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22B-001
The Commonwealth ofMrrssachucetttr Department of IndlAcc*dents k. fa Oice of Investrgatrorrs ' A' r 680 n Street Boston, MA 02111 www.nwSs.g ovv /d[a Workers' Compensation Insurance Affidavit Bide ra/Contra hers Annlicant Information Please Print Legibly Name C_ th i ,_ ! M P O KIkie N i Address: fy--d 6" 1C City /StatefZi : l t i i M 4 P hone #: X 4 . 1 — O 3 �c) I c) Are you an employer? Check the appropriate box T'Pe Poker (required): L tam a employer with `Z 4 - ❑ I am a general contractor and I 6. ❑ New construction (fun and/or Pa-nt)-s have hired the factors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working few me in any capacity. employees and have workers' 9. ❑ Building addition (No workers' comp insurance comp. .; Teg -) 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing reams or additions myself right of exemption per MGL [No workers' lt c. 152, §1(4), and we have no 120 ❑ f repairs employees. [No Other comp. insurance -] =Any applicant that dries bout' oast also MI out the section blow shnving the VAIIkele corm policy t Homeowners who submit this affidavit indicating they are d rag all wand( and then hue outside oaaaractors oust subunit a new affidavit indicating' such_ tContractors that check this box must attached an ocher an' al sheet shaming the name of the satreoatr ctons sod state whether or not those enures have employees. If the coekadoa<s have employees, they mast pnwide their markets' comp. policy number. I and an employer that is privitling workers' compensation insarrnsce for ag encloyeer. Below is the policy and jobsite Insurance Company Name: ! Y J l L. Policy # or Self- ins. Lic. #: 4 tt7 Li'L/ r Expiration Date /ill 7/iO Job Site Address: 2 D (v � t n .�1 Cit : 7'G U r ci 1 C' P / � 0 / Attach a copy of the workers' comp ti policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 andfor one -year imprisonment, as well as civil penalties in the farm 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 « gluier thl the , mrdp *perjury that the hffermation prvvidedabove is true and correct ' ue"r, rs : 4'' 11 A V S I I - ' V 'J� . i phone #- A ll - Itto - Official use way. Da not write in this area, to be completed by city or toter official City or Town: PerraitgAeense # I Issuing Authority (circle one): I 1. Board of Bealth 2. Banding Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8 - CONSTRUCTION SERVICES I 8.1 Licensed Construction S oervisor. t Not Applicable ❑ Name of License Helder : a rn e S ( `"i License Number ‘{- � YQ4 i ►(, M zi 35 1c 1t0(c0(y ) Address Expiration lade t{R" 3 Si tune Telephone 9. inters+) Home lmptvement Contractor: ' Not Applicable ❑ I VAL L -o _t lit ©v t N , , L t� C..,. t Company Name Registration Number I k 6y j,L , iy c 1 M ./.}- 013 t L t . - a.a- - Address i Expiration Date Telephoner ti 3 ` 4/3- SECTION 10- WORKERS' COMPENSATION INSURANCE AFFN3AVIT (M.G.L. c. 152, § 25C(6)) I Workers Compensation Insurance affidavit must be completed and submitted with this applicat ion. 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 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 huildiag 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 umy be Sable 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 ano icable) New House 0 Adder 0 cement AIffiraiion(s) j� Roofing ED Or Doors Accessory Bldg. Q Demolition Q New Signs [CU Decks [C 1 Siding [DJ Other [Gar Brief rr i c Descciption of Proposed ! _ G, , i 1 I.l l a t U � �1 a Alteration of existing bedroom � :-'No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes ---- No Plans Attached Roll - Sheet sa. If New house and or addltlon to existinu 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 a Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance_ Massc heck 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 Ic 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 ., l / ✓i ►'1 I , as Owner of the subject property hereby authorize J a. f'S E// I S to act on my behalf, in all - F • to work authorized by this building permit ication. //1/ permit Gib Signature of • Date PAW i , as Owner/Authorized Agent hereby dedare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Sign . under the pains and r penalties of perjury. ju me C C k 4 C ti . t of OwnerlAgent .. . 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 Budding Department . , Lot Size I ! . ,. _ .......________ - _. 1 _ _ 1 ! 1, i _ -- - - — Frontage _I I.. - - i , Setbacks Front F ---- 1 i Side 1.,:!.., ..._._ _: R:L..._ , . Building Height ____ ........ i , i Bldg. Square Footage f ; Open Space Footage % (Lot area minus bldg & paved parking) — , , 1 # of Parldng Spaces Fill: (volume & Location) '--- -- ', 1 A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 IF YES, date issued: 1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 . . IF YES: enter Book I I Page i ! ; and/or Document it B. Does the site contain a brook, body of water or wetlands? NO 0 ( DONT KNOW '-', ......-..,,' YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: 1 _I C. Do any signs exist on the property? YES C.) NO CO IF YES, describe size, type and location: i ! .. _.... . _ D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: 1 : E Will the construction activity disturb (denting, grading, excavation, or filling) over acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 49 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit '\ 212 Main Street Sewer/Septic Availability p . - Room 100 WaterlWell Availability ��, arlpton, MA 01060 Two Sets of Structural Plans phona4'13 -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 i - SITE INFORMATION } 1,1 Property Address: This section to be completed by office / L Map Lot Unit S D p r- n 51 , Zone Overlay District .l ? Yer\c e 44 1- C l 0(Q .9, Enn St District CB Dot SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 4. l vi r, N-0, 1 i D 9 t'w - ,'t 4dJej , 4(4 ® /D35 N ame (Print) Cr Ma il& � g Address: / 7 ( / 6 /� (�J A k ; // Tel ephone Signature ► Ilf 2.2 Author Anent a nv.e film L ie �d . � � �) M ? (5 N ame ) IL*(...__ Elfil 1— h -- 3 .(0 3 - 'c; I a? Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building - / ( / /. /r4, (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (VAC) 5. Fire Protection / �✓C�v 6. Total = (1 + 2 + 3 + 4 + 5) 1 �1 Jr I / • i' 6 Check Number ,/O7 ¢J J This Section For Official Use Only Date - Building Permit Number: Issued: Signature: Building Ccsnrnissionerfirispeclor of Buildings Date File # BP- 2010 -0705 APPLICANT /CONTACT PERSON IDEAL HOME IMPROVEMENT INC ADDRESS/PHONE 142 BOYLE RD GILL (413) 863 -2128 PROPERTY LOCATION 206 SPRING ST MAP 22B PARCEL 001 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out . Fee Paid OL Typeof Construction: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 091207 3 sets of Plans / Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION 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. • 206 SPRING ST BP- 2010 -0705 GIS #: COMMONWEALTH OF MASSACHUSETTS 12)1 r 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 -0705 Project # JS- 2010- 001049 Est. Cost: $1212.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: IDEAL HOME IMPROVEMENT INC 091207 Lot Size(sq. ft.): 161607.60 Owner: HALL ALVIN M & CHINA KATHERINE M HAURY Zoning: URA(100) //WSP Applicant: IDEAL HOME IMPROVEMENT INC AT: 206 SPRING ST Applicant Address: Phone: Insurance: 142 BOYLE RD (413) 863 -2128 GILLMA01354 ISSUED ON:2/5/2010 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION 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 2/5/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 - 1272 Building Commissioner - Anthony Patillo