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32A-239 (2) The Commonwealth of Massacliusetts Department of Industrial Accidents. _ 1 Office of Investigations Irr�tt_� 600 Washington Street °'eEef� . Boston,MA 02111 sy• www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organi7ation/Individual): ph,,,,. l a re k.. Address: 2 f Li-t=—i r--- r2 0 ' City/State/Zip: wa,S F. ' 1 A. Phone.#: c?— . Are you an employer?Check the appropriate box: Type of project(required): J 1.❑ I am a employer with 4.. E] I am a general contractor and I 6. 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 subcontractors have g. [1]Demolition . have workers' h employees anav working for me in any capacity. emp 9. ❑Building addition [No workers'comp.insurance •sm.insurance.$ required] 5. It We are a corporation and its 10.0 Electrical repairs or additions 3.El 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 120 Roof repairs • insurance required.]t ' c. 152, §1(4),and we have no ,�",, L employees. [No workers' 13. Other �GM c i`y� e comp.insurance required.]. r *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I 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: 2 / /V 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,'pains and penalties of perjury that the information provided above is true and correct. Signature: r,.. ----94 .,, Date: V2 // 3 , Phone#: C� Official use only. Do not write in this area, to be completed by city or town official_ i t y , ' y + 1 y , 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#: i 8 CONSTRUCTION SERVICES f • tensed Construction Supervisor: Not Applicable ❑ •a-,e _ ,:tense Holder: •:Pc)(tA, C/,t!_'fz- License Number Expiration Date Telephone :t= istereiHotneimpmvetnent£ontractarLy .. r _�s _ Not Applicable ❑ ,� V 6 Comoanv Name Registration Lim•er ` `— L'Z-/ Cv!S� t�i7 � .:dress Expiration Date i;;-.l:'✓r`/, fira: Telephone r .• • SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT{M.G.L.c.152,§25C(6)) `.Vcrkers Compensation insurance affidavit it be completed and submitted ra:-s a_:'.':a on. Failure to provide this affidavit will result the denial of the issuance of the buildi pent. Scned Affidavit Attached Yes N^ ❑ lloeer Exemption `c 7:: "=_ meowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families z s _- A-ner to engage an individual for hire who does not p -es:a license,provided that the owner acts as samerviser. 0.1R"80. Sixth Edition Section 108.3.5.1. £tea cf Homeowner-Person(s)who own a parcel of land on which be she resides or intends to reside,on x l ch where . cne :WO family dwelling,attached or detached ry w accessory to such use mitt or farm A venom who constructs more than one home in a two-Year period shall not be considered a homeowner. tom° :f'.wit to the Building Ofcial,on a form a centahie to the Building Official.that heishe shall be responsible for all such work performed under the building permit. As ac g =presence on the job site will be recce,e'-- _ 3 r �c.,,--ne to din-Ma and upon: completion ofthe 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 Macsachusetts General Laws Annotated. Homeowner Signature „/ ,. ��.f \iq „...................._. . _,•. S=-CON 5-DESCRIPTION OF PROPOSED WORK(check aitarciicet.::e-, New House El Addition i' :27' 1 Rec:acemerrint, Alteration(s) ,n1”- Roofing ri Accessory Bldg. E Demolition Li Ne-A S'crs :=: Decks [E.) Siding[0] Other[DJ ...--- t..._ Brief Description of Pro•osed — re7 4- -- i \,..,.,crt:: ---,---iu' -- --,t, :' ...:-r---':-- :--- ; --- ' -- /2,-;--- ?.-' .■-, Z 27 )K.--5 /-:te.r.e:lon of existing bedroom .....:.): • Y=s - .: -:.: :7 --= ps-- ,:om Yes Yes No ,-="7.:-..ched soil -Sheet ea-if Nevt.f-houte an&be-additictilmexisVart tic usincL-complete thlng: ,"- - 7. .1.- . C::r2er t 7.:C,775 7 ea:r fe-7---,. _----_- Number of Bathrooms -' a carace......77S7:7 . A :11- .7.. Pr.7..;:csat Sz_:E.--a f::race :- -t ::'....r.:-...:t:'... Dimensions z 4-t -4 e '..,..,7-7:e-p.‘•s-_:-es- Fireplaces o ■ oodstoves Number of each eck Energy Compliance form attached? • s ::-.:-:-_ .---_-- =-_pf 6-eOar,cs7 Y: : No. Is construction wit 00 yr. floodplain - Yes '- No ÷■,_ cellar floor beicw s-_ci crade corforrn to the Building - d Zon;n:-. regulations? ..- Yes No. L Sepio Tank k City Sew: Private well City water Supply SECTION 7a-OWNER AUT'ORIZATIGN-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT qr„Vo i< .71---r. r: AN:7.r. I-E-T( ,as Owner of the subject ,, perty )c- -. Pe-at :r ar,rr,- ...els ratr.ie tc wore authonzed by this building permit application. —- _ 7 SignattamV Dormer Date - -- - - ,t ----- _ -'"-- ,as Owner/Authorizeri Agerft-herecy ---ara tnat the statements and information on the foregoing application are true and accurate,to the best of my knowledge and beiie'. Signed uncer tta,pans and penalties of perjury. 41\ 1 Print Nanle---^ ' ,/%7 /_ ' /-.7 .v--)1: 9 /-77 Staff / Signature of OwnerAcxm_-- 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 i Frontage Setbacks Front I ■; `_ Side L: R:. —r R: •{ r_ Rear • Building Height ----1 r .--- i i BLVD JG e z LL'. z_ , -- Open Svc:e cc zge % ca - of? ___ z Spaces Fit:: 1.c_:.c _.xarionl A. -as a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW Q YES 0 IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW O YES C IF YES: enter Book Page. and/or Document# B. Dees the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained O , Date Issued: • C. Do any signs exist on the property? YES 0 NO ' J IF YES, describe size, type and location: ! D. Are there any proposed chances to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type arc location: E. Will the construction act, »r c ^ caring,grading,excavation,or filling)over' acre ';is it part of a common plan that will disturb over ES Q , NO O IF YES,then a Nt a e c . <rr , 'ater Management Permit from the DPW --ed. F (� ,L_- ''''r L- \' i__ � ©eparfrnenuseFoni} x City of NortF�arrlpton -Slat �y r 1 Building Department C urb eu1/001m1YA_YRPcrnit a w --. SEP 3 2013 °' 212 Main Street sewe ISe5triVA 1`fab%ti 3r+ ' Room 100 UUate dvAvailabittt}L tric,Plumbing&Gas Inspections Northampton; MA 01060 TTKO Sets ofStractura1Pahs * Northampton,MA 01��� ' phone 413-587-1240 Fax 413-587-1272 _--. 7:-----.7.:,-.L-.io/sit ns. � 7, Ot herSpectfy _ 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...- Cv IftW'f✓`l' 1 E"C CL''-~ Map Lot Unttr:_ r� f �} J1� /\f o-,,,--1-1., � ,. . ?—N fri f .Zone `Overlay District _ C> 1016 . m 5t District CB Distct ri- SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: r l,;I Yc.,f.-. t ‘ j(A- 1- sk ,_,-;)-t, a Pi),,,r, ,,.÷, s , , -e5. 6-07 ..4o,Q-,,,-/ ,uf ityli---- (7/c-..c7,,,,..--_,----- Name(Prin Current Mailing Address i[ ( _.s9 7/ (: _:.,--- Telephone Signature 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 -(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) j : . --� Check Number vii This Section For Official Use Only Date Building Permit Number. Issued: Signature: ' Building Commissioner/inspector of Buildings Date 2 POMEROY TER BP-2014-0395 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A-239 CITY OF NORTHAMPTON Lot:-000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: REPLACEMENT BUILDING PERMIT Permit# BP-2014-0395 Project# JS-2014-000685 Est.Cost: $5280.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN CLARK 049612 Lot Size(sq.ft.): Owner: MORALES RUTH C CIO HOLLY J KEITH Zoning:URC(71)/SC(29)/ Applicant: JOHN CLARK AT: 2 POMEROY TER Applicant Address: Phone: Insurance: 621 WEST RD (413) 568-5900 WESTFIELDMA01085 ISSUED ON:10/2/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT SKYLIGHTS 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 10/2/2013 0:00:00 $35.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner