32A-076 (2) Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursnant 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 checlang 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. Ilan 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 Iegibly. 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 Ieaves 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
Fax#617-727-7749
Revised 11-22-06
www.mass.govidia
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
y; - Office of Investigations
600 Washington Street
Boston,M4 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print Legibly
r
Name(Business/Organization/Individual): , 2ucJLI i h,0
Address: 10 Gets-,-,
a Evil
City/State/Zip: 6t c.r ", ��/. OI*, Phone#: LIl3- `j$t/— 357c
f
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. I am a sole proprietor or partner-
These 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. 0 We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their
3.0 I am a homeowner doing all work 11.0 Plumbing repairs or additions
myself [No workers'co right of exemption per MGL
Y comp. 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 must 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 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.
/do hereby chj iA under the pains a penalties ofperjury that the information provided above is true and correct.
Signature: 11�' Date: 7/�r j3 _
Phone#: '7/')` 5Sc/ 305-
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: ,,�,r 1 Not Applicable ❑
Name of License Holder: < 2v` `11 6 CS �3'13
�`�` License Number
70 CQ41/ar, no c/3/1e1013
Address - Expiration Date
M / 1 1A 0/0g0
Signa . , Telephone
9.Re.istered'4 e`Im.rovement Contractor :; Not Applicable ❑
Company Name Registration Number
vre 6// 2,44/
Address Expiratio y 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 ❑
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-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
1
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House E Addition fl Replacement Windows Alteration(s) n Roofing
Or Doors 1 _
Accessory Bldg. n Demolition ❑ New Signs [O] Decks [E] Siding[01 Other[�]
Brief D cnption of Propopsed[_/ Ant Q / [1 C. I SIT x. 60 1 f" N t
Work: Ace_ Aran .feia An i'er. Ie.,p6„ ' �YG+n�j reik.h tY4N.0�� repi�c� �f[l1" y3,- �S Vtecra,
Alteration of existing bedroom Yes / No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a. If New house and or or to existing housing,'complete the following:
a. Use of building : One Fami Two Family Other
b. Number of rooms in each family --t: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new constructio Di nsions
,
e. Number of stories?
f. Method of heating? ,Pifeplaces or Woodstoves Number of each
g. Energy Conservation Compliance. .,r',k nasscheck Energy Compliance form attached?
N.
h. Type of construction /. \t
i. Is construction within 100 ft. of wetlands? Yes No. Is c`Nstruction within 100 yr. floodpiain Yes No
N.
j. Depth of basement or cellar floor below f 'shed grade `..
k. Will building conform to the Buildi and Zoning regulations? Yes N No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGE T SR CONTRACTOR APP - OR BUILDING PERMIT
,,zi..:' I' ' / e
. •
, . -„........0 A 1 ■—ft , as Owner of the subject
property/
hereby/authorize .
to act on , y b= alf, i al ers relati = , ork authorized by this building permit application.
,rm / ,
SignArf Owner Date
5 2ucJ't tyvp , 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 enalties of perjury.
Print N-•-e/
i _'.,..
Sign. use of Owneitent D.te
. '
|�ecdo 4. ZONING / ^um�m��onmu�eecomp��u penn�omu*�m�dourra/ncomp��/:�rmu�^n '
�Section �
Existing Proposed Required by Zoning
This column to be filled in by
Building Depa ,=o, , ' f t
_-__
'
Lot Size ---
_______��____����
-_____ '
Frontage ----- �-------�^ �----� ____
Setbacks Front �-- � !
Side L R: ___. __-_-
____� �N -_-__
Rear ___ � __ _ ___
Building Heigh ----. �---7 ---_
._ _
Bldg. Square Footage m -- ___ .
_�� .___
Open Space Po-_�' % �__ �—�
(Lot area minus bldg& u _ ____� __ _ �� ___
narking-) ~+
_-7
#ofyadd �_
u�Spuo,o ----'
Fill: ' ---------------� - r
------ -----'---� ----------------'
(volume&uuuuvo ___ L _ —
A. Has a Special Permit/Variance/Finding ever been issued for/o
n 'th e
s�e? .
IF YES, date issued: /
IF YES: Was the permit recorded at the Registry of Deeds? .
NO 0 ,,,,,T,,KNOW_,,0 YES 9, 1
IF YES: enter Book e / and/or Document#
B. Does the si 1 brook, body of
IF YES, has a permit been or need to be obtartie„d from the Conservation Commission?
Needs to be obtained ObtaineV `C) , Date Issued:
C. -- -. signs exist o the property?
IF YES, describe size, type and locayon: ,.
D. Are ere any proposed changes - property
IF YES, describe size, type a location: ....
E. Will the construction activity di rb(clearing, grading, filling)
that will disturb over 1 acre?/YES NO
IF YES,-th-e—n a Northampton Storm Water Managemeht Permit from the DPW is required. ,..
Department use only
----e ity of Northampton Status of Permit: I
RL.CEI B»ildmg Department Curb Cut/Driveway Permit
12 Main Street Sewer/Septic Availability
Room 100 �!t/ater/We►i Availability
JUL I 12013
ort ampton, MA 01060 Two Sets of Structural Pans'
•- 3-5:7-1240 fax 413-587-1272 Plot/Site Plans
nEPT.OFBUIWING NS O S
NORTHAMPTON MA 01060 i
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: I This section to be completed by office
\1 ;\.C� .` C' Map Lot Unit
1 1 , Zone v Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 1
2.1 Owner of Record:
FfA a-1 Plhe, S ite
Name(Print) R Current Mailing Address: 16_iii J
, � , ) Telephone
Signature 111
2.2 Authorized Agent:
s , 2 i vw —70 Iek1-0‘.. 00J " 'h / fl A
Name r`) Current Mailing Address: t
"I / - ��1/- 36'7r
Sig -tWe ®Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
t Building /id,n L (a)Building Permit Fee
2. Electrical (b) E
Construction stimated Total fro m Cost(6)of ,
3. Plumbing Building Permit Fee
•
4. Mechanical(HVAC) t Q� 1j J 00
5. Fire Protection V
6. Total= (1 +2+1+4+5) Check Number
This Section For Official Use.Only
Date
Building Permit Number: Issued:
Signature: Al 7/11 13
Building Commissioner/Iospectorottiuridmgs ate
35 MARKET ST BP-2014-0018
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A-076 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-2014-0018
Project# JS-2014-000077
Est.Cost: $2800.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEVEN ZUCCHINO 021356
Lot Size(sq. ft.): 3702.60 Owner: SULLIVAN ANN&LINDA RAINVILLE C/O MEAGHAN M SULLIVAN
Zoning: URC(100)/ Applicant: STEVEN ZUCCHINO
AT: 35 MARKET ST
Applicant Address: Phone: Insurance:
70 Gleason Road (413) 584-3878
NORTHAMPTONMA01060 ISSUED ON:7/16/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR PORCH (FOOTINGS,FRAMING,FLOOR)
SAME FOOTPRINT
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 7/16/2013 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner