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The Commonwealth of Massachusetts
,, - . - Department of Industrial Accidents
4 + 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 Leaibly-
Name (Business( rganization/Individual): f t 14 h.4 ,, ) , 4 k c ' ,4• • z nj�� .....
Address: ' 6 P•' l '/
City /State /Zip: L J2- a--/ Jj ° / 4 ` { Phone ri: y/ 3 .sue V 9 Ze Z
Are you an employer? Check the appropriate box: Type of project (required):
4. I am a general contractor and I
1. ❑ I am a employer with � 6. ❑ New construction
mployees (full and/or part- time).* have hired the sub contractors
2. I am a sole proprietor or partner- Iisted on the attached sheet 7. ❑ Remodeling
ship and have no employees These sub contractors have 8. ❑Demolition
working for me in any capacity_ employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.:
required] 5- El 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. f No workers' cow. right of exemption per MGL 12.0 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 rust also till 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 contactors must submit a new affidavit indicatin_s such.
:Contractors that check this box trust atdehed an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees_ If the sub - contractors have anployees, they gust provide their workers' comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees Below is the policy andjob 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 5250.00 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 er the pain and pen _ s of perjury that the information provided above is true and correct.
Signature: Z. J Date: /i
Phone r: qyj ' j? V - 7 ze z.
t
Official use only_ Do not write in this area, to be completed by city or town ojjiciaL
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 #: i
SECTION 8 - CONSTRUCTION SERVICES
1
8-1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder : Ke MN-A-4 4 " ) • /I/v.6 ,4 #2 is c .S / .34.43
License Number /
•0 9
. - • r o,f? 7- Lc7• Lo//
Addres A Expiration Date
2 • 4 /3 - .-c; 4 ( ' 2. I 2.•
ure Telephone
9_ Re is tered Home linprover enf Contractor „k y , z ;' ; Not Applicable ❑
t h n- l.9 r Nh
d.z ,.., 3 7 7
o Name Registration Number
Address / / Expiration Date
A .) 44_
Telephoney /J = V t
SECTION 10- WORKERS' COMPENSATION INS
NSURANCE AFFIDAVfl (M G L c 152 § 25C(6))
Workers Compensation Insurance affida ' ust be completed and submitted with this application. Failure to provide this affidavit will r
in the denial of the issuance of the build' permit
I Signed Affidavit Attached Yes No ❑ 6 K. c L
The current exemption for homeowners" was extended to include Owner - occupied DwellinEs of one (1) or two(2) familie
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 10835.1.
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 -vear 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 Massach_ usetts General Laws Annotated, von may be liable for person(s)
you hire to perform work for you under this peimit '
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. Sign ature • . - • .
-. _ . -
L ' L ,
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House 1 1 Addition 1 1 Replacement Windows Alteration(s) I 1 Roofing J
1 Or Doors G
1
Accessory Bldg. 1 Demolition 1 1 New Signs [p) Decks [Q Siding (DJ Other [01
i
Brief Description of Proposed n ' Q w N ,�, go '� 3 � work: : �p o s f � v c� .l +�v�T � X 40-• vw.
Alteration of existing bedroom Yes 1..."' Aaorng new bedroom Yes i �
Attached Narrative Renovating unfinished basement Yes 4,,..- No � i ►Y R 1
Plans Attached Roll - Sheet
6a. If New house -and. or' addition: to existing. io%isinq,'complefeahe
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 stones?
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 fL 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
I � h r; s y Jl /i__ _ , as Owner of the subject
property
ereb a j( tIL tJ L,4) h A hereby authorize .2. a Tak ov-A " L
64-" ��
to act on my beh. , in all matters - - =t to work adthorized by this building permit application.
., % . l 2 - �5 0
Signature of • !. - r - " _ _te
• k - ' A 2 - z izi -.' & � Y �
as 0v/ter /Authorized
Agent here •y declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
i
Signed under he pains an penalties of rjury.
i.
ev. h. Gi • - wi,c
Print Na e
J
Sign. t e of eWQ+er /Agent - ate ■ 0 /
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
I .
Existing Proposed Required by Zoning
Lot Size
This column to be filled in by
B uilding Department
Frontage _ -- ._ -___ _ ___ __ _ _
Setbacks Front __- _
Side L:.—_ R: La__I R: ._____-,—. ---
Rear _ .__.
Building Height — -
Bldg. Square Footage r ___._, % r -- :------
Open Space Footage
(lot area minus bldg & paved r !� } ,
parking.)
# of Parking Spaces `
Fill: 1 `
ff
(volume & Location) 'I
A. Has a S at Permit /Variance /Finding ever been issued for/on the site?
NO DONT KNOW Q YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book j Page? I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW Q YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , Date Issued: `
C. Do any signs exist on the property? YES Q NO 10
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO g
IF YES, describe size, type and location:
E. Wll the construction activity disturb (cfearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
t
P-- •
•
Department use only
City of Northampton Status o f Permit:
Building Department Curb Cut/Dnveway Permit • 212 Main Street S ewer /Se ;
4, L 4� Room 100 WaterMTeII Avadabthty
�s Norttiamptc n, MA 01060 Two Sets ' .
phone 413 587 1240 Fax 413-587-1272 PIot/Site Plans
OtherSpecfy - • .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION I t ( C c ` g J o 7 91 : ( ALL 6) €i rzt;A
1.1 Property Address:
This section to be completed by office
' Ala*. /4_,7-- j'y t.v� Map Lot Unit
11 / '7 1 ve. iA A j . Zone Overlay District
an St. District_ CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT I
2.1 Owner of Record:
C A 1 Ir v 1( - l/ L ,5/Y.. Ant#. cl v u-
Name (Print) Current Mailing Address: y
i — X4 1 . . 4 4 Telephone , v,3 S 7S yd od
Signs • -
2.2 Authorized Agent
nA k ,,.c ft, La L & 4 - ,2.2 9e_ D. &X / '/dr Lx..,c&, , . o, o
Na e ( n n / , Current Mailing Address: /
_ y /3 -s8 y- 92-d Z •
Si .. • Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS f
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building j490. (a) Building Permit`Fee
2. Electrical 1 ' (b }Estimated Total: Cost of
Construction -fromf }
3. Plumbing .•••■•'' Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) . / 0. '�� Check. Number , �. -
This Section For Official Use Only
Building Permit Number Issue
Issued:
Signature: ___ y 3/ r b x
77
Building Commissioner /Inspector of Buildings Date
8§ ST BP- 2010 -0770
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A - 020 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- 2010 -0770
Project # JS- 2010 - 001151
Est. Cost: $3680.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KENNETH LYNDS 013668
Lot Size(sq. ft.): 6316.20 Owner: MARK JASON N & CHRISTINE E HENRIQUES
Zoning: URC(100)/ Applicant: KENNETH LYN DS
AT: 89 MARKET ST
Applicant Address: Phone: Insurance:
P O BOX 448 (413) 584 -9282 WC
LEEDSMA01053 ISSUED ON :3/5/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE PORCH ROOFS
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: j It 3/ 2 I 0 G-o:d [ S
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOL ION OF
ANY OF ITS RULES AND REGULATIONS.
,
Certificate of Occupancyv-- // - '1/Signature:
FeeType: Date Paid: Amount:
Building 3/5/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo