13-017 (5) No
ifLN The Commonwealth of Massachusetts
Department of Industrial Accidents
AO: Office of Investigations
600 Washington Street
Boston, Mass. 02111
www. mass.tov /dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant information: Lance Hodes Please PRINT legibly
Business/Organization Name: Haydenville Woodworking & Design, Inc.
Address: P.O. Box 1070
City /State /Zip: Amherst, MA 01004 (413) 665 -7402
Are you an employer? Check the appropriate box: Business Type (Required):
1. X I am an employer with 6 employees (full 8. ❑ Retail
and/or part- time)*
2. 9. ❑ Restaurant /Bar/Eating Establishment
3. ❑ I am a sole proprietor or partnership and have no
employees working for me in any capacity. 10. Li Office and/or Sales (incl. real estate, auto, etc.)
[No workers' comp. insurance required]
11. ❑ Non -profit
4. ❑ We are a corporation and its officers have
exercised their right of exemption per c. 152, § 1(4), 12. ❑ Entertainment
and we have no employees. [No workers' comp
insurance required]*'* 13. ❑ Manufacturing
5.
6. ❑ We are a non-profit organization, staffed by
14. ❑ Health Care
volunteers, with no employees. [No workers' comp.
insurance required] 15. X Other _ Construction
7.
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
* *If the corporate officers have exempted themselves, but the corporation has other employees,, a workers' compensation policy is required and such
an organization should check box #1.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information.
Insurance Company name: A.I.M. Mutual Insurance Co. Insurer's
Address: 330 Whitney Ave.
City /State /Zip: Holyoke, MA 01040
Policy # or Self -ins. Lic. ## WMZ8006257012010 Expiration Date: 7/6/2012
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 ofa STOP WORK ORDER and a fine of up to
$250,000 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 certify under the pa' / nd realties of perjury that the information provided above is true and correct.
Signat Date
Print Nam Lance _/-lode Phone # (413) 348 -2733
Official use only. Do not write in this area to be completed by city or town official
City of Town: Permit/license #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office 6. Other
Contact person: Phone #
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : G g 64)004* yy3/ 4
License Number
? I w Fi 6'L 1.) iQ D /BRA h''.9/Y /h/` c51 00 / o l L AS
Address Expiration Date
v3) 3 it Epa ?
_•. nature Telephone
9. Reaistered Home Improvement Contractor: Not Applicable ❑
//o ?3 a.
Company Name Registration Number
/7 u /A1.,E" Ge o c O;) tei0, / J E'.ce• Cs ot) , .,r, /, /3
Address Expiration Date
5".9 o 4,11 / Sp. pF/?1rieL1), Telephone (yY3)6 GS - 7yo�
0a323
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 tom 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 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 General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ri
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [0] Other [a]
Work: Description o h e ose4- 1 , --5 / r' c / J h c c p r o S S -► ) V
Wor K � � J,, � v •—, . /` c •• o U a e -. c Q S A Ta d1 �A � •-. a
y
Alteration of existing bedroom Yes 1 ." --- No Adding new bedroom Yes ' No
Attached Narrative ,,.. Renovating unfinished basement Yes � No
Plans Attached Roll Shee
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
j<1 C e �' / ` 14-5 , as Owner of the subject
property
hereby authorize L. #910 flro O. S
to act y behalf, in al matters relative to work authorized by this building permit application.
Signature of Owner Date 3
1 '9 eO c F 11/406--1 , as Owneri uth ztro ed
M A e hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
n lief.
Signed under the pains and penalties of perjury.
1 - /9 w c ,ice'. #o 0A
Print Name y/ /
ig ture of Owner /Agent Date
Na G 4 P► -.9c t0 a. # � ° n
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 YES 0
W YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW V YES Q
W YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained fl Obtained Q , Date issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
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. Witt the construction activity disturb (clearing, grading, excava n, 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.
Department use only
City of Northampton Status of Permit:
RECEIVED Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
APR Room 100 Water/Well Availability
3 2012 .tth- ampton, MA 01060 Two Sets of Structural Plans
phone 41c-5E7-1240 Fax 413 - 587 -1272 Plot/Site Plans
. OFBUILDING INSPECTIONS Other Specify
NORTHAMPTQN Ma plow
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Addres s: / < [/ This section to be completed by office
7 Woe.. 4 /a < y ) / Map Lot Unit
J Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
13 2u e-- ,R Q1A l t'1 o7 /G-.d W.-;
Na Tint) Current Mailing Address.
Telephone
Signature
2.2 Authorized 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 / (a) Building Permit Fee
oda
2. Electrical ASoO (b) Estimated Total Cost of
Construction from (6)
3. Plumbing S 80 Building Permit Fee
4. Mechanical (HVAC) NA1
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) .2 � O 90 Check Number 4 61, W/3 3 g
/.36' This Section For Official Use Only t
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0944
APPLICANT /CONTACT PERSON HAYDENVILLE WOODWORKING & DESIGN INC
ADDRESS/PHONE P 0 BOX 1070 AMHERST (413) 253 -3229
PROPERTY LOCATION 27 ROCKLAND HEIGHTS RD
MAP 13 PARCEL 017 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out � 0/ 3 1
Fee Paid � 6 I
Tvpeof Construction: RENOVATE KITCHEN & LIVING ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 044314
3 sets of Plans / Plot Plan
THE F , OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
Demolitio Delay
- 1 4 ;?-- - / —i ,,,e,,--' 2-7,/;--
tgnature of Buil . ing 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.
27 ROCKLAND HEIGHTS RD BP- 2012 -0944
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 13 - 017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP -2012 -0944
Project # JS- 2012- 001643
Est. Cost: $22080.00
Fee: $138.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HAYDENVILLE WOODWORKING & DESIGN INC 044314
Lot Size(sq. ft.): 24393.60 Owner: KRASIN - SAVENKOVA BRUCE W LUDMILA V SAVENKOVA - KRASIN
Zoning: Applicant: HAYDENVILLE WOODWORKING & DESIGN INC
AT: 27 ROCKLAND HEIGHTS RD
Applicant Address: Phone: Insurance:
P 0 BOX 1070 (413) 253 -3229 Workers Compensation
AM H E RSTMA01004 ISSUED ON: 5/2/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: RENOVATE KITCHEN & LIVING ROOM
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 5/2/2012 0:00:00 $138.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner