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43-043 (2) The Commonwealthof Massachusetts 1 rnntrorm 1 Department of Industrial Accidents � V ._ Office of Investigations T�= 1 Congress Street, Suite 100 • - , Boston,MA 02114-2017 . , www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,�j J Please Print Le ibl Name(Business/Organizatio clividual • j/w h.A L+(f Ce- Address: po gp(5,_ )ii City/State/Zi. 4 0 IOS Phone#: . . -,U) — Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am mployer with 4. ❑ I am a general contractor and I 6. ❑New construction oyees(full and/or part-time).* have hired the sub-contractors 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' 9. ❑Building addition [No workers' comp.insurance 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 Pl ing repairs or additions myself. [No workers'com right of exemption per MGL my [N comp. 12. oof 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. 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 nployees. If the sub-contractors have employees,they must provide their workers'comp.policy number. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site !formation. Isurance Company Name: — olicy#or Self-ins.Lic.#: Expiration Date: )b Site Address: City/State/Zip: Mach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of westigations of the DIA for insurance coverage verification. do hereb certi , ' a pains and penalties of perjury that the information provided a ove is true and correct. ianature: Date '' AVAMIE111111111111 hone#: Y/3 371 7F°J 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: Not Applicable ❑ Name of License Holder: (✓J'Yk.97Z y 3• L U�� /0 0 5 7 5 J License Number v Go 6 /V z S MA )/6 3 % /5 ,L Ad ress Expiration Date y i 3 . 7& 3 ignature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ a-- L oz.-g Company N e Registration Number (jam I7 -2 1� 0. Rd .�2 / / Address �X `L Expiration Date 4-eeiA /A O/ c) Telephone 7/3 / 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing p Or Doors ❑ Accessory Bldg. ❑ Demolition El New Signs [p] Decks [p Siding[p] Other[rte] Brief Description vroposed Work: r� � cue._ roc) w i� �/G v I roof Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ea.If New house and or addition to existing housing, complete the following: a. Use of building: One Family 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 attached? h. Type of construction i. 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 a , as Owner of the subject property r 0_ Li)Cam_ hereby authorize I i✓14.0 to act on my beh all matters lative to or authori;d by this building permit application. I � 1 ' !/ G� —30 —J3 Signature of Own Date - 1—')C,2 , as Owner/Authorized Agent hereby ded-re 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 Sign ure of Owner/Agent Date 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 Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (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 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO (2) 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 ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO IF YES, describe size, type and location: E Will the onstruction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan x will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. 4 T-: c �4" 13`73 .5 1�� Department use only \ , , City of Northampton Status of Permit r ' JUL Building Department Curb Cut/Driveway Permit li s aJ - 42013 , 212 Main Street Sewer/Septic Availability _J Room 100 WaterNVell Availability Electric f,,.rr i.(,i cci,ten.i ray .l cr. r, _� Northampton, MA 01060 Two Sets of Structural Plans Mphone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office ,i6 Aj....00.0,..... D r _ Map Lot Unit Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ,-- -_ert(si)nom ul---7-er- a ►4.. L flqr1 cbk-i O(?IC0 Name Print Current M. Ii ddr A1 Telephone J�` _`. S Signature / 2.2 Auth size, Astent: 91;4_oi . 1 - I-.V cam._, Po 3 /`-( Lis 44 O/0c) Name(Print) Current Mailing Address: **---"\-":„c/ie-----,r^—,- In 5TI- c2) Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building `i°6€ -. (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) /YO0`' Check Number This Section For Official Use Only Building Permit Number: I sssuu ed: Signature: 2--C1 J allW g � r Building Commissioner/Inspector of Buildings Date 46 AUTUMN DR BP-2014-0025 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:ROOF BUILDING PERMIT Permit# BP-2014-0025 Project# JS-2014-000083 Est.Cost: $8400.00 Fee:$35.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TIMOTHY J LUCE 100515 Lot Size(sq.ft.): 10149.48 Owner: BUTLER GERRIANN Zoning: Applicant: TIMOTHY J LUCE AT: 46 AUTUMN DR Applicant Address: Phone: Insurance: P 0 BOX 14 (413) 387-9800 LEEDSMA01053 ISSUED ON:7/16/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REMOVE & REPLACE W/METAL ROOF 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 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner