49-020 (4) „',.t The Comtnonwealth of Massachusetts
Department of Industrial Accidents
, Office of Investigations
f...r , ;' 600 Washington Street
- ___ sr
Boston, MA 02111
> F ; _= 7 www. mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business; Organization Individuall. tjtu (,°, j v-- Lam (,.D //'J S'} e I°-iv /'/Li-c ) _
Address: 351 t,) tt l— il.,tt.T S T ill r
City/State/Zip: 1 X 1 3 7 ' 4 i
•his.; �'W1 !►� C l "� Phone m:
Are you an employer? Check the appropriate box: Type of project (required):
- L-- 4. am a general contractor 1. am a employer with -1-7 I al tcto and 1 6. n New construction
employees (full and/or part- tune).” have lured the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have S. ❑ Demolition
working for me in any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp. insurance.=
required.] 5. 7 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.[ Plumbing repairs or additions
mvse]f. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] _ c. 152 §1(4), and we have no
employees. [No workers' 13 Other .-Pi- ' C.! t'�'�k. L' 1
comp. insurance required.] t '`'� S i
".-gym applicant that checks box. =1 must also 0ll out the section halo \a showing their porkers compensation policy information_
Homeowners who submit this affidavit indicating the' ara doing all \cork and than hire outside contractors must submit a now affidavit indicating such.
'Contractors that check this box. must attached an additional sltaat 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. police 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: L-t .61: Ti Wl. to T 141kt_ t ld S 1,1 0 -- N Yv _
Policy # or Self -ins. Lic. #: Vv 1315 3 7 4'4) O 1 1 Expiration Date: 5 1 112
Job Site Address: 3 6 f +P/l'ldik f 1d cit AAA Gil up (b
Attach a cola 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 ti' erificaliurr.
1 do hereby certify under the pains and penalties of perjury. that the information provided above is true and correct.
Signature: / 4,4"-- Date: LI' 21 — 1 2—
Phone #: L h 3 - 2 Otis et 1 ;
Official use only. Do not write in this area, to be completed by city or town official ■
s
City or Town: Permit /License # ?j
Issuing Authority (circle one): ii
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing inspector
il
6. Other
Contact Person: Phone #: I
SECTION 8 - CONSTRUCTION SERVICES
X8.1 Licensed Construction Supervisor /� Not Applicable ❑
Name of License Holder : 2Q aje- Vr E 1.� (,d S 4 e '1 -P _
I License Number
2 -7 Loose uf 5 0
Address Expiration Date
relazt Kt R l «S )VIA O i o /
Signal Telephon
irba
Registered Home Improvement'Contractor: Not Applicable ❑
r � -/ �
g08�2� 3 cis E/ey s2
Company Name Registratio I`} umber
I AJDOW Wpiz o OF (Ape s-reP-Jv f 4 S, IML AS-PI
Address Expiration Date
3s`/ Am j Sfi fX-1 1/13- 7g10 -
Telephone
_ 4 ei,t,t,ia MCI OtOol
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 not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth Edition Section 108.33.1.
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 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 building 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, von 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition 1 1 Replacement Wi aelifws Alteration(s) in Roofing
Or Doors
Accessory Bldg_ 1 1 Demolition P ( New Signs [0] Decks [Cj Siding jDJ Other [Oj
Brief Description of Proposed '
- ' Work: S ,p)d -ti-M e- " w jn rtov✓ 5 f s4 - fri m
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes 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 .
L 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
I, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
(IV e/M4Y4 OA )
Signature of Owner Date
I, I w p, . 8 (,(. 14-el , 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.
(Zoae42-T eus)-lPy
pint Nam
, _*17/ i S '
Signature of Owner/Agent ent Date
9 g
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
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 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES a
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained
, Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required_
RECO , 9 Department use only
ity of Northampton Status of Permit:
Z 2012 ;; uilding Department Curb Cut/Driveway Permit
Apit 212 Main Street Sewer /Septic Availability
__ 3 ■ Room 100 Water/Weil Availability
p OF 6UILDiNG INSPECTIONS hampton MA 01060 Two Sets of Structural Plans
NORTHAMPTON, MA 01060 1 •
phone 413 -587 -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
V l 3 G.1 ct P ( Map Lot Unit
F (0 r e/1\ cc. AAA 0 ( 0 (0'2 Zone Overlay District
/ I
Elm St District C8 District
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
' y
� e- E i�5b �L1 okkIA'} S l • E±
i 1 Name 5 ) - Current Mailing Address:
./ /AI L l - 7 fcip C5icV t
Signature i Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSB'
lte n Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
/�1. Building 3 �-f (n j ; 2 (a) Building Permit Fee
�/ 2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection i
6. Tota! =(1 +2 +3 +4 +5) 3 (p L( 7 t Check Number ajp9/ d(
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature_
Building Commissioner/inspector of Buildings Date
•
343 GLENDALE RD BP- 2012 -0934
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 49 - 020 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 -0934
Project # JS- 2012 - 001628
Est. Cost: $3642.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT E BUSHEY JR 57011
Lot Size(sq. ft.): 43560.00 Owner: BRAKEY SANDRA D
Zoning: Applicant: ROBERT E BUSHEY JR
AT: 343 GLENDALE RD
Applicant Address: Phone: Insurance:
351 WALNUT ST EXT (413) 786 -9906 WC
AGAWAMMAO1001 ISSUED ON:4/26/2012 0:00:00
TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOWS
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 4/26/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner