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38B-027 1 it )191 1 , 41 ii IN/ "�.,: vd-- -73 1-1-1 ..i.dod 6D- - d jV W 17 ,i 1rh �-F N511 , 1 r _______ _, ' Zvi S -7/1..../5 ip 0, ' 4?-1V -4 1 F11 1 10 \-1 3 js Mr.i! S - a l ?' '� -4 r i i t di) 01,fi .74' I ■3 ' fle i I J4 0 ° 1 Q 0 r i9111 i P 1 -1- Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law ", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual , partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withh the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. • Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the "law" or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Afffca of Investigations 600 Washington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727 -4900 ext. 406, 409 or 375 i at ; - -- -- The Commonwealth of Massachusetts Department of Industrial Accidents -- - Office ofloresilgaUons °- ff 600 Washington Street --,,� ' Boston, Mass. 02111 Workers' Compensation Insurance Affidavit r -111 -y h'Fi .J Fi - " ro� a'a fA F" (. ;' G :J N1 ; °Y -- - - -. __.._ -- -- -- - _ - - - _ ____- -- name: Jli %bGlf%t 514eC 61 ,• location: 60 1, ),s• a ii-I- city 1V i II4I kr /iC /'(4 o/o f' phone # @3.' /fz9 S.- p I am a homeowner performing all work myself. - - _A I am a sole proprietor and have no one working in any capacity • o I am an employer providing workers' compensation for my employees working on this job. company na me. ..... - a .. : -:. .. . .: . .E . ':.- : . ... .. • city: p}ron insurance co. policy #:: . . o I am so a proprietor general contractor, or homeowner (circle one) and have hired the contractors listed below who have the foliowmg workers' compensation polices: n compay name: "i./fl address: city: phone #: insurance co, company name: :. • - - address: city phone #: insurance co. :..:. Failure to secure coverage as required under Section 2SA of MGL 152 an lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.011 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is taste and corms Sisnature g� JA w `'� i /- Date t`k °L/ Print name i aIieil,c ...s-k/zer ley Phone if t 1/ 3 3 - aft" I" -45i . official use only do not write in this area to be completed by city or town official : city or town: permit/license N nBuilding Department °Licensing Board 0 check if immediate response is required °Selectmen Office °Health Department contact person: pbone %; nOtber i:evned 3i95 PJA) + a SECTION 4 - Workers' Compensation Insurance Affidavit (M.G.L. c. 152 s.25 C(6)): Workers' Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this affidavit will result it the denial of the issuance of the building permit. Signed Affidavit Attached? 0 Yes )4 No - SECTION 5 - Description of Proposed Work (check all applicable): ❑ New Construction 0 Addition At Other (specify) • Existing Building ❑ Accessory Building ❑ Demolition Remarks: • Alteration(s) 0 Repair(s) n Proposed Use: 3 & Haw , ' `� " - � em ` t e r<I1 .1 apem - SECTION 6 - Building Detail: ❑ Fire Suppression Installed Stories: Width: Length: Height Area: Volume: No. of Dwelling Units: ❑ Fire Supression Proposed Building Description: Emoting proposed Existing Proposed Construction Use Group: Use Group: Hazard Index Hazard Index Type: gelf c1 i./4 le- 41/4 5© e I f SECTION 7 - Estimated Construction Costs: Building: Electrical: Plumbing: Mechanical: Fire Protect Total Cost Permit Fee: For O nly al own 3 �az��� Da use only —7 - SECTION 8 - Owner Authorization. To Be Completed When Owners Agent or Contractor Applies For Building Permit: I, 13 1+1281 i�,IT 6 t / "` , as Owner of the above subject property herby authorize • &&) J -5 L4 - i to act on my behalf, in all matters relative to work authorized by this building permit. cr L a. �2-a ^ II - \ " -1v Signatur • � ' ` Date: - SECTION 9 - Owner/Authorized � Agent Declaration: 1, 6 Q ham► 2-4 6 ( 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. 0 J Sgna I , re of • - r - Agent - Date: - - SECTION 10 - Approval Status: ( For Official Use Only.) Application Date: Status Date: Remarks: 0 Approved 0 Denied ❑ Pending ❑ Abandoned Permit Number. ❑ In Part ❑ Voided Print Inspector Name: Signature of Inspector. Date: Application to Construct, Repair, Renovate or Demolish a One or Two Family Dwelling (page 2 of 2) • Application to Construct, Repair, Renovate or Demolish a One or Two Family Dwelling INSTRUCTIONS: Please complete all sections using ink. Please print Iegiy. Incomplete applications could result in delays or denial of application — SECTION 1 - Site Information: 1.1 Property Address: ..1.2 Assessors Map, Block, Number. 1.3 Zoning District: f -it; Foil 4//u, 7e 9" A Pr ' . 1.4 Property Dimensions: 2 1.5 Building Setbacks: Area: Frontage: Frrlt. Rear. Right Left: % Lot Coverage: 1.6 Water Supply: 1.7 Sewage'Disposal System: 1.8 Flood Zone: Flood Zone Map: o Public 0 Private IN Municipal Q On Site Disposal System 4 — SECTION 2 - Property Ownership/Authorized Agent: 2.1 Owner of Record: 2.2 Authorized Agent Name (print) Name (print) I LP FO Rr [4-t LL T if2 Address Line 1 Address Line 1 Address Line 2 Address Line 2 IvoR -ice- e ►� , 11A oun City, State, ZIP City, State, ZIP 4(3 (-- 3 i3 Telephone Fax Telephone Fax /ilq' m k' 9ttele yors -jv Signs ire Date Signature Date - SECTION 3 - Construction Services: 3.1 Licensed Construction Supervisor. 3.2 Registered Home Improvement Contractor. CS 60 g 1 .2 — / 3 - /r License Number Expiration Date License Number Expiration Date • r1 4 t'/X. S ick'zic r Gli.e, - 5 4,2o &, • Name (print) Name (print) � U Lris -d tu L!) L,frise Address Une 1 Address Une 1 Address Line 2 Address Une 2 • City. State, ZIP City, State, ZIP err g-Y - Yy el/ 3 9 — Telephone Fax Telephone � Fax ✓< .,A - l/ i/2 S ` i�, e —/h !f Signature Date Signature Date 0 Not Applicable 0 Not Applicable Page 1 of 2 • File # BP- 2010 -0927 APPLICANT /CONTACT PERSON ROBERT SKROCKI ADDRESS/PHONE 60 L , »ED RD HATFIELD (413) 247 -9244 PROPERTY LOCATION1ORT HILL TER MAP 38B PARCEL 027 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee % y 3 Fee Paid id *---- Typeof Construction: RENOVATE ATTIC SPACE (BEDRM/BATH) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 060949 3 sets of Plans / Plot Plan W -i-OLE +. f c (S E /. (Asr f AVE E S r".@ KE A !-) Ct? berEcT@ - PE Q cQA p re tor C THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF PRESENTED: 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. ;, trd w BP- 2010 -0927 GIS #: COMMONWEALTH OF MASSACHUSETTS : 388 o2 : 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-2010-0927 Project # JS- 2010- 001377 Est. Cost: $23000.00 Fee: $138.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT SKROCKI 060949 " Lot Size(sq. ft.): 4007.52 Owner: BEACH BARBARA Zoning: URC(100)/ Applicant: ROBERT SKROCKI 1 ' , AT: 16 FORT HILL TER Applicant Address: Phone: Insurance: 60 LINSEED RD (413) 247 -9244 HATFIELDMA01088 ISSUED ON:5/5/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE ATTIC SPACE (BEDRM /BATH) 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 5/5/2010 0:00:00 $138.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo