29-127 Save Home Energy 860 -829 -9991 p,2
The Conunonweaith of Massachusezms
S .
Department ofladustrutl Accidents
t Office of Investigations
660 Washington Street
Boston, Mass. 02111
www.mass.gov/dra
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Lefeibly
Name ( BusiaessfOcganization /1ndividuat) :
Address j / c/91.-0711/fly1.77/ ,
City /State/Zip: /t4&c41 [.:�1/,, '&37 Phone #: - 2
A an employer Check t priatc box: Type of project (required):
1. am an employer with 4. 1 1 am a general contractor and 1 6. 0 New construction.
employees (full and/or part time).* have hired the sub-contractors
2. L 1 am a mole proprietor or partner- listed on the attached sheet. j 7. P Remodeling
ship and have no employees These sub- oontractors have 8.1- Demolition
working for me in any capacity. employees and have workers' 9_ r Building addition
[No workers comp. insurance comp. insurance.:
required] 5.L1 We are a corporation and its 10. fl Electrical repairs or adci'ctions
3. [ 1 1 am a homeowner doing all work officers have exercised their
myself [No workers' comp. right of exemption pain MGL 11. ❑ Plumbing repairs or additions
insurance required] f c. 152, § 1(4), and we have no 12. Cl Roof repairs l�,.•� r
employees. [no workers' 13 Other %J�eI44q
comp. insurance required.]
* Any applicant that ebecks box Mt moat Ids* fin wt tie section bebop. sh+wtrs their workers' eotpeasatioa policy information.
tfioaseormera who subunit this affidavit indicating toes are doi6 all want and flea bide outside eaahweta s oast submit a sew affidavit bib:alias saeb.
tCswiaetors Oaf cbeck tide ho: mud attach as addilient sheet **Meg the same if the fib- s try ws cad atatewhether or met those entities bane arspio>yem. if
tin enb- eoatractors Lae - .., .. tiny mot rw ide their workers to number.
1 am an employer that isproviding workers' compensation insurance for my employees. Below is the policy ant site
Insurance Company Name � �� j� per^/ +� /
Policy # or Sel:fins. Lie. #: /J/ /, `i'!.' 4t /,� 'r te ' " Q s71i+5 'mil Expiration Date:
a 2
Job Site Address 1TIt ' 1 _ Cit 6i
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 152 can lead to the imposition of crhtninal 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of investigations ofthe
DIA for co a veri on.
1 do herby eel- y - 1' f � and penalties ofpe >y that the information pre Mf e above is true and corm
dr
Signature: �' Date:
Print Name: ! rk in Phone #: 2 AO -' f
Official use only Do not write in this area to be completed by city or town official
City or Tows: Permit/license #:
Issuing Authority (circle one):
i.Aoard of Beath 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact person: Phone #:
Save Home Energy 860 -829 -9991 p.3
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Appiicabie CJ
filArne of License Holder : yr("24 t2 /D /3
t��ti�d� Izi+ • � license Number
Address , Expiration Date
ti
Signature Telephone
S. ' ':7t;�e.. l e it, 1= : �r_ a . Not Applicable 0
< }r4 �� r r _ /f, q '
Company Name Registration N
041 AlO
Address i-at'S-437r4V-7.1-r �/ /� �J p/ Expiration Date
(.fi r lYtF7i�s /Telephone " 2 ! r
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. e: 152, § 25C(6)) 1
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit wdl result
in the denial of the issuance of the btdtdirig perm.
Signed Affidavit Attached Yes.. No 0
11. - Home Owner Exemption
The current exemption for "homeowners" was extended to include Owner- occunied 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. S 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 constricts more than one borne 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 sudr work performed unditr the baillding 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 uhich 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 Leos Annotated, yon may be Habig 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
Neon 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [CI Siding [0] Other [
Brief Description o Proposed /n � /�
Work: /� J— 0.s # Y a e yd / - b 0v4' G ' CI S
Alteration of existing bedroom Yes )( No Adding new bedroom Yes 1‹ No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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
1, 6 ( 4 ND e 6 ('.egAkybt) , as Owner of the subject
property i � ,,
hereby authorize SA .> ' �, ' - e 6 &�'�' , L /tic_
a t on my behalf, in all matters relative ;o work authori d by this building permit application.
j
/G% , ° 1 , erg -rr4 - /4, C ' 2 f/'"
Signature of Owner v Date
I, SA•k-Q... 6-\--Q P(14,_ e ``'�`c 1 U�� C , as Owner /Authorized
Agent hereby declare that the statements'bn inf on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed 069,4 under the pains �and penalties of perjury.
Pi ame
Signature of Owner /Agent Date
ED Department use only
R E EN G ity of Northampton Status of Permit
B Tiding Department Curb Cut/Driveway Permit
f:Eb 2. , 20 12 012 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
ort : mpton, MA 01060 Two Sets of Structural Plans
0 0tiN t* -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
7 (�
4/ iQ "4-6 C--t- Map Lot Unit
' f A 14 - d ! 06 0 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
a t re Cie , f,, 0 A-141/) 0 C• -,
Name (Print) Cupnrerre ri1/1 p
1•06
// %/ •// c/ Telephong y, , % - ! r/ gy
`7 ID Z 0 (Q
Signature
2.2 Authorized Agent:
SAS ICJQ. L i �a3�
Name (P ' Current Mailing Address:
Le- ROO Q 66 c96
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) Estimated Total Cost of �Ct6 --
Construction from (6) 1
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) /4e7
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 4 1 / is f { � Check Number //55 ? i' 3' 5
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0752
APPLICANT /CONTACT PERSON SAVE HOME ENERGY INC
ADDRESS /PHONE 1082 FARMINGTON AVE KENSINGTON (860) 828 -6686
PROPERTY LOCATION 20 ALAMO CT
MAP 29 PARCEL 127 001 ZONE URA(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
F eelPaid Permit Filled out //1,&7/W5—(7 j ' -
Tvpeof Construction: ADD INSULATION IN GARAGE WALLS
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/ Statement or License 101326
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFpRMATION PRESENTED:
V Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay
/ — .
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
20 ALAMO CT BP- 2012 -0752
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 127 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0752
Project # JS- 2012- 001330
Est. Cost: $1840.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SAVE HOME ENERGY INC 101326
Lot Size(sq. ft.): 12283.92 Owner: GREENWOOD DIANE
Zoning: URA(100) / /WSP Applicant: SAVE HOME ENERGY INC
AT: 20 ALAMO CT
Applicant Address: Phone: Insurance:
1082 FARMINGTON AVE (860) 828 -6686
KENS I NGTONCT06037 ISSUED ON:3/8/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD INSULATION IN GARAGE WALLS
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 3/8/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner