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23A-246 The Commonwealth of Massachusetts r. Department of Industrial Accidents :: t? Office of Investigations . 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Le v;5 ,J ' G l'-4/6.t. 4 Address: vt y � N/� `�Q��V i 1 L.E t 4 City /State /Zip: L ,p S j. D) 6 5 3 Phone #: 4 /3 — 86 `- 7 9 a� D Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. n I am a general contractor and I employees (full and/or part-time).* have hired the sub contractors 6. ❑ New construction 2.1g I am a sole proprietor or partner- listed on the attached sheet. 7. 121 Remodeling sub-contractors have ship and have no employees These su 8. El Demolition working for me in any capacity. employees and have workers' 9. n -- Building addition— [No workers' comp. insurance comp. insurance. required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing repairs I am a homeowner doing all work ❑ g airs or additions P 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. 1. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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: Date: Phone #: y l 3 5 74 — 7 L;• Q Official use only. Do not write in- this 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 #: SECTION 8 - CONSTRUCTION SERVICES ; I 8.1 Licensed Construction Supervisor: Not Applicable 0 I -T ` Name of License Holder : L o L S �l . �j ! �G �J c s ©6 7 -7 ` License Num er / 1 AYoENV',Lc,� /2,0 LEiE�os / a /of? 14. 11113 Address Expiration Date f st� Signature Telephone I3 -58C : - 7 L f0 1 - 6 9714eiktered Home'Imp1-ovement Contractor _ _ ,, � .' r _ _ ,. � }; Not Applicable ❑ Sit 4i ,vl/E. /33 9 9 `� Compan Name Registration Number 0 / L/ ism, o eti v .'L L e "4 , 117 /,-o /3 Address Expiration Date • Telephone SSG ,7 `71'0 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.- 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 and 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 • SECTIONS- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition n Replacement Windows Alteration(s) I I Roofing n Or Doors C Accessory Bldg. ❑ Demolition 1 1 New Signs [D] Decks [E] Siding clic Other [0] Brief Description of Proposed y Work: A& s 1' 4 E A 17T 1 9 Alteration of existing bedroom Yes _ No Adding new bedroom Yes � N Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa_lf,: .F...�, Fl�w harass and or.adr�9ti�n to ei�tirrif hasir�,crmpicte t�+E fo9fawin`q: 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, Pot:fr t c ] O a , as Owner of the subject property hereby authorize L O U I S S* G r it . d S to act on my behalf, in all matters relative to work authorized by this building permit application. Par) ut*A-ia) o - - Signature of Owner Date L o v i S 7, G t `'✓(, 4 b4 S , 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. Lo v ;A./6 rf5 Print Name Signature of Owner /Agent Date , t Section 4. ZONING Alt 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 ---- - - -_- _ _ Y __. _.__ . ____.�______ Setbacks Front m Side L:- R: L::______' R i i Rear " _- Building Height i Bldg. Square Footage i ! % —" a I Open Space Footage __ _ (Lot area minus bldg &paved ��_ —� i } I parking)---- _ . - - -- # of Parking Spaces - ' Fill: . , , (volume & Location) --m- ----- •--- ; - - ---- -- — A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW 0:4 YES 0 IF YES, date issued IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW *9 YES 0 IF YES: enter Book ` Page' and /or Document # B. Does the site contain a brook, body of water or wetlands? NO #470 DON'T KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained t Obtained , Date Issued: C. Do any signs exist on the property? YES t NO 4 ® IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, exc.vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO " IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , - - - City of Northampton StatUs Perimt Building Department 212 Main Street • Se,wer/SaptioAyallability Room 100 till( 3 0 Stt Northampton, MA 01060 TWc ts af Struc P1 an ne . 13-587-1240 Fax 413-587-1272 ,., MAW' '` OtheISpecify. o •ca APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELUNG SECTION 1 - SITE INFORMATION = 1 by office Property Address: 1) 5 No-A/oToi-ic ST - Lot • `Ar; F 11. 6A/c E A-119, 0 Zone = ,- „Overlay District- EIm ..-• - : St. - = :-"'- - - " CB intsitict- • SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: p fi T lUi / )24:,' Name (Print) Current Mailing Address: J 4 I Telephone Signa jk-i- tYg 9 53 g 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone -SECTION 3--ESTIMATED CONSTRUCTION COSTS - Item Estimated Cost (Dollars) to be - r Offlcial Use Ony - . - completed by permit applicant • . , - 1. Building i 0 • 0 0 (a) .Building Permit Fee:- - - - e 1/2 00 z - 2. Electrical (b) Estimated Total Cost of - Construction from_(6) - _ - - - - - 3. Plumbing Building Permit Fee . _ - _ , _ - - - -- 4. Mechanical (HVAC) 5. Fire Protection 1 3 - 6. Total (1 +2 + 3 + 4 + 5) o D C 0 8 Check Number , This _Section For Official Use Only - . _ - - _ Building Permit Number: Issued: - - - - - - Signature - - - _ - - _ . - • .. _ _ Building Comrnissioner/Inspeotor of E3uildings _ - - - - 185 NONOTUCK ST BP- 2012 -1055 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 246 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: vinyl siding BUILDING PERMIT Permit # BP- 2012 -1055 Project # JS- 2012- 001821 Est. Cost: $2000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LOUIS J GINGRAS 087279 Lot Size(sq. ft.): 9408.96 Owner: KOPKA PATRICIA A TRUSTEE Zoning: URB(100)/ Applicant: LOUIS J GINGRAS AT: 185 NONOTUCK ST Applicant Address: Phone: Insurance: 244 HAYDENVILLE RD (413) 586 -7420 LEEDSMA01053 ISSUED ON:5/30/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: RES I D E ADDITION 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 5/30/2012 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner