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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 until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented 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-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(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
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 7-2010 Fax# 617-727-7749
www.mass.gov/dia
Print Form
The Commonwealth of Massachusetts ._.. ..
Department of Industrial Accidents
Office of Investigations
t� 1 Congress Street, Suite 100
,, :,,,o4:::-- . Boston,MA 02114-2017
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):Barry Cohen Renovation&Construction
Address: 40 O'Donnell Dr
City/State/Zip:Florence, MA 01062 Phone #: 413-559-9683
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2. 4 I am a sole proprietor or partner- listed on the attached sheet. 7. p Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
g y p ty insurance.$ 9. ❑ Building addition
[No workers' comp.comp. insurance
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §I(4),and we have no Deck, Porch
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 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:
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$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 perjury that the information provided above is true and correct.
Signature:I T-' ,� .Date]6/6/2013
Phone#: 4(f - c.l 5 - j 6 c 5
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#:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor
CS-005639
tstarne of Licerise Holder ar rY R. Cohen
, .
40 O'Donnell Dr. Florence, MA 01062 7/9/3013
9. Rests ered Home Improvement Contractor. N A cao e
Barry Cohen Renovation&Construction 106056
Company Name
40 O'Donnell Dr Florence, MA 01062 7/21/2014
Ec'ra*c,--1 Date
(413)559-9683
SECTION 10-WORKERS. COMPENSATION INSURANCE AFFIDAVIT (M,G,L. c. 152,§ 25C(6))
s -ce sitf
a I.s-t"-
j Ytt''t N77 7
11. - Home Ow ncr Exemption
0■Sner-oceivied Ds ethn '
1,, ■„'1,2.;':i: Wd!'.id0:1! as ,1!. prm Ricci that the 40,s nee acts
as supers ism.( -81), `NiO F ilition Section IOS.3,3.1,
liefinition ut llomelos MA" t ..1 i.t710 t-11.1.111,:h shV t,t,ttdc-, mtem.1,t,-
dij,t,hL:d Ltroi
k person siho constructs more than one home in a tti.o-Aear period shall nut he considered a hoineos tier
e HiMd.11,1 a -1 re (,',.ertrtKe a tJdae that he she shall he
responsible for all such mirk performed under the huilditill permit.
onostrtiClinn SUperNisor o 1^;.: 1,-1,1111111..1d
r cm'peas.*-,nt mid ( aark.'r 17'; I
:1.. tria'■ he liatsle re
",,IL"; "Ph pc'! '' !
‘Wti tOt 0'1
N, f,' 1".p1 i ad \71,1,-„Itcj
ilomeov,hier Sp4lialtirtt
Section 4. ZONING 41: ir'4".:.,m3t'c' Y.,:Y- f3i-,- (.1,'---i::ii`ie: 'Pi-Tht Fir' ''-: D;i''-'• -,e,-.iirri,etrii--r,,,,,,,,,i.,y,
i
Ii s .i'oili.: i'reiii ,i 1 kc,iiiircid icimil,,„:
10163 sq.ft. 10163 sq.ft. i
, ! i
t i 101.13' f---
I 101.13'
. isetimeki, f_r:elit 45' ! 45'
i !
20' k: 25' 1 , 20' R. 26'
1
31' 24'
1.Z.,.. r i I
,
Itoikine I ici.iiii 18' 18' ! !
I I . ---+
B14 'ii,,r,iiiie I,,,it,i,ici 1676 . 16 -- I 1857 i 18%
t- 'i i .......4.
( y'' ras:c I
8487 . 84 ! 8306 82%
--t-----1 I
----1--
1 1
- 0! Aripii,. sn,i
-if- i + i----i
I i
- t -4--
1 i
N/A N/A
A, Has a Special Permit Variance--Finding ever Dee': issued for on the site?
NO 0 DON T KNOW ® YEs n
IF YES, date issued:
IF YES: Was the permit recorcied at the Registry of Deeds':
NO 0 DONT KNOW YES 0
IF YES: enter Boo Page and/or Document
F5' Does the site contain a biook, hod ii of ware' or wet taiiids7 NO D0f,IT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
Date Issued:
---.
NO
, ‘
C. Do any signs exist. on the property! YES 0 No ts,29
IF YES. describe size, type and tocation:
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:
r.he,7:::''':';tr,JC;t,.:!' a,ii,i, ,-'..'y d's,-,'t --,:re3' :` :1;'Zt■ti:'t,. " • :.;ti.a t•::.r t':-t t:.:' !.'3 t3,•C' Tti C'C:' ...t,t '3. .: ;..7.a .a'a a.:::,1a.,-r,..-- :-,•.i.-.,-.
1 St ;,t, 0,€., ' aa'e. vES 0 NO (x,
Es !net- a ri,--,.-,-,'-a ii-,ati.-.- Sic-ri '1,inii-Ma 7iaii,i,e2iE..--ii Pei— t ficii- :-e DP‘,f-,i-s-el,.-el
ii.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
: New House Addition Replacement Windows Alteration(s) 71. Roofing
I Accessory Bldg Dernolitior. New Signs :0] Decks Siding :C3: Other:33'.
- Three(3)season porch;deck
ueoo"^v''9 .:`"'o-euswuenent Yes x__mo
=a-,s. ,1:acrecRe Oreo�
6a If New house and or addition to existing housing, complete the following
a
Use ca�
:Yrs ' eaCn [a� y -n:_____
� /s �rc'ez �a'ageacacra�r ______
| � p'cc:sec e
e
F.�e�aceno,vvco�s�o�es �vmuero� eacn _
E-e'gvConc:/a-ce ^ur~ at:ac,etr
(
Nc /s m.n.- 0.7 Ycy____��
}
Oec'~ c/case_e� a-a' a'coo' oe./r^
----- ---- - }
� ' B 'o ^ Z ' s- Yes
N i
� o -e .� �`S ar. z` �g e�ua.�cr __ __ u
P:"a/e^e`
SECTION ta -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Barry Cohen Renovation&Construction
6 43
- - _— ____ „ _ — . _
Derarttren :sennv
C/ty of Northampton j5!a1,_;so, Pe'n'\
BuHdmg Department Cu^t-CADnvewey Pcr,Tht
APPLICATION TO CONSTRUCT, ALTER, REPAIR. RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
_ `
SECTION 1 SITE INFORMATION i
----- ` ----- This section t"be completed ---
11p/ope�yAdd�ss ' office
Map Lot Un.�
------ !4G Autumn O� — - —
Florence, MA 01062 Zone Overlay District .
Elm St. District CB District '
! 2,1 Owner of Record:
! Gerriann Butler 46 Autumn Dr. Florence, MA 01062
i SECTION 3 -ESTIMATED CONSTRUCTION COSTS
—:274e----- - 7.
This Section For Official Use Only
°
File#BP-2013-1218 p l,11N J CI(
•
APPLICANT/CONTACT PERSON BARRY R COHEN aa ,^,..�
ADDRESS/PHONE 40 O'DONNELL DRIVE FLORENCE (413)559-9683 0 ` J ^J
PROPERTY LOCATION 46 AUTUMN DR
MAP 43 PARCEL 043 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 1�� et 59
Fee Paid �{7
Typeof Construction: CONSTRUCT 3 SEASON PORCH/DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 005639
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9.RMATION PRESENTED:
Approved 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
di0e#1° -
Signature of Building Official 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.
46 AUTUMN DR BP-2013-1218
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:43 -043 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ADDITION BUILDING PERMIT
Permit# BP-2013-1218
Project# JS-2013-001992
Est. Cost: $43000.00
Fee: $59.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BARRY R COHEN 005639
Lot Size(sq. ft.): 10149.48 Owner: BUTLER GERRIANN
Zoning: Applicant: BARRY R COHEN
AT: 46 AUTUMN DR
Applicant Address: Phone: Insurance:
40 O'DONNELL DRIVE (413) 559-9683 0
FLORENCEMA01062-3525 ISSUED ON:6/24/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:CONSTRUCT 3 SEASON PORCH/DECK
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 6/24/2013 0:00:00 $59.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner