44-059 (2) The Commonwealth of Massachusetts Print Form
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114 -2017
www mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Lezibly
Name ( Business /Organization/Individual): � / J
Address: "� zyX �
City /State /Zip: A f 4 knl4- 61,0 93 — Phone #: &"4/ 5 - 7 S`
Are you an employer? Check he appropriate box: Type of project (required):
A l — I am a employer with _/ 1, 4. ❑ I am a general contractor and I
employees (full and/or part - time).* have hired the sub - contractors 6. F 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 g. ❑ Demolition
working or me in capacity. employees and have workers'
g any P tY• 9. E] Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their IJ,[� i 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: lJh
Policy # or Self -ins. Lic. #: C 33 �1 C) Expiration Date: f _a V do � 3
Job Site Address: l � �'�'' l �-� City /State /Zip: A� 7;PA- s7 �-
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 n rte pains an aloes ofpeiyury that the in ormadon provided above is true and correct.
Si afore: Date
/ 7
Phone #: L 11 3 7 `-/- - 724' 3
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/Lkense #
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
8.1 Licensed Construction Supervisor 2 � Not Applic ❑ r
Name of License Holder � �� —`- f Y� C J
License Number
Address Expiration Date
Signature' Telephone
8. Re list red Home Improvement Contractor Not Applicable ❑
,5� L I Li -e7
Company Name Registration Number
Address Expiration Date
Telephone �-S
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.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [q Siding [lam] Other [O]
Brief Description of Proposed
Work: - S " T `, k0"
1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
ea. ff 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 o construction. _ Dimensions
e. Number of stories?
f. Method of heating? laces or Woodstoves Number of each
g. Energy Conservation Compliance. Massche ergy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. o tlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cel r floor below finished grade
k. Will building conform the Building and Zoning regulations? Yes N
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORMATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I _� .- ►Q / ( - y h as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to w9rk authorized by this building permit applic)ation.
rgnatu 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 t and penalties ofperjury.
Print Name
Signature of OwnedAg t Date
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
# of ParkiU Spaces
Fill:
(volume & Location)
A. Has a Speci Permit /Variance /Finding ever I n issued for /on the site?
NO O DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permi ecorded at the R istry of Deeds?
NO O NT KNOW YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or n d to obtained from the Conservation Commission?
Needs to be obtained Ob ed O , Date Issued:
C. Do any signs exist on the pro rty7 YES O NO O
IF YES, describe size, ty and location:
D. Are there any proposed anges to or additions of signs intetl�ed for the property ? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb (dearing, 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.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
JU I _ Room 100 Water/Well Availability,
r�
orthampton, MA 01060 Two Sets of Structural Plans
e4 3-587 -1240 Fax 413 -587 -1272 Plot/Site Plans
u
OF s`u Other Specify
NORTHgMp .MA 'CTICN.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address This section to be completed by office
�C)n L\> In.) I LSDiv ZA Map Lot Unit
Zone Overlay District
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
r S � z � a� l Lzz LGh fA
Name (Print) Current Mailing Address:
Telephone —
Sigrr'ature .5 /�° Lf,
2.2 Authorized Agent:
_T"45�5 �S ��- jt t f / .vt >. fy %fit e.�,. ✓�A 1��O�:E'
Name (Print) Current Mailing Address:
q 1 .- 3;7 y- - 7 '1 3
Signature Telephone
SECTION 3 AsTimATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by rmit applicant
1. Building J OD U ` (a) Building Permit Fee
2. Electrical C (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) _ Check Number
This Section For Official Use Onl
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
107 OLD WILSON RD BP- 2013 -0069
GIS #: COMMONWEALTH OF MASSACHUSETTS
MQ:Bloc 44 - 059 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2013 -0069
Project # JS- 2013- 000099_
Est. Cost: $8000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JDR BUILDERS 074105
Lot Size(N. ft.): 26136.00 Owner: ROBERTS LORRAINE M
Zoning: Applicant: JDR BUILDERS
AT: 107 OLD WILSON RD
Applicant Address: Phone: Insurance:
P O BOX 4 (413) 665 -7587 WC
NORTH HATFIELDMA01066 ISSUED ON :711812012 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE HOUSE & GARAGE ROOF
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 7/18/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner