Loading...
42-103 i2') GA RN^ N-lk" 4 t l i, t co, f�Jy t\)^ 1( vNo \aw \04,6( - * 5 , d s..,* a. t r 'I r 10 r y,... Ca v,,p„ Y 1 (0 a •"------..... \P" v 5 ;:t.f \ YL I A "'0y ...fork 5 4 4 r C ol 11)..t., Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." • An employer is defined as "an individual, partnership, association, corporation or, other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work n hl acceptable evidence of compliance with the insurance requirements of this chapter have_beenpresented to_the_contracting- authority." - - - -- ---- - - - - -- -- -- -- Applicants • • Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub - contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited LiaailityPartnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self- insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. • Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city`or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.. :. • The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address, telephone-and fax number. :The Commonwealth of Massachusetts . • Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617- 727 -4900 ext 406 or 1- 877- MASSAFE Revised 11 -22 -06 Fax # 617 - 727 -7749 www.mass.gov /dia The Commonwealth of Massachusetts _ Department of Industrial Accidents It z _ ►.` l Office of Investigations =1�l= T 600 Washington Street W Boston, MA 02111 www.mass.gov/dia / • Workers ' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Cr r'1 r c w h Address: 13) rfx-eha a \L. City /State/Zip: \ U r4. v, r'1/a- Phone. #: y 15 13' — 18/ Are you an employer? Check the appropriate box: Type of project (required): i / I. ❑ I am a employer with 4. . 0 I am a general contractor and I 6 New construction _ -_ -- employees (full and/or part= time).* have hired the sub- contractors • 0 2. ❑ I ani a sole proprietor or partner- meted on the attached sheet. 7. 0 Remodeling ship'.. M have no envloyees These sub - contractors have. . g. 0 Demolition working for me in an y capacity. aci ty employees and have workers' 9. 0 Building addition [No workers' comp. insurance come. insurance.# . required:] 5. 0 We are a corporation and its 10.[] Electrical repairs or additions 3.A.1 I am a homeowner doing all work officers have ,exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required:] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 roust 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 contactors 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: rob 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 a 152 can lead to the imposition of crimin31 penalties of a fine up to S1,500.00 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 pedury that the information provided above is true and correct Signature: i n ~'n"— Date: �'t�l- �. Phone # �, i, l — r vi - i l $9.. - ' 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 CIerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other . 0 Contact Person: Phone #: i SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 1f Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor: Not Applicable V Company Name Registration Number Address Expiration Date Telephone 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 d 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 -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 buildine 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 Version!.7 Commercial Building Permit May 15, 2000 SECTION 10- STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes O No SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , 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 (1 f r© . ' - , 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/Aasint Date SECTION 12 - CONSTRUCTION SERVICES 10.1 Licensed Construction Supervisor: Not Applicable El Name of License Holder : License Number Address Expiration Date Signature Telephone SECTION 13 - 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 0 No Version1.7 Commercial Building Permit May 15, 2000 SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE) 9.1 Registered Architect: Not Applicable 23 Name (Registrant): Registration Number Address Expiration Date Signature Telephone 9.2 Registered Professional Engineer(s): Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone _ Expiration Date 9.3 General Contractor Not Applicable El Company Name: Responsible In Charge of Construction Address Signature Telephone Version1.7 Commercial Building Permit May 15, 2000 8. NORTHAMPTON ZONING 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 �o Open Space Footage °Io (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW ® YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ® DON'T KNOW O YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO 03 IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Versionl.7 Commercial Building Permit May 15, 2000 SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000 CUBIC FEET OF ENCLOSED SPACE — Interior Alterations ❑ Existing Wall Signs ❑ Demolition❑ Repairs ❑ Additions ❑ Accessory Building ❑ Exterior Alteration ❑ Existing Ground Sign 0 New Signs 0 Roofing 0 Change of Use 0 Other ❑ Enter a brief description here. Brief Description e %....., \:, � <A , 11, ,-4 ,-4 v `^^ ��^ A41_ ` ¢. - N „. 0 S en lo LA—A., Of Proposed Work: 7 "`) " k---1 k---1 kt c• k o ■-■ SECTION 5 - USE GROUP AND CONSTRUCTION TYPE USE GROUP (Check as applicable) CONSTRUCTION TYPE A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑ ❑ A -4 ❑ A -5 ❑ 1B ❑ B Business ❑ 2A ❑ E Educational ❑ 2B 1 ❑ F Factory ❑ F -1 ❑ F -2 ❑ 2C ❑ H High Hazard ❑ 3A ❑ 1 Institutional ❑ 1-1 ❑ 1-2 ❑ 1 -3 ❑ 3B ❑ M Mercantile ❑ 4 ❑ R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34): Proposed Hazard Index 780 CMR 34): SECTION 6 BUILDING HEIGHT AND AREA OFFICE USE ONLY BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION Floor Area per Floor (sf) 15t 1st 2 nd 2 3 rd 3 rd 4 4 t 4 Total Area (sf) Total Proposed New Construction (sf) Total Height (ft) Total Height ft 7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone❑ Municipal ❑ On site disposal system pe, S ��w ( Version1.71 Building Permit May 15, 2000 t Department use only �` l~C j. I i7. !, ity of Northampton Status of Permit: I uilding Department Curb Cut/Driveway Permit 1 JAN 2 9 2013 212 Main Street Room 100 Sewer /Septic Availability i l _ Water /Well Availability DE Northampton, MA 01060 Two Sets of Structural Plans ti�F rh�mFi�r� uo u phone Fax 413 - 587 -1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: 13- G- -t-, (1, a \ C 11-a- Map Lot / Unit \ or th iA. 'MA p I u (,), Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1 ) 6-.1 R. .. a c, i e 11 � 0 01O(o y ,J Name (Print) 6- Oar r : r ,'^'-- Current Mailing Address: 1- i U ,- e�.ct Signature al V "..-15‘ Telephone ti l l- S PI 11 kS 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building - 3 r G (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing 51 3 a (o \ Building Permit Fee j o{ 4. Mechanical (HVAC) 41 :5 7 - 5 5. Fire Protection f/) 6. Total = (1 + 2 + 3 + 4 + 5) 3 (o 1 0� Check Number V / U This Section For Official Use Only Building Permit Number Date Issued Signature: Budding Commissioner /Inspector of Buildings Date File # BP- 2013 -0728 APPLICANT /CONTACT PERSON BROWN MARGARET M & GARY W ADDRESS/PHONE 137 GLENDALE RD FLORENCE (413) 584 -1189 0 PROPERTY LOCATION 137 GLENDALE RD MAP 42 PARCEL 103 001 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 Tvpeof Construction: ADD BASEMENT 1/2 BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ON PRESENTED: pproved 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 Demolition Delay 1 0 cne / //--- 5 °r — 7 7 Signature of Building if` " cial 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. 137 GLENDALE RD BP -2013 -0728 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 42 - 103 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP -2013 -0728 Project # JS -2013- 001237 Est. Cost: $3612.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 19994.04 Owner: BROWN MARGARET M & GARY W Zoning: Applicant: BROWN MARGARET M & GARY W AT: 137 GLENDALE RD Applicant Address: Phone: Insurance: 137 GLENDALE RD (413) 584 -1189 O FLORENCEMA01062 ISSUED ON:1/30/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD BASEMENT 1/2 BATH 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 1/30/2013 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner