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29-301 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street z+ Boston, MA 02111 www.mass. /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization /Individual): ejaZA HCAYIC Prrn an 0_0 Address: l 'a o e c Sa-i' (S Sb!`t-c 4 City /State /Zip:L SW t ! ' lPhone #:(l c S29. O ..0 Are you an employer? Check the . ppropriate box: Type of project (required): 1. ( I am a employer with (j 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. ❑ Demolition working for me in any capacity. employees and have workers' working ) p h 9. 0 Building addition No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ 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.] r c. 152, §1(4), and we have no employees. [No workers' 132` comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. I. 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: :! 0 . ' a I nLtu Policy # or Self -ins ic. #: ` te ~ 3 01 '- o 1 Expiration Date: 11/ 1) d 2_ LO )is Sob Site Address: A f t� J'� f City /State /Zip: 0.,V7 C r� (,Q. r- 6106,4-, 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 e rtify under the pains nd penalties of per' that the information provided above is true and correct. Signature: Date: L0 it! //:2_ Phone #: 6 S 9 6( 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: • Y SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) /0 ,Z.) ci 1 f � j License Number Expiration Date Name of CSL- Holder List CSL Type (see below) inSU / Cd or L c ) I bn ► - Slrei its ? h�. Address Type Description U Unrestricted (up to 35,000 Cu. Ft.) ���%%% t R Restricted 1&2 Family Dwelling / Si ature M Masonry Only 1 °� 1 �O © RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor (HIC) Cozy liver) e_ Pei A) et c_e____ LL--C_. 1(o `7 ,' HIC Company Name or HIC Registrant Name ` Registration Number 1 ;P ats l . . /.3 Addr ss �Cu1"�,(f —)-(A, t b3) SA9 • 0 a20G x piration Date Signature Telephone SECTION 6: 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 ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OW ER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, .AV (. , as Owner of the subject property hereby authorize ( . J }k`r,- ' ...4, F,ic. ._ .Li to act on my behalf, in all matters relative to work at orized by this building permit application. ,--- / ,- - 2 , <" / 6,- ) 0 I a, i., ) ),), - of Owner Date SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION M —A I, V _ 4^ Cl - 2.., , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behal f^ IN r ` -\• 2 1 1 <-.. Print . " / e7 / Signature of Ow r A uthorized gent Date (Signed under the pains and pen es of perjury) NOTES: 1. An Owner who obt ' s a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned, provide the information below: Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for "Total Project Cost " - a . • r •••••-•,........ .., ...._ __ RE CErV, r 2 ., 120a i 1 - - DEPT. OF BIJILIDING 1 s...,x1r. .7f . NORMA/0pr ON, A 0 ,N ,. ....4. • ................................ The Commonwealth of Massachusetts Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR I FOR I lvILTINIICIPALITY USE j uilding Permit Application To Construct, Repair, Renovate Or Demolish a I Revised Mar 201 1 One- or Two-Family Dwelling i This Section For Official Use Only ,.. Building Permit Number: Date Applied: ----- . . . ,.. Building Official (Print Name) Signature Date SECTION 1: ME INFORMATION 1.1 Property Addcess: L2 Assessors Map & Parcel Numbers t0 PNC.rti,i a\\(; .(' . 1.1a Is this an accepted street? yes _ no Map Number Parcel Number L3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private 0 Zone: Outside Flood Zone? municipal 0 On site disposal system 0 Check if yes0 Sif-C - z't.rUcittEittv ..... _ .. ..... ...., . 2.1 Owner' of Record: S(-1 '-¼) 6- (...o co cY rnfi Di 0(j Name (Print) City, State, ZIP 1 l'.-- S 1 1 -4 6J1 3 _ No and Street Telephone F.mail Address . , SECTION 3:13ESCRIFTION-ovatROPaStD=WORIC -(cbeck ailatAPPV New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units_ _ 4her 0 Specify_ Brief Description of Proposed Work . 1 " ___(e.9.__\Jfir-4 s. P1 ) )(--, . . _ . . SECTION = $ Estimated Costs: .. Item OIficiai Use Only . _(Labor and Materials) 1,,,u ik 1 A 1.4 1. Building Permit Fee: $ - Indicate how fee is determined: , 2. Electrical $ 0 Standard. Ciry/Town'Application Fee , - --------- 0 Total Project Cost (Item 6) x multiplier x 3. Plumbing 1 S 2. Other Fees: $ _ 4. Mechanical (EVAC) i $ List: 1 5. Mechanical (Fire I s / Suppression) L Total All Fees: $ I Check Ng(, Check Amou4 .._ Cash Amount: ' I 6. Total Project Cost: ' $ (:)..., ,, i) 0 Paid in Full — 0 Outstanding Balance Due: . ■ ( File # BP- 2013 -0508 APPLICANT /CONTACT PERSON MARK LANTZ ADDRESS/PHONE 180 PLEASANT ST EASTHAMPTON (413) 320 -7611 PROPERTY LOCATION 430 ACREBROOK DR MAP 29 PARCEL 301 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid VC IA Typeof Construction: INSTALL ATTIC INSULATION & AIR SEAL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 102169 3 sets of Plans / Plot Plan T ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I NF ATION PRESENTED: Appr oved 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 1 olition Delay .mil S/ Sigma : ' . ing i fficial 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. 430 ACREBROOK DR BP- 2013 -0508 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 301 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2013 -0508 Project # JS- 2013- 000813 Est. Cost: $2200.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANTZ 102169 Lot Size(sq. ft.): 1 1064.24 Owner: LOCOCO SAMUEL J & KATHLEEN A Zoning: Applicant: MARK LANTZ AT: 430 ACREBROOK DR Applicant Address: Phone: Insurance: 180 PLEASANT ST (413) 320 -7611 WC EASTHAMPTONMA01027 ISSUED ON:10/31/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION & AIR SEAL 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 10/31/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner