29-172 (10) •
Information and In
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, 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, §25C(6) also states that "every state or local licensing agency shall withhold 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, MGL chapter 152, §25C(7) states "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 out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited LiailityPartnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit 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. Self-insured companies should enter their
self- insurance license number on the appropriate line.
City or Town Officials -
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. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city'or
town)." A copy pf the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. .... • ' .. _ . .
The Office of Investigations would like to thank you in advance for your 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
Office of Investigations
600 Washington Street .
Boston, MA 02111
Tel. # 617 -727 -4900 ext 406 or 1- 877- 11rfASSAFE
Revised 11 -22 -06 Fax # 617 -727 -7749
www.mass.govidia r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
C °-4411= ° 1 600 Washington Street
C €�
Boston, MA 02111
www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information ` Please Print Legibly
Name ( Business /Organization/Individual):. / ("Pi
Address: �0 l/c it w�
City /State/Zip: Se /'7 1 5 Phone. #:
Are you an employer? Check the appr opriate box: Type of project (required):
i k 1. ❑ I am a employer with 4., 0 I am a general contractor and I
employees (full and/or part- time). * - have hired -the sub- contractors 6, ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have g. 0 Demolition
working for me in any capacity. employees and have workers'
Y P tS' # . 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
10.0 Electrical r airs or additions
required:] 5. 0 We are a corporation and its ❑ rep
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 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 /l/ (GSA + +`
employees. [No workers' 13.0 Other /
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.
xContractors 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 - contract 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:
Policy # or Self-ins. Lic. #: Expiration Date:
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 certi under th > p and penalties of pedury that the information provided above is true and correct.
Signature: / 1 /_- Date: _
lr✓ _
Phone #: •
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 #:
• •
•
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure_ to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
jermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
h
tiVrYCia r understand the above.
e owner /residen ignature requesting exemption)
I , call to schedule all required building inspections necessary for the building permit
issued to me.
Date /
Address of work
location - D -F rt` 6 , E 1,D 1 R
1 L atvvc e 441. c'i ()
• . .. r,
The Commonwealth of Massachusetts
. Department of Industria I Accidents
Office of Ini
• 7. -'-." I a i Ciz . . -- .-. , . ; 600 Washington Street
• --lar— r., Boston, MA 02111 . .
vv/
www.mass odia .
"b
,:.
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
' -
Applicant Information - Please Print Legibly
Name pusineseOrganizationAndiviihiaD: ,
. .
• - Address: ,- . - •'
, .
City/State/Zip: - . Phone.#: - -
Are you an employer? Check the appropriatebox: • . .Type of project (required): /
• 1.0 I am a employer with 4• 0 I am a general contractor and I
6. 0 New coistruCtion
employees (fall and/or part-time).* have hired the sub-contractors
2.0 I ani a sole proprietor or partner- listed on the attached sheet. 7- Q. R,emodeling
•
ship and have , ...io .:iloyees These sub-contractors have -8. D Demolition
. .
' working forme m any capacity exixquecs-ndlave workers'
• 9: lailinA4?kiiiiitrin '
[No werkeTs' comp-. insurance ' .. ccraP-inturanee— , . . _______ _._ . . .
10.0 Electrical repairs or additions
required.] , • 5. 0 We are a corporation and its
fxer. aised their .
3. I am a homeowner dOimg all woti officers haVe
c 11.n Phiabing repairs or additions
myself. [No workers' comp. • 4A of exemption per MGL 12.0 Roof repairs
insurance required.] t
. c 152, §1(4), and we have no
• ,
' •
e [N wor 13.0 Other
- •
' c.comll insurance recIliired-1 • 1 • • . . .
Any applicant that checks box #1 must also fill out the section belotv.shovring their Workers compensation policy idealisation:.
t Homeownera Who subinit this affidavit inccatiMg they art doing all work and then hire outside contraitorS must submit a newiffidavit indicating such
Contractors that rhe•ric this box mist attached an arkonal sbeet showing the name of the subcontractors and state whether-or notthose-entides have
employees. If the sub-contraCtorshaVe employeeS, they mist provide their workers comp- policy number.
. .
-
lam an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information. .
• .
" - -
Insurance Company Name: • .
. • • - . .
Policy # or Self-ins Lic. #: - . Expiration Date - • - .• ' ,
. . .
. . . , .
Job Site Address: : • - . .
'' City/State/Zip: • . . . - .-
. •
-Attach a copy of the workers' compensation policy declaration page (showing the policy mimher and expiration date).
. . .._
. . .
Failure to secure cOvergge:iSregOite Secticin 152 can lead p iiiiPositib of aiiiiii;11 penalties of a
fine up to 51,500.00 andlor one-year imprisonment as well as civil penalties in the form of a STOP WORK-ORDER and a fine
. . _ the ,,... ..„_,...
of up to $2504)0 a day against the violator Be advised* a copy of this statement may be forwarded to Qfrice of
- EVeilliallaiis ofthe - " .: --- TT . 77 _
.0 i'diT7: olperjraythai the info'rntationprOvitiMITabouaindiorier
j
" : . _ ... _ ...... _ ..._____ . ......, . .
ignature: 0 told a: _ . Date: 5 q ---// •• , -
Phone ii: .4 / i .---' 5 e 6.4B 67 :_-_-• --. , ... • •• -
: - Official use only. Do not write in this area, to be completed by city or toWnfficiaL
... 1 C .iBty Board d T o o fea
v::
Issuing Authority (circle one):
H 2. Building Department 3...City/Town
P tri ector 5. Plumbing Inspector
6. Other , • • E. • '
1
I Contact Person: Phone #:
•
- '
,
r-
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction S ervisor: ( \y Not Applicable ❑
Name of License Holder : air ....3711.14 �17Li X
/ /cfC i r c'l i y �> License Number Co 3L / / `
Address Yedie/ Expiration ate
Signature Telephone 1'
9- - 'Retristere lomeliiltio ietiiiiif Ontii eto►~ iatZ Mil� � _ �. ; .. .
- . Not Applicablg
j 1n 1-06 1-06 Cft.m S io / ce 1I3 '
Company N a e Registration Numbe
Address � Expiration Date
>t.ii'l H OD ,/ • 0/0 Telephone 916
)
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 ❑
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 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, 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 neral Laws Annotated.
Homeowner Signature a V
,,,,,,s-70
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition New Signs [11] Decks [[J Siding [CI] Other [DI
Brief
Description of Proposed
Work:
Work: c) 0 Gtni .M� .✓ Q—EX) 1
Alteration of existing bedroom Yes \(' No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
, a ,at a� - z .. � ;ue � ,a
sa.: f [�vr i s is anc : r a� ic�t �ci` xi l �g2, ial smq�::cr pt+ei .t l+ °. otta lr<c .
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
i all m -■11111OrkMr 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.
Signature of Owner Date
I, \ i�5 V gCj , as Owner /Authorized
Agent hereby declare at 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.
{
Print Nam
111, /IAA
Signat - o Owner /Agent ' Date
}
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information f
Existing Proposed Required by Zoning `
This column to be fi ed in by
Building Department
K _
Lot Size 1 i 1 _ -----
Frontage . . -
Setbacks Front i j ? a
Side Li. R :? L:1 _ i R: _..i ___ ._.._
Rear 1 1 _ ,
Building Height , L i
Bldg. Square Footage 1 1 f
Open Space Footage %
(Lot area minus bldg & paved i u
parking)
# of Parking Spaces _ .
Fill:
I � € �
(volume & Location) ----- _.
A. Has a Sp ial Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page] t and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO
(2(
DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: 1 ___
'el D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, exc anon, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
ECF!VED Y �
3 ,F
Building Department::
2 Main Street Fs I
MAY NY
a3 LU (i Room 100 rFe
Northampton, MA 01060 d .
OTC p Ci t of Northampton one 413- 587 -1240 Fax 413 -587 -1272 m $ 1
oio60 fl
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address: (�
e C )-4) Map Lot Unit
i L O r C (Y)14 Y 4. 0l0 6 Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
` S11.0\ ES GR . 05S cif6 ®°e -ec z • DP ILL rr4z .
Name (Print) Current Mail g Address:
IA Telephone =
2. �• uthorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION' COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 3 (900 (a) Building Permit Fee
2. Electrical � l i' / (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 77
This Section For Official Use Only
Date
Building, Permit Number: Issued:
Signature' !�
Building Commissioner /Inspector of Buildings; Date
98 DEERFIELD DR BP- 2011 -0964
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 172 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2011 -0964
Project # JS-2011-001582
Est. Cost: $3000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DALE SMITH
Lot Size(sq. ft.): 16770.60 Owner: GROSS SHARON M & JAMES
Zoning: URA(100) //WSP II Applicant: GROSS SHARON M & JAMES
AT: 98 DEERFIELD DR
Applicant Address: Phone: Insurance:
98 DEERFIELD DR 0 586 -8867 0
FLORENCEMA01062 ISSUED ON:5/24/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 5/24/2011 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner