22D-005 The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I
employees (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.
$
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.E] 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' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
tHo meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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: 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 t pains and penalties of perjury that the information ovided above is true and correct.
Si ature: Date:
Phone#:
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#:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not C.5—Applic�!a**ble £
Name of License Holder: &vi C C,3a,) e b� 7 2(06q
License Number
Address Expiration Date
Signature Telephone
",_"ci
9,Registered Home'ImarovemenYGontractor Not Applicable £
Ji,4,fc Co,,L R c 4-1 o v) 17 (a g
Company Name Registration Number
C /0-
Address S� � Expira� tion Date Wl
Telephone
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:Egemption
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 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding [❑] Other[❑]
Brief DescriBtion of Proposed
Work: K k(e Kfictier, �Hbh/ i i iaat��t� cvcoX C SAFE"
Alteration of existing bedroom Yes No Adding new bedroom Yes �No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a,if Nevin house and'or.add tion to exist 0,housing, complete the foiiowing!:
a. Use of building : One Family Two Family 'V Other
b. Number of rooms in each family unit: cZ Number of Bathrooms '
c. Is there a garage attached? WrIvo
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? 6 /
f. Method of heating? Cwt-s A'111(le Fireplaces or Woodstoves .Nei 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
i
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
as Owner of the subject
property
he by authorize
t act my beh , in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1 � /�y �✓�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 and penalties of perjury.
E-e✓I e
Print Name
Signature of Owner/Agent 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
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage 010
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces LLD
A. Has a Special Permit/Vahance/Finding ever been issued for/on the site?
�� ��
NO �~/ DON7KNOV/ YES �~��
�
IF YES, dateioued� /
' �
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �
DONTKNOV YES
IF YES: enter Book Page and/or Document#1
B. Does the dt econ t i n abrook, body of wa t erorwetlands? NO DONTKNOY � YES
C)
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tnbeobtained v=� Obtained �-` Da%e |�sued.
'
�^� �_� '
��
C. Do any�gnsedston the property? YES v=� NO
|F YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs inte/ ded fnr the pmperty? YES 0 NO (7k
IF YES, describe size, type and location: �
J.
E. Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orioit part ofa common plan
' that will disturb over 1acre? YES NO K~ �0
IF YES,then a Northampton Storm Water Management Permit from the DPW iarequired.
i�3 s sF . , €7epartmeht use only r. .-°' �
of Northampton $atus ofPermit r'"� wr "'
Iding Department Gtir cut/Drie�ira'y Perntt#kr'
F h
12 Main Street Sewer/SepticA�airabillty
Room 100 Water/IAtelCAvatlafJthty
I� 08!-
rth mpton, MA 01060 Twets QfS#ructuri Plan$'
a -1240 Fax 413-587-1272 PIot/Slte Plans A
Plumbing Otfier_5�eci#y' _; � f .
' hampton,M�01080 _
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 Property Address: Tfiis section to be completed by office
&-7 RyC�,� Cn Map Lot Unit;
° Zone Overlay District
A-1 fi ru-►nW,Nlc�
Elm St District CB District =
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT -
2.1 Owner of Record: p
A—�C1 (19:2 I1 VC4 k) F l6 C64.✓t C t el
e(P' �l'aZt!� Curr��..J���t Mailing Address:
nt/�
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mang Address:
Signature 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=0 +2+3+4+5) Check Number
This Section For Official Use'Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2014-1063
APPLICANT/CONTACT PERSON RENE GAUTHIER
ADDRESS/PHONE 82 PEQUOT RD SOUTHAMPTON (413)455-5580
PROPERTY LOCATION 67 RYAN RD
MAP 22D PARCEL 005 001 ZONE URA(100)/WSP(100)/WP(0)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPLACE KITCHEN CABINETS&FLOORING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 098654
3 sets of Plans/Plot Plan
THE FO OWING 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
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
o " el
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.
67 RYAN RD BP-2014-1063
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22D-005 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-2014-1063
Project# JS-2014-001823
Est. Cost: $15000.00
Fee: $90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RENE GAUTHIER 098654
Lot Size(sq. ft.): 40380.12 Owner: DECKER RACHAEL
Zoning: URA(100)/WSP(100)/WP(o) Applicant: RENE GAUTHIER
AT. 67 RYAN RD
Applicant Address: Phone: Insurance:
82 PEQUOT RD (413) 455-5580
SOUTHAMPTONMA01073 ISSUED ON.411612014 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE KITCHEN CABINETS & FLOORING
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 4/16/2014 0:00:00 $90.00
212 Main Street, Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner