42-035 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
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 Legibly
Name ( Business /Organization /Individual): ? f f D cu..L l r c•
M
Address: 1 1 1Qt f\
City /State /Zip: Gran �Q.t � ) tAQ _ D`KI) \ Phone # y\ 3 ' 113 • It 1
Are you an employer? Check the appropriate box: Type of project (required):
I. - I am an employer with 59 4. - I am a general contractor and I 6. - New Construction
Employees (full and/or part- time)* have hired the sub - contractors
2. - I am a sole proprietor or partner- listed on the attached sheet. I - Remodeling
Ship and have no employees These sub -contractors have 8- - Demolition
Working for me in any capacity. workers' comp. insurance. 9. - Building Addition
[No workers' comp. insurance 5. - We are a corporation and its 10. - Electrical repairs or additions
required.] officers have exercised their
3. - I am a homeowner doing all work right of exemption per MGL 1 1. Plumbing repairs or additions
myself. [No workers' comp. C. 152, ' 1(4),_and.we_have..no -- 1 -2. - Roof repairs
insurance required : RI employees. [N .- 13. - Other
- .. o avorkers'
comp. insurance required.]
Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
H Homeowners who submit this affidavit in dicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
I Contractors that check this box must attach an additional sheet showing the name of the sub - contractors and their workers'
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information.
Insurance Company Name: -' an oU x T Q (\SuC (1 Cc n ea n
Policy # or Self-ins. Lic. #: I,) N ' Gl n (O1.Q-00 Expiration Date: I "\ ] 1
ItV 13
Job Site Address: 735 es-t'f i rr* cL Cit y /State /Zip: Fl () li i n& / t1 +. 010(02-
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 . der the pains and • enalties of perjury that the information provided above is true and correct.
Si• nature: " NM' AA`. ,,J444.�� Date: it / (
Phone #: L ila 7310 • (?_,3 g } C lDd—
Official use only. Do not write in this area, to be completed by city of 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 #:
.i
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : O Q,V 1 cL C - A-e _ ( �I L 9 1 `T !
License Number
55 t n �t- . C ��� r' �� � tACt 01 31 � V•
Address ` Expiration Date
00)ItQC LIt3.77 a o1C3
Sign Telephone
3: Rec tilt+ iii :f til eimfff0 rfteht:t oifttldpto w.. m.,_ ' ; !. :`' "V 7- Not Applicable ❑
?e- ( . 1 'k Cb cart. C.-kS l i\C� • l 42.2 7 `?
Company Name Registration Number
1.55 FAQ n : C7rein .e.1 Ht. b1 3o\ 3 2y
Addre Expirati Date
CIPtAt9 C � l 4 11 k Telephone —'[ l l `2 • b 15
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 at
No ❑
11. ionteuwnerzxer tiori
The current exemption for "homeowners" was extended to include Owner- occupied DwellinEs 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 [ � Wows Alteration(s) d Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [C] Siding [CI] Other [❑]
Brief Description of U
f Pro. • ed . . ` 1
Work: I a. a, • U ► L { t • • ••� ► : 1 , • �� O S C E
/ / C. k nc •
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓ No 2
Plans Attached Roll - Sheet ,�,( —V C� Lle. ' 3
ea if New. °tius:,,rid +t ac�dititn to existing I�n�isir��iGcmpl+ #� �i #11�riivr:
a. Use of building : One Family I/ 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 atta
h. Type of construction lIbme � VAeYWQ Men CWT W 9'12P l�C rne- T)
1. 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 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, - o ad, as 4 A hC..lT\ , as Owner of the subject
property
hereby authorize ?CA \. G 4 O LA c- } YU •
to act on my behalf, in all matters relative to work authorized by this building permit application.
(bnky S∎gAg . 14-%. vetc 1 L \ s \VD
Signature ottOwner I Date
R (u tit C • f k.0 • , 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.
` 1)c u cL C• L3 h t —
Print Nam D OCk Th A19 • (\COYa —-
Signature of Owner /Agent Date
1
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 _. f m _ _- -_ _,i
Frontage , A __ _.._.._ _.. _ . . _ _ ,_ _- ..... __ .. .
Setbacks Front
Side LE 1 R:
Rear — .._ -----
Building Height 1,....._,J
Bldg. Square Footage _ %�'�
Open Space Footage °
/o
�
(Lot area minus bldg & paved _ i_ _.-J
parking)
-
# of Parking Spaces �� m -,'
Fill: 1
(volume &Location) L� ._._ _ __._ _ _. i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW el YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Re istry of Deeds?
NO 0 DON'T KNOW YES 0
IF YES: enter Book _j Page 1 and /or Document # µ
B. Does the site contain a brook, body of water or wetlands? NO ec DON'T KNOW ® YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained i Obtained , Date Issued
C. Do any signs exist on the property? YES 0 NO ef
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
IF YES, describe size, type and location: "
E. Will the construction activity disturb (clearing, grading, exc ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Dee ti u se : ' i
�. City of No rthampton �1`a �
e ms - B uil d i ng Department i ce: y -,
212 M ain Street
' J.. 1 1 / Room 100
o � NSPeat ■ 'rthampton, MA 01060 w g r 1 '.
� ;` ^ '01.i o, -- 13- 587 -1240 Fax 413- 587 -1272 ^ : R MA r
A TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DE M OL ISH A ONE O TW O FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: n ' This section to be completed by'office
13 W.€# am ��oi* -1 R " Map Lot Unit
�) o r.e n L2 0 d 2 — Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
�` •
�./ I — c, K 735 13 QS�1na m eto >n •
Name (Print) urrent Mail' s: es
MI:* Telephon
Signature
2.2 Authorized Agent:
V', 11 �e ��a�1 �u�.1e, � �nL I5� �Q � r� S� . �-1t22n k � Name mt) Current Mailing Address Q cJv�
c Lt1' 7117— O con)
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated 5.300 . °C) Cost (Dollars) to be Official Use Only
completed by permit applicant
.
1. Building (a) Building Permit Fee
2. Electrical (b) Es Total Cost of
C from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 5300�� Check Number y i % ( �
This Section For Official, Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
735 WESTHAMPTON RD BP- 2013 -0566
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 42 - 035 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2013 -0566
Project # JS- 2013- 000914
Est. Cost: $5300.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 091496
Lot Size(sq. ft.): 30361.32 Owner: FRADKIN DAVID L & JOAN ROBB
Zoning: Applicant: PELLA PRODUCTS, INC
AT: 735 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772 -0153 WC
GREENFI ELDMA01301 ISSUED ON:11/19/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 4 REPLACEMENT WINDOWS
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 11/19/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner