18C-141 (11) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
UIP Boston,MA 02111
www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/OrganizationMdividual): Bonde Constniction
Address: 205 Park St.
City/State/Zip:Easthampton,MA 01027 Phone.#: 413 529-2176
Are yotyan employer?Check the appropriate box: Type of project(required):
1. II am a y em p to er with 1 1 4. [] I am a general contractor and I
* have hired the sub-contractors 6. E]New construction
employees(full and/or part-time).
2.❑ I am a sole pioprietor or partner- listed on the attached sheet. 7. ®Remodeling
ship and have no employees These sub-contractors have g. E]Demolition
working for me in any capacity. employees and have workers' 9 E]Building addition
[No workers'comp.insurance comp.insurance.t
required.} 5. [] We are a corporation and its 10.0 Electrical repairs or additions
officers have exercised their I L repairs or additions
3.01 am a homeowner doing;all work ❑Plumbing
myself.[No workers'comp. right of exemption per MGL 12.E]Roof repairs
insurance required.]t c. 152,§I(4),and we have no
employees.[No workers' 13.[]Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homdowners who submit this affidavit indicating they are doing all work and then hire outside contractors roust subntit a new affidavit indicating such.
lContractors that check this box nvAg attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. W the gub-contractors have employces,they must provide their workers'comp.policy number.
lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: Travelers' Ins.
Policy#or Self-ins.Lie.# U, i' Expiration Date:
ipEastham ton MA 01027
Job Site Address: 7 er i\ `,J 0L,tV7-)A►4P L ity/SiaOZ
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 ofMGL c. 152 can lead to the imposition of criminal penalties ofa
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 tine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under the pains and penalties of perjury that the information provided abovejj true and correct.
Sim ature- okk Date: _
Phone#: 413 529-2176
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#:
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Noldsr: (
. J A 6 TI5 2
License Number
Address Expiration Date
Signature Telephone
9. Reaistered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
2 L 5 tZy 1 t�1 S�-1Ai`-1 1 � 4!,-' Z — `�
Address Expiration Date
Telephone 1'3 jZcJ—Zi'71.,
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....... G.p'r 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 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 %
(Utarea minus bldg&paved
parking)
#of Parking S aces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW k YES a
IF YES, date issued:
IF YES Was the permit recorded at the Regist of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW V 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 O NO a
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excyation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YEE O NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
i
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. [] Demolition ❑ New Signs 1D] Decks [❑ Siding D=]] Other[C3
Brief Description of Proposed
Work: C""& `51''&19ctA Art,
Alteration of existing bedroom Yes L,-- No Adding new bedroom Yes t.-- - 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 .
1. 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
as Owner of the subject
property
hereby authorize �� _ p.t�(=
to act on my behalf,in all-matters relative to work authorized by this building permit application.
Signature of Owner_ J Date
,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 and penalties of perjury.
:?_Z�rvivc
Print Name
,(-�OA ::��2
Signature of weer/ ent Date
F
Department use only
—., ity of Northampton Status of Permit:
,`lam' uilding Department Curb Cut/Ddveway Permit
Ire,; , ;:
lI Fj 212 Main Street Sewer/Septic Availability
i ' 7 20N Room 100 WaterMell Availability
j
El J orthampton, MA 01060 Two Sets of Structural Plans
ectric F' .-�-- _.
p4 3-587-1240 Fax 413-587-1272 Plot/Site Plans
Sc �eo
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
Map Lot Unit
Cat`s` ���.��� �'� •e � a-�
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: C
Name{Print) Current Mailing Address:
Telephone
Signature
r
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signat a Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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) µ Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-0856
APPLICANT/CONTACT PERSON MARK BONDE
ADDRESS/PHONE 205 PARK ST EASTHAMPTON (413) 535-9529 Q
PROPERTY LOCATION 680 BRIDGE RD-2 ASPEN LN
MAP 18C PARCEL 141 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid pr
Typeof Construction: CONVERT 3 SEASON ROOM TO LIVING SPACE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 67758
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
Signature of Building dffici al 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.
680 BRIDGE RD-2 ASPEN LN BP-2014-0856
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 141 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-2014-0856
Project# JS-2014-001500
Est. Cost: $9000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin MARK BONDE 67758
Lot Size(sq. ft.): 1497897.72 Owner: LATHROP COMMUNITY INC
Zoning: Applicant: MARK BONDE
AT. 680 BRIDGE RD - 2 ASPEN LN
Applicant Address: Phone: Insurance:
205 PARK ST (413) 535-9529 O WC
EASTHAMPTONMA01027 ISSUED ON:21712014 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 3 SEASON ROOM TO LIVING SPACE
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 Occupanicv Si nature:
FeeType• Date Paid: Amount:
Building 2/7/2014 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner