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11A-050 The Commonwealth of Massachusetts Department of Industrial Accidents vri4 ® � { 14 Office of Investigations ..— 600 Washington Street Y = Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Z 0 U 15 6-IA/ A/I s Address: ? I I L! h oi E f& . City /State /Zip: £ E t 3 /`? 4. 0 l o Phone #: 7' / ` -5"ir‘ r 9 0-0 Are you an employer? Check the appropriate box: Type of project (required): 1. E I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. ❑ New construction listed on the attached sheet. 7. j Remodeling 2.N I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. (l Demolition working for me in any capacity. employees and have workers' 9. -f-- Building - addition— comp. insurance.$ [No workers comp. insurance p required.] 5. [1 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 myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.E Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1 Contractors 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 - contractors 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 certify under the pains and penalties of perjury that the information provided above is true and correct. ., • Signature: J. Date: 5 7 bd Phone #: 4 1 3 – - 7 O 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 #: a SECTION 8 - CONSTRUCTION SERVICES' I 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 1'40 . • U + N6; 4 S License Number 0 y 1-)11 v fro. Cs —© 7X') Address n G / V ,p Expiration Date L gL,o5 i R • / c' 53 d- 1 it 13 Signature Telephone O Registered- Home Improvement Contractor . r : ...._ .._... y : _ Not Applicable ❑ 6 4,5 4oat/ /33 Company Name Registration Number Address Expiration Date Telephone 1/7/13 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 No ❑ 11. _Home. 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 • J SECTtON5- DESCRIPTION OF PROPOSED WORK (check all applicable) „ New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors 0 Accessory Bldg. n Demolition 1 1 New Signs [0] Decks [Q Siding [X] Other [0] Brief Description of Proposed L Work: iv k w S i in/6 1.5 AYN 7 11'6. kleA, A ode I_ Alteration of existing bedroom Yes X No Adding new bedroom Yes 7 No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa, if Nevv'haius�.a�id or.ad titian- ta'exi t rare ti0usi �; cari7pfcte ttie. €oliouvinq: 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 1, ! L i"` (` ( LOi t1 i. "`� , as Owner of the subject property J � ^ hereby authorize L' D V ! 5 D.-. u i 4/6 ,9 . to ac n y b matt:o. - . e to work authorized by this building permit application. - Signature of Owner Date I, 1- et/ iss 6j i A/64_ A - , 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 andkpenalties of perjury. c , Print Name 1_01/1 ae G;A/G 4S S/ 7110)- - Signature of Owner /Agent Date f Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information h Existing Proposed Required by •Coning This column to be filled in by Building Department Lot Size ._._ _ ____ Frontage —__.__,_-__— ____ Setbacks Front _.___ Side L : R:= -_.__= L:; : R: = i i Rear € l — Building Height Bldg. Square Footage l % -- Open Space Footage % (Lot area minus bldg & paved , _ 1 1 1 -- I parkin %) i # of Parking Spaces — Fill: I j (volume &Location) - --- ----- A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW, YES 0 IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book ! Page; i and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 4 DON'T KNOW 0 YES Q 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 Q NO >411 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES I NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO 4 4 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Departmepit t1se only City of Northampton Status of Permit Building Department Curb trt7Da ay Pe,mtt -` t 212 Main Street Sewer /SepttcAvailatitty Room 100 WaterIWeil Avaiiabil�ty Y� a 3 0 N rthampton, MA 01060 1111 Tvdo Sets of Structural Plans x {� n 41 - 587 -1240 Fax 413- 587 -1272 PIntlSite Plans. �_� ; r �TiONu OtherSpectfy } Fk� G pEPi 'IaL • �' = ' 01 o ' ONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 17 SITETNFORMATION 1.1 Property Address: - ;:=1.:C'; - . " 5: Tt rs , sec t on to b e com by o -. 44 7 V, L L. DA/E el it e Map Lot =U L 4- os /--1- o f o� 3 «' Zone s Overla Drstnct Y ;_EIm St :District : CB Dfsfrrct SEC TION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ,-� R i - 1 o,v - roo [, L( Lei s - c5 ( Name (Pri-' _ Cun'ent; M�� g Areg� t--(( �! : Signature Telept 375 ! 1 7 2.2 Authorized Agent: l /l /�� 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 - 0, 4 2. Electrical Est (b) imated Total Cost of S — 1-10"E o w.vE� Construction from (6) 3. Plumbing Building Permit Fee S u D— 40 -^1 F c w.✓F.'' . 4. Mechanical (HVAC) 5. Fire Protection ✓ `- `E o 6. Total = (1 + 2 + 3 + 4 + 5) 1 0 o00 00 Check Number _ This Section Foi Official Use Only Date Building Permit Number Issued. Signature: _ : Building Commissioner /inspector of Buildings Date File # BP- 2012 -1054 APPLICANT /CONTACT PERSON LOUIS J GINGRAS ADDRESS /PHONE 244 HAYDENVILLE RD LEEDS (413) 586 -7420 PROPERTY LOCATION 7 VILLONE DR MAP 11A PARCEL 050 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ¢� Fee Paid ,q53 W Typeof Construction: REMODEL KITCHEN /BATH & NEW SIDING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 087279 3 sets of Plans / Plot Plan THE FO 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 D- • e 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. 7 VILLONE DR BP- 2012 -1054 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 11A - 050 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 -1054 Project # JS- 2012- 001819 Est. Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LOUIS J GINGRAS 087279 Lot Size(sq. ft.): 10672.20 Owner: MONTGOMERY MATT Zoning: URA(100)/ Applicant: LOUIS J GINGRAS AT: 7 VILLONE DR Applicant Address: Phone: Insurance: 244 HAYDENVILLE RD (413) 586 -7420 LEEDSMA01053 ISSUED ON:6/1/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN /BATH & NEW SIDING 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 6/1/2012 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner