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The Commonwealth of Massachusetts
} �v:
Department of Industrial Accidents
=r�t1w, l Office of Investigations
:iii=
_ 1 Congress Street,Suite 100
t "'°_Aff Boston,MA 02114-2017
-404 vis. www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): in/4)-7-1-e. 'C✓J'7oa ���j _
Address: f? 0. e�x /O 2 G
City/State/Zip: /✓A 74AAe rj' — _ Phone#: 533 ' ffi 0 0
Are you an employer? Check the a+propriate box: Type of project(required):
1.LI I am a employer with 4. ❑ I am a general contractor and I 6. El 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. 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.t
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 12.0 Roof repairs
152
C. 152,§1(4),and we have no
insurance required.] t c 13.0 Other
employees. [No workers'
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.
tContractors 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: 4. /. iew
Policy#or Self-ins. Lic.#: w O(/1 Z g-O0 S 6 70/ 2G/Z Expiration Date: /213 3
Job Site Address: 62- / "b<S 4V/7G6.e° 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 pedury that the information provided above is true and correct.
Signature: I "' 4 Date:
Phone#: 633—i DG
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: 44 Not Applicable ❑
Name of License Holder: /el C`7G ,144 /i C S 0.7 34/5c/
License Number
z S ►✓le- aktsori -ve 1- Li G z-e- WIA - /O „ re-/
Address Expiration Date
4/1 4 -- '9/3 zg7 - 2
Signature Telephone
9.Reaistered Home Improvement Contractor Not Applicable ❑
ia) /4'14e evfr"? e(ef.i
Company Name / Registration Number
O . 6oX /O2G a I `{
Address �i/� Expiration Date
444- � hvoi L . /7' Telephone 533- 9 0
—
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 CV 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 Vljindows Alteration(s) Q Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [17:1 Siding[0] Other[co
Brief Description of ProposedQQ 7� / �p
Work: ���-r /erladti7`/srr a of 7-7?
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes s'' No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll (Sheet/
6a. 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
I, / V\Arr.Arr. d,w"- O ,as Owner of the subject
property /
hereby authorize /c2/ CGI<-t,-er /-J /J7Y7 b1 ) / - -i'f 2,,se7 s--�
to act on my behalf,in all matters relative to work authorized by this building permit application.
S 4 1)11 q 101.3
b •
Signature of wrier Da
/0 /V( 4ti ,as Owner uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my ge
and belief.
Signed under the pains and penalties of perjury.
Print Name 04- -- 9 - 5 i3
Signature of Owner/Agent Date
ry� Department use only
City of Northampton Status of Permit:
1,j, E
i Building Department Curb Cut/Driveway Permit
€. i l
{ 212 Main Street Sewer/Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
(1, = E phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans
Other Specify
ArrLICATION 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
oz. ✓7.&-e Map Lot Unit
rG•.-ri/.1*)-3 1.74 Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/9/161 s rte....- d G z ArG h .s z'iv��4e—e 14"
Name(Print) Current Mailing Address:CFP2
Telephone JJ
Signature
2.2 Authorized Agent:
/
Name(Print) Current Mailing Address:
-297— GZ9
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building /<j_ o G U (a)Building Permit Fee
2. Electrical (b)6 (b)Estimated Total Cost of
`
Construction from(6)
3. Plumbing r., o U Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Z 6 - 6 Check Number /v 4-/a2o
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0267
APPLICANT/CONTACT PERSON RICHARD AHLSTROM
ADDRESS/PHONE 215 MADISON AVE HOLYOKE (413) 533-9900()
PROPERTY LOCATION 62 FORBES AVE
MAP 31A PARCEL 138 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 3�1 (a
Fee Paid
Typeof Construction: REMODEL BATHROOM&REPLACE FRONT DOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 073454
3 sets of Plans/Plot Plan
THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I FO ATION 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
D olition Delay
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.
62 FORBES AVE BP-2014-0267
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A- 138 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-2014-0267
Project# JS-2014-000458
Est.Cost: $20000.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD AHLSTROM 073454
Lot Size(sq. ft.): 7230.96 Owner: TAMAYO ANDRES
Zoning:URB(100)/ Applicant: RICHARD AHLSTROM
AT: 62 FORBES AVE
Applicant Address: Phone: Insurance:
215 MADISON AVE (413) 533-9900 () Workers
Compensation
HOLYOKEMA01040 ISSUED ON:9/9/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM & REPLACE FRONT
DOOR
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 9/9/2013 0:00:00 $120.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner