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23A-057 (3)
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I \ Irni 4 ( i -- -r.-- , -7.-- --- P I V /4 ,- ,._ ,,, _ 0 s'- )e.,;;-t■ i 9 C '1r -di -1.1.-.0 c ),4-i The Commonwealth of Massachusetts "� -- Department of Industrial Accidents Office of Investigations 49 600 Washington Street t Boston, MA 02111 • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): Address: • • • City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ 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 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub - contractors have 8. n Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3. C 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. ❑ 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. 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 #: — 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): Board Health Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing In I. LlAlarU of la l.al LLa �. 1J iiuulfa� yf epar • +/ p Plumbing 6. Other Contact Person: Phone #: SECTION 5= "DESCRIPTION OF P.RO:POSED WORK (check all applicable) ,� New House n i Addition Replacement V /� endows Alteration(s) (. Roofing f Or Doors [ Accessory Bldg. n Demolition n New Signs [D] Decks [E Siding [D] Other [DI Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa Wi4ew `I;ouse.�and or ad.dit on.;to;existin.q housinq,,compiete theHfollow nq: 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 OWNERAUTHORIZATION' TO BE COMPLETED WHEN OWNER AGENTORC.p0VACTOR APPLI ESFORBUfLDING I, , 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 , 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. Print Name Signature of Owner /Agent Date r . , ; . n ,a,��u ' � y a r € s tDepa a lt"suse •nl City of Northampton S atus of etmt Building Department @ r t,!t3 la a . it JUN 25 2012 v 212 Main Street Sewe • t 'yatlabi :� i � a Room 100 Ater " elf yalla5t1 ,E uE T oFeui� �sPecrioivs i Northampton, MA 01060 o ets tr tura� NORTHAMPTON, MA 0106 �ihone 413- 587 -1240 Fax 413- 587 -1272 P at! a A la Other Specify �. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION .1 SITE INFORMATION .; 1.1 Prop Address: / � /� 2f This section to b' completed by office } Zone Overlay Dtrict Elm St 0 stric e ' CB "District ." SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Ai Name (Print - Current Mailing A dress: — Telephone Sig 2.2 Authorized Aqent: Name (Print) Current Mailing Address: Signature Telephone SECTION3 = ESTIMATED�CQNSTR"UCTION�COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant . 1. Building / (a) Building Permit Fee ' 2. Electrical (b) Estimated Total Cost of � d Construction from {6) 3. Plumbing Building Permit Fees 4. Mechanical (HVAC) z �` 5. Fire Protection s . F V 6. Total= (1 +2 +3 +4 +5) ��; G}� Check Number This Section For-Official Use Only' Date V V Building Permit Number: V Issued, Signature <. , Building Commissioner /Inspector of Buildings V V Date File # BP- 2012 -1166 li APPLICANT /CONTACT PERSON STEPHEN YOSHEN J1 ADDRESS/PHONE P 0 BOX 41 CUMMINGTON (413) 695 -7801 0 �� PROPERTY LOCATION 62 MIDDLE ST MAP 23A PARCEL 057 001 ZONE URB(l00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid -( f R4=ci° Building Permit Filled out Fee Paid Typeof Construction: Addition New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 88490 3 sets of Plans / Plot Plan THE FOLLOWING A N HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION P SENTED: Approved Ad ditional permits required (see below) �/ PLANNING BOARD PERMIT REQUIRED UNDER:§ 35 L�- S (fit j � 3 7 Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BERMIT 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 • lay Si dr., /0"1.1.1:111( tc.-;?°7--1.3- _ e o Building Iffi al 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.