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Information and Instructions
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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, §25(7(7) states 'Neither the commonwealth norany 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 prese ntod 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-contiractor(s) name(s), address(es) and phone numba(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partne ships (LLP) with no employees other than the
members or partners, are not required to carry workers' co on insurance. If an LLC or LLP does have
employees, a policy is required. BF advised that this affidavit maybe submitted to the Department of Industrial
.. Accidents for confirmation of insurance coverage. Also be sure to sign sad 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 orif you are required to obtain a works'
compensation policy, please call the Deimrtment at the number listed below. Self - insured companies should enter their
self wee license number on the appropriateiine.
City or Towp Officals •
•
Please be sure that the affidavit is complete 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 his to contact you regarding due applicant -
. Please be sure to fill in the pesmidlioease number which will be used as a reference number. In addition, an applicant
that must submit multiple pemitflicense 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 _ or
town)"A ctipy of the affidavit eat has been officially stamped orspoked by the cityor town may be provided to the
applicant as proof that' valid affidavit is on file for future permits or ficeascs. A must be 51iod out each
- +-.` * Vu f if*** a: fioease .ocpdmitnot>ir.LOiit4 or onumauiat
(Lc. dog PCp rho bm eavtx et rip is t NOTE *, affierf . ` r *,11,
• a . . •
Im►esttgations would like to thank you in advance for yWr coopaadaa and slr0ul&ylou have Iny question,
please do not hesitate to give us r4•41"14-"7. k ... ; .•, The Deps 's address, telephone-and fax number:. .
The Coinrnonwealth of Massachaseqs
•
• Department of I11� AcoL&uts
" '"E ice'of In : Milo' s
600 Washin�gtou Street
. Wi02111
Tel. # 617- 72 ?- 490d•ext 406 or 1 «877- MAS$AFB
• Revised l l 22-06 Fax # 617.727.7749 • • .
www.mass.gov/dia •
•
•
The Commonwealth of Massachusetts
II — fit
Department of Industrial Accidents
-V►= - Office oflnvestigations
� 600 Washington Street
=ail_
• Boston, MA 02111
✓. .4; www mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information ( Please Print Legibly
Name ( Business /Organization/Individual): S. La c. Cwt V o I K S i n
Address: 1 4 J•c t-+ F Scf , J
C i t y / S t a t e / Z i p : No rk `^-u• w-r ' i v " ` 016 6 o Phone. #: 4 ( " 3 - - 5 1 ) 7 — I Z
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a employer with 4. 0 I am a general contractor and I 6. ❑New construction
employees (full and/or part- time).* have hired the subcontractors
2.0 I am a sole proprietor or partner- listed on the'attached sheet. 7. [Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition .
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp. insurance t 9. ❑Building addition
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ® I am a homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions
myselt o workers' right Of exemption per MGL •
insurance r e q u i r e d . ] t � c. 152, §I(4), and we have no 12.0 Roof repairs
employees. [No workers' 13.0 Other
comp. insu ancc.required.]
Any applicant that checks box #1 mrstaho fill out the section below showing their workers' compensation policy information. .
t Homeowners rho submit this affidavit inclicating they arc doing all wale and than hire outside contractors must submit a new affidavit indicating such. '
*Contractors that chock Ibis box must attached an additional shat showing the name of the and state whether or not those entities have
employees. If the have employees, they oust provide their worters' 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: : • Qty/State/Zip:
Attach a copy of the workers' compensation policy declaration page'(showiag the policy number and expiration date).
Fai tue.to secure coverage as required under Section 2SA ofMt3L c. 152 can lead to theimposition of criminat penalties of a
fine tip to $ 1.50000 and/or one -year imprisonnient, as well as dv11 peailfies cute Rani ofa STOP WORK ORDER and a fine .
• of up to $25000 a day against the violator. Benidviaed that acopyofthis statenintmay be for arded to the Office of
. ..:lions . fthe tIAfor ,i.n. •. ' - _ •verification. .
I do Isaviv awl ' atndar the paliundpenalties ofpairay that the ti{forniadon provided show ls true and owed
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• SLa�• 5 4 4 tiv�, - , _. 7. 20 /a
Phone if: • A 1 3 - ) ' ( - 2 - 3 • .
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Official use only. Do not write In this area, to be compldudby. c (r or town of`klaL •
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City or Town: Permit/Ltoense 6
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 #:
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City, of Northampton
e Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
1,173
� , 212 Main Street • Municipal Building
^' Northampton, MA 01060
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
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 any person(s) who seek to use the home
owner exemption, to 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 permits 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 /
1, S, Lh t- E y Jo t-1 N 5'I<o N / 5, 454-4 nderstand the above.
(Home owner /resident's signature re uestin exemption)
( 9 q 9 pt )
I will call to schedule all required building inspections necessary for the building permit issued to me.
Date ` + 7 7) /0
Address of work location (4 S E w ETT ST
N ofZTt•1►gPAP N !^'t 15 (0lQ 0
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone_
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 108.3.5.1.
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.
JCL. Homeowner Signature 5 • �1 L..1. RNA
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ® Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [Qj Decks [[I Siding [D] Other [CJ]
Brief Description o Pr[oposed t ^ (id/ 1
ix I
Work: A o lx-t ' � -5 SW- a w 'oR4 3 7 )
J
Alteration of existing bedroom Yes DC No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes PC No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
a. Use of building : One Family iX Two Family Other
b. Number of rooms in each family unit: e, Number of Bathrooms
c. Is there a garage attached? O
d. Proposed Square footage of new construction. 2 - I 5Y _ Dimensions 4. 3 K 7
e. Number of stories? ls t�
F WAr
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? X _ Yes No .
I. Septic Tank City Sewer JC Private well City water Supply X
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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 , '5 • L A L E y J O lA N 5ra Q , 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.
S. LAt`E Y Jo NN SToNJ
Print Name
S, � �- -, t d 7 2v t o
Signature of Owner /Aged Date 1
} 6
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
67
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 OD YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW O YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
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
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 0,
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Dep ent use only
n ' SP City f Northampton Status of Permit: \ \ \ \ \ \ \
1 $uildi Department Curb Cut/Driveway Permit
`6c Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
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 Progeny Address: This section to be completed by office
14 .J E W E TT ST Map Lot Unit
f o 2'T to M4 W k iQ T O !J ) Nil A Q 0 0 Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
5. LPt.6Y Jot\NStoN / C.oLLEE?'f Ft JNE6-A'M
Name (Print) Q Current Mailing Address: p O J C
4 ). ct , e,-4 Telephone `7
Signature 41 t 7— 3 V 2 - 3
2.2 Authorized Aaent:
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 6-00 U (a) Building Permit Fee
2. Electrical b U O (b) Estimated Total Cost of
_ Construction from (6)
3. Plumbing 2000 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
' 6. Total = (1 + 2 + 3 + 4 + 5) ¶ o o O Check Number �p e MS"
This Section For Official Use Only
Date
Building Permit Number: Issued
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0236
APPLICANT /CONTACT PERSON FINNEGAN COLLEEN B & S LACEY JOHNSTON *W
ADDRESS/PHONE 14 JEWETT ST NORTHAMPTON i\)Ee
�
�V PROPERTY LOCATION 14 JEWETT ST ESs ,b\
MAP 31A PARCEL 124 001 ZONE URB(100)/ /071(6°
THIS SECTION FOR OFFICIAL USE ONLY: � Q
PERMIT APPLICATION CHECKLIST ��� .h 3
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out �y
Fee Paid / IP `)
Typeof Construction: CONSTRUCT INTERIOR DOWNSTAIRS BATHROOM
New Construction (Vt { [ N,A V f : VEPRLAIlo 1D
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
1-' 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
Demolition Delay
/
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.
f ,
14 JEWETT ST BP- 2011 -0236
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A -124 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2011 -0236
Project # JS- 2011- 000399
Est. Cost: $8000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10541.52 Owner: FINNEGAN COLLEEN B & S LACEY JOHNSTON
Zoning: URB(100)/ Applicant: FINNEGAN COLLEEN B & S LACEY JOHNSTON
AT: 14 JEWETT ST
Applicant Address: Phone: Insurance:
14 JEWETT ST
NORTHAMPTONMA01060 ISSUED ON:9/17/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT INTERIOR DOWNSTAIRS
BATHROOM
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 9/17/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner