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" P -w.mass.govIdia
Workers* Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A nollca it Information Please Pant Le!zibly
Narne (Business/Orzanization/lndivi(ivaI): —
A 4,4
City/State/Zip- Phone :
Are you an employer? Check the appropriate box: Type of project(required):
I am a employer.with 4. ❑ I am a general contractor and I
employees (fu;] and/or part-time). have hired the sub-contractors
6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no erployees These sub-contractors have S. ❑ Demolition
worlcing for me in ary capacity. employees and have workers' v a
E-No workers' comp. insurance comp- insurance.?
9. ❑ Building addition
4required.] f. ❑ We are a corporation and its 10_❑ Electrical repairs or additions
myself am a homeowr_er dointz all work ofricers have exercised their 11.❑ Plumbing repairs or additions
[No workers' comp. right of exemption per 1IGL 12.❑ Roaf repairs
insurance required.] t c. 1 f2, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
.Ar y applicant that checks box Fr 1 must also fill out the section below showing their workers'compensation policy information.
Ho meowaers who submit this affidavit indicating they are doing all work and then hire outsidecontractors must submit a new affidavit indicating such.
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 worlters'comp.policy number.
I asp an employer that is providing worlrers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Seif-ins. Lic. Expiration Date:
Job Site Ad�_i:tw 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 NIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,00.00 andior one-yeas imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to ,5250.00 a day against` P.yioiator. Bz advised that a copy of this statement may be forwarded to the Offce of
Ir_vesLigatiors of tI e D
Lor leis-urance covera_o'e verlficatlon.
I do hereby tie i y deafperjuMattne information provided above is true and correct
Date: -
-�-- �'-'cr-Lai'�:,�--otz�.--.Z2o�zo��i�zlhis ttrea to b�com�leied by city or town o "-chat
City or Town: Permit,-License>r
IssDDuin;_-authority (circle one):
-��..� f:r-,;T., 1 I n G Da .ag n�^e�i0r
�_ ti3 ,1u11?`�vtu i1 :�cnt _LL r i v'ry L 1L'r;i -. r ieL'tr;L'a. InS e�` r _. i L•_.. i ��
NLA
GlCeo
Z3 t>! CIIIIW1 i TR
aliows &—e h e 1-1;gLir=der 78 OC-N'T, 1 CS-3
a(:-,-az LL'1,2�r Cor--,=,ca-or-- fc-�- The S-zat (,-�,tELes "Homeovyllel-7, af, Persca(s)
WL0 0-,-L-5 P -I' on wh "des or - --L, to be, a ane or two
Parc I 'Lich�e/sl:d resides Late- fiunzi�7
acc-esscr-y to such u----ard/cr fa=. , Struc—c-'res. A
person 1;;-I,C COE-s,—ucts lor--tlLaz ore home Iz a --,LaJT not be corsidered a
home O—eiZef."
for t CIVY Gf*-Nc--r-,,�f:T-rP.+,Cv-waiz�, -Y Ferscz(s)'Who Seek to
zr- ;cr,;jc-�
-7ir cans
ce with sate buEdinz codes
tint by doin so ybu becno=e re-spo=ble for compan-
and Frcc,-----,re qL±,es tLat the buLzd-mg depx=ent be calleal
to j=. 7Ce,_-t Woe.(-at :-es ch irclid-rOLndatio footings I-before bacZEA
,rc,us S�L,�
5411-notube holes f-Deffore vour). a rough b,uRdip-:ft=ectfon-(be-fore work
— - is
Lea =LW.a.- reg-uLed)argil f111 hl i=ectlon- Tae
bu- din?deppa=ent r.--uires;these inre ons before the wors; is failure to
s-,cure these-insrectiom can result in failure to obtain a c£-tificate of O-SC ID2132v
res,01±er-nrades to pertorm worms plu—n-bing gas) Elie
=7 ISsule;.;,
per-m-ats La ccorjuzction to -E-e buLldi=g pe. - and that they get their re Tlired
Lispections-Failure cf'Le -dividual t7al-es to sec the pe:-=irs and as
177 AY rl�e -roT un-til such ti—me as he proper per-=itS and i=ect,:ons ar--
,q'L"-: ed Cza D.L��
mzd-
T 7 =--der--,,=Id the above-
5iz.-atU,r-- rc-questing elem-ption)
for tL Lzl-1 lr�-:Pen—niTt
CaLl to SIZLedUj,-a-I.T rz�--Uifed eb ' d
issued to me.
D 2:-e
. ,
Address Expiration Date
Signature Telephone
S Registered Home Improvement Gdir actor 'µ_ . _..... Not Applicable ❑
Company Name Registration Number
4ddress Expiration Date
Telephone
iECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,.§25
Vorkers Compensation Insurance affidavit must be completed and submitted with this application- Failure to provide this affidavit will result
i 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-vear 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 a ssumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and �...v Laws Mate of Massachusetts General Laws Annotated.
Homeowner Signature
r'
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House D Addition Q Replacement Windows Alteration(s) Q Roofing
Or Doors D
Accessory Bldg. d Demolition 0 New Signs [1D] Decks Siding[®) Other
Brief Description of Proposeg r
Work: \/iN SiiiNG* 1—g 1' STOM&E & wwG i8 R.t�cwo AM6ur 6 A#ID Pcx!It..
Alteration of existing bedroom Yes No Adding new bedroom Yes I/ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.If New house and.Qr=addition.to ex�si ng hous9ricf:cornp[ete tfie`f�[tawirrs:
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;BECOMPLETED WHEN
OWNERS AGENT OW CONTRACTOR APPLIES FOR'BLOLDING PERMIT
1 as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1 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 ai u
Pnnt Name
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information ti
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size 100�ry.��...f-
Frontage .0i!.. ._..
Setbacks Front
�N
Side L:a`44 R:�J--- LL",— R ._.,.._._
Rear
Building Height
Bldg. Square Footage .......___._. % fig,,
Open Space Footage _,_ % _
(Lot area minus bldg&paved
oarkine)
#of Parking Spaces —Y -.•.
Fill:
(volume&Location)
A. Has a Sposciat Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO C) DONT KNOW 0 YES 0 _ ^
IF YES: enter Book Page and/or Document#
—B. Does the site contain a brook, body of water or wetlands?m NO 0 DONT KNOW Q YES
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: PEDxiHG CA06!;1NG fRONf KIC- (A-r C-OWeR
D. Are there an proposed changes to or additions of signs intended for__.__._�.__.__.____^^ _ _.._._.. _..,.__...
Y P P g ,..__._ __g d r the property ? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, exravation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Wafer M agement Permit from the DPW is required.
• Departmeht use only
City of Northampton StatusofPermlt
Building Department Curt"Eut(Drtveway P6, ctrut,
212 Main Street SewerfSepficAvaElabfliflC
Room 100 water weltA4ailabdhY'
Northampton, MA 01060 Two Sets of'Sttuehtral:Plans
phone 413-587-1240 Fax 413-587-1272 Plotlite Plarss
Others pecify
APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION {i �)
This section to be completed by office
1.1 Property Address:
11$ Dr.GRr4EL-D D2. �AY — 9 "" Lot Unit
FLORENCE. /VA A• � Zonq .-- Overlay District
�6 Elin CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHCIRIZE8 AGENT
2.1 Owner of Record: 1 lQ DatEXFKcL-O D?--
FLw a_w,V G4E MA,
AT 121 C AT L-ETT P O x OQ`i o? o I 0G,2.
Name(Print) Current Mailing Address:
14 13- 5 8C0-►'-�Lk0%
Telephone
Signat re
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 ermit applicant -
1. Building y' yL'S/Oi �pQta•�C;oirAGE (a)Building Permit Fee
6 �;SOO-
2. Electrical (b)Estimated Total Cost of
(L cr. Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 1 D)150,00 Check Number
This Section For Official Use.Onl
Date:
Building Permit Number: Issued:
Signature:
Building ComFii sfonedlnspector-ofBuildings Date
i6
File#BP-2008-1000
r
.�' APPLICANT/CONTACT PERSON CATLETT KATHRIN M
ADDRESS/PHONE P O BOX 60407 FLORENCE (413)586-1442 Q
PROPERTY LOCATION 118 DEERFIELD DR
MAP 29 PARCEL 185 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
TSpeof Construction: INSTALL VINYL SIDING 12 X 14 SHED& 18'ABOVE GROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F,PLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IV96MATION 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
Demolition Delay
J 2�8
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.
11� -..-b i
BP-2008-1000
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
yLot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-1000
Project# JS-2008-001499
Est. Cost: $10150.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 14984.64 Owner: CATLETT KATHRIN M
Zoning: URA Applicant: CATLETT KATHRIN M
AT. 118 DEERFIELD DR
Applicant Address: Phone: Insurance:
P O BOX 60407 (413) 586-1442 O
FLORENCEMA01062 ISSUED ON:511612008 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING, 12 X 14 SHED & 18'
ABOVE GROUND POOL
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 5/16/2008 0:00:00 $50.002052
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo