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The Commonweallh of Massachusetts
Department of lndns&W Accidents
NOWOffice of Invesfigadons
600 Washington Street
Boston,MA 02111
www.massgov/dda
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Analicant Wormation � Y /Please Print Legibly
Name(Business/OrganizationtIndividual): G 4-T e 1 ST/AJ n 5 dV
Ad&ess:LZ Al ,� } s � vcl Je,
Ci /State/Zi : LJ"7.D 1-4 Phone#:
Are you an employer?Check the appropriate boa: of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. p I (mil )
employees(full and/or part-time).' have hired the sub-contractors 6. ❑New construction
2.f I am a sole proprietor or partner- listed on the attached sheet. 7. Wemodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working or me in an capacity. employees and have workers'
�1°g Y ���'• 9. ❑Building addition
[No workers'comp.insurance gyp•insurance.:
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL 12.❑Roof oo
t c. 152,§1(4),and we have no repairs
insurance required.]
employees.[No workers' 13.[:]Other.
comp.insurance required.]
'Any applicant that chech box#1 must also fill out the section below showing their workers'co ation policy in%nnation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside conMcton must submit a new affidavit indieding such.
2Cuntractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entitles have
employees. If the sub-oahtnactors have employees,they must provide their workers'comp.policy number.
I am an employer dew h providing workers'compensation baurance for my a nptoyees. Below is the polky and,job site
Information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 and penaltles of perjury that the Information provided above is true and correct
SigQ§WM: Date:
• �
Phone : 3 6 K
O,d?clal use only. Do not write in this area,to be completed by city or town oiyicial
F City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Elealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Iuspector
6.Other
Contact Person: Phone M
Maureen (Mo) Borg ♦ 413 896 6742
CS 96664, HIC 158356
PO Box 904, Williamsburg, MA 01096
rafters
e & Garden ♦ Design & Build
New & Renovation
Subcontractor List for
15 Ladyslipper Lane
Florence,MA 01062
Finish a 25'x26'section of existing basement.
Electrical Subcontractor
Cristina Shen
14 N Bears Den Rd
Sunderland,Ma 01375
' The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
." Boston, MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �n ` 1 r Please Print Legibly
Name (Business/Organization/Individual): I' ► V fZ Cl - Q �Q P—G-
Address: PCB FGk qb ( aty\S F>U P fy) -
City/State/Zip: 1A71 i l i OWLS. gU GL 64 i Phone #: 9 l-3 6-7
Are you an employer? Check the appropriate box-�' Type of project(required):
1.❑ I am a employer with 4. I 1�a general contractor and I
gmployees(full 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 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. F1 We are a corporation and its 10.E] Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.F] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 1-
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.
lContractors 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 thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 thepains and enalties ofperjury that the information provided above is true and correct.
Si ature: Date: .'C) /0
Phone#: H c?(o 7 q-2_
Official use only. Do not write in this area,to be completed by city or town officiat
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. Not Applicable
J ❑/� / ,
Name of License Holder: I Y 1 ��(�—��� C's `6l v L�
License Number
Pa p,UK U (� l /iv /2o 1 b
Address Expiration Date
o
g pre Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
F f-() M C r 9� IF� K C I `� (%J� �,
Company Name Registration Number
}`?(5 WX Cif{ p )(I C)I C�q� I/l(v /2(-)I ()
Address p Expiration Date
Telephone ��I�J O�� ���
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....... 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 buildine 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 Gable 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 Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other D
Brief Description of Proposed / S PL y
Work: FwtsH 2�xZ�, Sc:o-ion OF �✓ N �.
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes V----No
rw �-.y zocm
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 bl� 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, �lD (/� v�f'Nw as Owner of the subject
property
hereby authorize M�M��h'� I✓`Y
to act on my behalf, in all matters relative to work authori d by this building permit application.
3/10 /01
Signature of Owner Date
I, �b n 4 4 , as Owner/Authorized
Agent hereby declare that t e statements and inTmation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
L
Print Name
Signature of Owner/ en 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
�,f � Building Department
Lot Size b (` Yr
Frontage Po ci,-a—ke
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage % �P
Open Space Footage %
(Lot area minus bldg&paved
parking) r I,
#of Parkin Spaces Y"G� lam'
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding Rver been issued for/on the site?
NO ® DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regist of Deeds?
NO ® DONT KNOW YES Q
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW - YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained l0 , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q—
IF YES, describe size, type and location:
E. Will the construction activity disturb(Gearing,grading,excavation or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
• �� S Department use only
City of Northampton
Building Department Curb Cut/DrivewayPermit
212 Main Street MAR fere"ticAvAilapility
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Stgicturar,Plans
phone 413-587-1240 Fax 413-587-1272 PlofjSte Plari
Other Specify._,__.__.
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address: i I
Is- L,CiA c Il per La�"-e Map Lot Unit
`o�-e'el\c`- PA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
F� ,c �k.,iw I r �,•rrnw Lh. . I'i•%�, nom- o�a6Y
Name(Print) Current Mailin Ad ss:
'tls rt y P• o
Telephone
Signature
2.2 Authorized Agent:
e PCB qL-'A 011t OLVVISL1213Z 0101'1,
Name(Print) Current Mailing Address:
►3 'Rqb -7 Ll
-fignaiVe Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Building I SCE 0 (a)Building Permit Fee
2. Electrical -7— (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) CO Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2009-0729
APPLICANT/CONTACT PERSON MAUREEN BORG
ADDRESS/PHONE P O BOX904 WILLIAMSBURG (413) 896-6742
PROPERTY LOCATION 15 LADYSLIPPER LN
MAP 35 PARCEL 248 001 ZONE SR(100 /�P II
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out CE
Fee Paid
T_ypeof Construction: FINISH BASEMENT(FAMILY ROOM)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 96664
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan A' G �a�A
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit- Variance*
4,/G L gGtd�
Received&Recorded at Registry of Deeds Proof Enclosed /-'d�C
Other Permits Required: ',!Al'oe
Curb Cut from DPW Water Availability Sewer Availability ,%S 0 �2 O
Septic Approval Board of Health Well Water Potability Board of Health esleW
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition Delay
Signa re 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.
BP-2009-0729
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit# BP-2009-0729
Protect# JS-2009-001087
Est. Cost: $18000.00
Fee: $108.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin MAUREEN BORG 96664
Lot Size(sq. ft.): 59677.20 Owner: CHEUNG FLOYD&SHERI
Zoning: SR(100)///WSP II Applicant: MAUREEN BORG
AT: 15 LADYSLIPPER LN
Applicant Address: Phone: Insurance:
P O BOX904 (413) 896-6742 WC
WILLIAMSBURGMA01096 ISSUED ON:311212009 0:00:00
TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT (FAMILY ROOM)
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 3/12/2009 0:00:00 $108.001188
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo