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably ▪ connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER 006192 W20P1G02 The Commonwealth of Massachusetts - - -.- ---,, Department of Industrial Accidents 1;, - -t inomme Office of Investigations �� ry ="4, 1 ~' 600 Washington Street " • -' Boston, MA 02111 ` `>� '/_ - -5s,:v www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): l� �/� I) 1 U s . \Z. { 2,F Address: I O 9 (1..._ C. 01, , v „ ,1C9 1• GL Sk re,d City /State /Zip: 4eLavyi ` ✓/ {$ 0 1 --a- -o Phone #: L!t3- -7`1 -3 co 1 Are you an employer? Check the appropriate box: Type of project (required): 1. X I am a employer with Z. 4. El I am a general contractor and I 6. ❑ New construction employees (full and/or part- time).* have hired the sub - contractors listed on the attached sheet. 7. ❑ Remodeling 2. 11] I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' g Y P h' 9. ❑ Building addition [No workers' comp. insurance comp. insurance .t required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152;- §1(4), and we have no . -• employees. [No workers' 13.1g Other ,� 1 Sv L - - 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: i i2-)1'r Carl 2 1,n SUY r ce CO. Policy # or Self-ins. Lic. #: (,Z.ZU 3 - 35-14 P IA - L-,1 Expiration Date: C, s/yV /0l. 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 do hereby c;' under the pains and penalties of perjury that the information provided above is true and correct. Signature: 10 � ' V..\ \31/4.kkA ” Phone #: Date: tl. ' 6— 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 #: giTlee -604—wiecdt4 , / , , 'F Office of Consumer Affairs and : usiness Regulation i • — 10 Park Plaza - Suite 5170 – - ' Boston, Massachusetts 02116 Home Improvement Contractor Registration ,.-_- Registration: 159784 --:-_,-- ---,- ----2,--,-_,=.; Type: Individual _ 1 "- - ----=--- - : -,;_. Expiration: 5/27/2012 Tr# 208960 L - ---- - DAVID S. MEIER DAVID MEIER 108 1/2 COLUMBIA STREET ,--■._ -:-_---, - . ADAMS, MA 01220 \:-, --- - -,------ - Update Address and return card. Mark reason for change. --- 0 Address 0 Renewal 0 Employment ii Lost Card )PS-CAI 0 50M-04/04-G101216 — — • ef g e,,emk,ackaea __N,, Office of Consumer Affairs & B iness Regulation License or registration valid for individul use only '- HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: „159784 Type: Office of Consumer Affairs and Business Regulation Expiration: 5/ 2712012 Individual 10 Park Plaza - Suite 5170 Boston, MA 02116 154 MEIER - T , ' , -- -- E -- -- - -= 7-;- - , ----- ' ■1 DAVID MEIER ■--_=;,_-, - .=----.- :' 108 1/2 COLUMBIA'*TREETC ,E-1- Q..."-----,e5;3...5-- $1 4) l i C\ /(0Q■..-LI _ - Undersecretary I Not valid without signature Vtay,achusetts - Department of Public Safet 7 Board of Building Re-2111116w ) and Standard' lip ...--„, License: CS 54937 Restricted to: 00 . DAVID S MEIER 108 1/2 COLUMBIA ST i lio ADAMS, MA 01220 --_-,—_-.-.._ --- _ Expiration: 4/12/2012 ( 4,4111111 Tr: 24795 I SECTION 8 - CONSTRUCTION SERVICES 8.1 licensed Construction Supervisor: (�/� Not Applicable 0 j NUcnnseHokter: b S • ` ►' ' e J \ l License Number tot L k- (ee (90%\') A 2_._- 1-, Ad• .,. Expiration Date • 1 • Telephone 9. Registered Home Improvement Contractor: Not Applicable Aak/ib S. Al\ o_ r oZ t S 1 c L Company Name c ( Registration Number (11. Ct5 C �� � U1v c,, �- z — -� Address Expiration Date a ► •l! / A. Ah ► Telephone t kt3 -7 3snt SECT 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.C.L... 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 I Signed Affidavit Attached Yes No 0 11. H ©me. Owner Exemption ITS current exemption for "homeowners" was extended to include Owner- occupied Dwellings of one (1) or two({) 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 ac eptabie to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor you presence on the job site will he 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) + 1 ` New House U ' Addition C ' Replacement Windows Alteration(s) ► i Roofing i i i Or Doors 0 i Accessory Bldg. r Demolition U New Signs [0] Decks ED Siding [0] Other [ t it 1 i i Brief Desert lion of Proposed K Work: - fib tv‘S � l 0. La3oCa,■r1,�c9.s-' G. a__ y`'1�S S S 6 14 L12,1 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roil - Sheet Ba. if New house and or addition to existing housing, complete the following l a. Use of building : One Family Two Family Other 1 1 b. Number of rooms in each family unit Number of Bathrooms 1 { c. Is there a garage attached? I d. Proposed Square footage of new construction. ^'..tensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. tvtasscheck Energy Compliance form attached? ( h. Type of construction Is construction within 100 ' . wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement • cellar floor below finished grade k. Will buildi • •• nform to the Building and Zoning regulations? Yes No . I. Se• ank City Sewer Private well City water Supply t F-- SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN F--------- OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT R � � / is c:: L.A. /� as Owner of the subject p roperty } hereby authorize b A VMp S• N\ E Z to y behalf, in II m rs relative to work authorized by this building permit application. Signature of Owner Date 1.1'0M--% Y S - VA V �' � � . 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. Silted under the pains and penalties of perjury. b t ‘ vt t S . Vv G '. c. 6Z, Print Name Signature of Owner /A. - , 1 Date I Section I tion 4. ZONING ` Alt Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information I i Existing Proposed I Required by Zoning 1 1 i This column to be filled in by i ' Building Department i Lot Size I Frontage 1 Setbacks Front i I i Side L: R: I L. R: I I 1 Rear f 1 Building Height i 1 1 Bldg. Square Footage % } i Open Space Footage % I OEct area minus bldg & paved • mo, I I J i I 1 # of Parking Spaces i 1 I Fill: i j • (volume & Location) 1! 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 V YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetland NO Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtai < rom the Conservation Commission? Needs to be obtained a tab d 0 , Date Issued: C. Do any signs exist on the property? S Q NO ..J IF YES, describe size, type a• location: D. Are there any proposed - anges to or additions of signs intended for the property ? YES 0 NO IF YES, descri+- ize, type and location: E. WV the co clion activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will • rb over 1 acre? YES 0 NO 0 IF ES, then a Northampton Storm Water Management Permit from the DPW is required. , RECE V i City of Northampton De Rent use only Pa & /- 1 ..tait uts , o f p 1 Building Department 1 e/tad !Curb Cu Cul/DrWevaty . i 1 - 'JAN 1 I 2 1A - 1 212 Main Street IsekveriSeptieAvaitabikty 1 I f- Room 100 i waisrmen Amiabaty . BUIL PECTIONSINS 060 *rthampton , MA 01060 Two sets eistructteei Plans 1 1 1 NORTHAMPTON, MA01 , - - _ 3-587-1240 Fax 413-587-1272 [Rents Plans 1 I 10dier Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING , 1 i SECTION -, • SITE INFORMATION This section to be completed by office 1 1.1 Proper y Address. 1 — &Id e ri Drix_ i ( Map Lot Unit I Tioa vice_ 41i4- CI 06)- 1 i zone °vette*/ District i 1 i Eirn St. Di.rsure' CB District i SECTION 2 - PROPERTY owNERSHIPIALITHORIZED AGENT 1 i r I 1 2.1 Owner of Record: I $kre ( ' • Ipit /1 51 1 Nar'l- Current -km. :.... Add .rew: 1 I 1 g -Cd -Cer rr I 4..1 .. i sig i i La Authorized Agent i I 1 . 3 p..r..b 2 tYviz.... ZIER____ i cl b 1 7— Co \ .i., \ C; cL c—t‘-v- Alt 6 1 N (Pri r CUSTert tilalkig Address I. I ' I / 4av 0 g i 3 -- ik-t - - 3c Sigratire %lir' — 1 Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1 item Estimated Cost (Dollars) to be Official Use Only I completed by permit applicant 1 1 Building A god?) 0 D (a) Building Permit Fee i i s._ Fi - (b) Estimated Total Cost of Construction from (6) 1 3. Pktmbing I Building Permit Fee 4 I i t 4 Mechanical (HVAC) 5. Fire Prot ,6 TotaiJ--=(1 -i-27--1-4.+5) R-coot e'f9_6"" I Check Number I This Section For Official Use Only 1 1 i i 1 Building Permit Number: I Date issued: Sioatire: i 1 BulkEtna Commission...Br:Inspector of Braidings le 47 GOLDEN DR BP- 2012 -0649 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 423 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit # BP- 2012 -0649 Protect # JS- 2012- 001117 Est. Cost: $4000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID MEIER 54937 Lot Size(sq. ft.): 14374.80 Owner: GOODWIN STEVEN D & GAY L Zoning: URA(100) //WSP Applicant: DAVID MEIER AT: 47 GOLDEN DR Applicant Address: Phone: Insurance: 108 1/2 Columbia St (413) 743 -3501 ADAMSMA01220 ISSUED ON:1/11/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL WOODINSERT & LINER 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: FeeTvpe: Date Paid: Amount: Building 1/11/2012 0:00:00 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner