29-137 ' r
y
NOTICE NOTICE
TO o TO
EMPLOYEES ,�� EMPLOYEES
V
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 - http://www.state.ma.us/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30,this will give you notice that I (we) have
provided for payment to our injured employees under the above-mentioned chapter by insuring
with:
Farm Family Casualty Ins. Co.
NAME OF INSURANCE COMPANY
PO Box 656 Albany NY 12201-0656
__.-_.....-.__ _-
ADDRESS OF INSURANCE COMPANY
2008W6204 4/17/05 - 4/17/06
POLICY NUMBER EFFECTIVE DATES
Chad P Meyer 237C Greenfield Rd -S Deerfield MA 01373-9790 413-665-3015
-----._.__..................
- ---- --------
NAME OF INSURANCE AGENT ADDRESS PHONE#
Jeffrey Crans_t_o_nDBA J_& J Home Improvements PO Box 307 Williamsburg MA 01096-0307
EMPLOYER ADDRESS
EMPLOYER'S WORKERS'COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish
adequate and reasonable hospital and medical services in accordance with the provisions of the Worker's Compensation
Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own
physician. The reasonable cost of the services provided by the treating physician will be paid by the insurer, if the
treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention,
employees are hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
WC 7506f(7-0',)
O¢'StSAMP�O
.Crxty of Nart4a mptart
�855AC�lIStttS
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DEPA TMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Northunpton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as his/her construction super ,•isor. The state defines "Homeowner" as, ",Person(s)
who owns a parcel on which he/she resides or intends to be,a one or"twofaimuffyp -
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•cohsidered a
home owner."
The buil tng department for t1fe City of Northampton wants any person(s)-who-seek-to
use the home owner exemption, to act as their own construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and r',egulations. The inspection process requires that the building department be called
to inspect vOork at various stages, which include foundationlfootings(bef®re bacld"diil),
sonotube holes (before pour) a rough building inspection (before work is
concealed) insulation inspection(if required) and a final building inspection.The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work(electrical, plumbing& gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
permits in conjunction to the building permit issued, and that they get their required
inspections.Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
L understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
- -
issued to me -
Dates
Address of work
location
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A l E g143zKchntrtIs'
DEPARTMENT OP BUILZDr),�G INSPELi io?"S
j 212 Alain Strcct - Municipal Building
NorthampLon, Afass. 01060
..:. .... .. . .. . .«c0RItLI S CON L' NSATION D SVJ.V1.l�CE AF i'.1 ,A..`Tj'..
i
(li ccnsxlperm,tt"cx)
%IVILb a principal place of business residence at: ---
C�U 4iK 30_ ra (phone-;) -14 "?!S
( SDP) --�—/-
do hereby certify, under the.p2.ins and penalties of perjury:, hai
(,,) Tam an employer providing the followin-.workcr's comocasadoP coverage for my
etvpioyccs «orng on this job:
O=u-ra=Corr.�.) J (Polio: (E:-pirrion Dzsc-)
i . .
O I
am a sole proprietor, general contractor or homeowner (ci:cie one) and have hired
the conira tor's Usted below who hive the `ollowi.nQ -worker's comoeD_sadon pokier
i
I
0,;=c of Conr^c-'Or) (ItlRrancc Colrrpanyil oUCi !-"UMh-:T) (H�JIrwuon D.Itc)
(N amc of Conu-zaor) Mstlrane Compan}vPa!ie; tiuncrr) (–Exnir=tion Dale)
(Name of Condor) (Insuranec Compan)-/PoUq- Numb.-J) (Ecairtioo Datc)
I -
(NZ-Mc of Contractor) (Insutan Comrzzy/PoUcy Numb,-r) (Hxpp ,noa Da1c).
(atI1C-31 octil r3cu,,r accc'...a_'S-to mclud=,arorT+•�on pc-t,a fans to'U co=--='o=)
i
( ) I am a sole prop
netor and have no one woridng for me.
l
( ) I am.a home owner performing all the work myself.
NOTE:pl=c be aw-arc ri—wee hcmrov oe wbo esploy Pe--<r=to(JO rrnir-Ork 03 of
tux mote t!`a t:-r+r_=rs is«mac i+ the botaoo-n roedc oc oc the p-ouar5 xppurte- _ the Yn�z ooe -�r-.ky o eee-ai w be
e�xplayc ttnGe the..�i_-� - -_-*oa Act(GLil52.:1(3)�:ppUciE=b-f a bomeowx fc_tip-or pcmit=- y ei&m d-:
I-PJ ctz-tu of as-=Ployac-odor tho W octola co�o Act
1 uodcszxad the a copy of thu¢atcmcm—y be foe-- rded to the p.opanmcaa otln&ztricl Acodaty office of ltru+ooe rc"tb.
Goveasc veil-cmioo aad thet L-ilta-c to soyre tovcxase ta>dC�jpd 23 A of htoL 132 m led to the i�msioa arcimiai!penalIie
c a :;::g ora riot orup to s1 soo.00 andr«as;a;ao¢ orup to o0c r�Lod aNi1 p=Al-,;a;a cb,.rte,or,Stop Wort Ordc a d a
rl=of S 100.00 a d_y cpi=me
For y.r 1 u,c only
j pernit NuIDt>G -
P -r 0 r L
I crm;tt�- LF3te I I
SECTION 8`-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone `
g..Re isdWo'"h6 1M iam :Cobitm a
Not Applicable ❑
Company Name 'rr Registration um er - -- --
1 �7 4),aLA wn j�.,,n.+. v..d QJJ9�o 0(./,*(o
Address Expirati n Date
Telephone.2&1-3�gy L�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFEFDAVfT'(M.G:L.c.fS2,§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...... ❑
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 shag 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
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J.,...
SECTION 5-DESCRIPTION OF PROPOSED WORK(check alk applicable)
New House ❑ Addition ❑ Replacement Wows Alteration(s) Q Roofing ❑
Or Doors ti
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks (M Siding[0] Other[0]
Brief DescrigWDn pQf Proposed \\ i
Work: 71VSfw([_ -7 /QG/�..A[em., L.l►N w 5
Alteration of existing bedroom Yes r.,--11—o Adding new bedroom Yes di1Vo .
Attached Narrative Renovating unfinished basement Yes __A,,==AJo
Plans Attached Roll -Sheet
sa [�=Nev���ro�se�a�d�r r'c% � �stt nc��horrs�nc��=,EOrl�s?ie���ti�fotfaur+<Fng:
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 CONT,RACTOR-APPLIES'FOR BUILDINCx PERMIT
I,
17 YtG r(A ? MG C Le U r as Owner of the subject
property
hereby authorize
m ehalf,il all matters-relative to work authorized by this building permit yipplication.
Aate Signature of O r
I,_ G1� ��b4s✓S � ,as Owner/Authorized
Agent herebf declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed nder the pains and penalties of perjury.
Print Na
Si a of wner/Agent Date
"
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Section 4. ZONING All Informat-i6h 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
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
` ^
A. Haso Special Perm it/Vahanua/Findi ever been hsuedfor/on the s�e?
' �~�^ �~� �
NO ��" DON7 v+� _ YES �_x~�/
IF YES, date issued:!
IF YES: Was the permit recorded ot the Registry of Deeds?
NO ����
� DON / m"u~ 0 .^^
IF YES: enter Book Page!
ag and/or Document#'
��
B. Does the site contain u brook, body of water urwot|un�? NO ��, DON'T KNOW v�� YES
IF YES, has permit been nr need uo be obtained from the Conservation Commission?
'
Needs tobao6talned Obtm[nmd �~� Date
�
v��0 '
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C. Do any ggnsexist on the propor�? YES . NO x_�
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES �~� N |
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradin g
bun.orfiNng)ovor1ooneoriuitportoy000mmonp|un
that will disturb over 1acre? YES NO
'
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton o>*` � � V
Building Departmentr �CutlD ve
212 Main Street setnte rl t
Room 100 �
Northampton; MA 01060 rak
phone 413-587-1240 Fax 4.13-587-12- 2
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1 r j r Tfiils,VDction o be completed by office
1.1 Property Address: U 6r
Zone .Overlay D�stnct
�Elitt St:Distrrct CB DrstcicL ,-
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGE,NT
2.1 Owner of Record:
3'l 1 Kr4c1.�/�! LSD K�
Na Curre ailin dress:
Y Vi's SQL- "g s—:
Telep
gn t
2.2 Authorized Agent: e Q
,.7G 0
I
dam► �Q FslJ1C � -az''1"' L1/l.J�r
Name(Pri Current Mailing Address:
413) 216k, c]SZI�
Sign Telep
SECT1 N 3-ESTIMATED CONSTRUCTION COSTS'
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee Zt;. G d
3-7
2. Electrical (b)Estimated Total Cost of 3-7
Construction from 6
3. Plumbing Building,Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 3-7 X5' Check Number I L197
This'Sectiori For Official Use Only
Date;
Building PermitNumber. Issued
Signature:
i
Building Commissioned]nspectorof Buildings Date
__
311 RYAN RD BP-2006-0603
GIS#: COMMONWEALTH OF MASSACHUSETTS
�MMBlodt:29- 137 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0603
Project# JS-2006-0882
Est. Cost: $3725.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Jeffrey Cranston 101176
Lot Size(sq.ft.): 22172.04 Owner: MACLEAN RICHARD P&AMY J
Zoning URA Applicant: Jeffrey Cranston
AT. 311 RYAN RD
Applicant Address: Phone: Insurance:
P O Box 307 (413) 268-3504
WILLIAMSBURGMA01096 ISSUED ON.12/1/2005 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 12/1/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo