49-001 The Commonwealth of Massachusetts
- Department of Industrial Accidents
Office of Investigations
X 600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Bu sines s/Organizati on/Indivi dual):
Address: 4v '
City/State/Zip: 1 ovvvc-t 0 to �- Phone #: ---345
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. F1 New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.1a Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their It.M Plumbing repairs or additions
6 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 l�•' c�-�-
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.
$Contractors 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 the pains and penalties of perjury that the information provided above is true and correct.
Sip-nature: Date:
Phone M
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 Applicable £ i
Name of License Holder: `- 1/�V1 �/�v�n 7-P�-1 . C `— �Fs1
License Number
Expiration D e
Si ure Telephone
9.Registered Home:Imarovement Contractor Not Applicable £
Company Name Registration Number
Address Expiration Date
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 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"ce d ass responsibility for compliance with the State Building Code,City of
Northampton Ordinances,Sta and Loc ng Laws an State of Massachusetts General Laws Annotated.
Homeowner Signature.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemen W'ndows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding[❑] Other[❑]
Brief Work:Description of Proposed ' GA .I12-kA T-dVf^ 1 1"y--, �
Alteration of existing bedroom Yes No Adding new bedroom Yes X No �
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.""If New House and"or addition to�ezisting.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.
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
:a-tA-X^ CA,, ,,` ,�,, IiI' _ as Owner of the subject
property -III / �/
hereb authorize r ✓i"- 9 -�'`�"
to ac on my al i all matters relative work authorized by this building permit application.
Sig wner Date
I,
re A^ Nrt-' dIJ as Owner/Authorized
Agent hereby declare that th statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penal jies of perjury.
r,.r.,C—
Print
c Ll
Signatu w ent Date
.A
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
Tbis colunin to be filled in by
Building Department
Lot Size
Setbacks Front
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Vaharce/Rnding ever been issuedfor/on the site?
�� ����
NO ��k DONTKNOW �� YES
IF YES, da1eixsued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO K � DON7KNOVY YES
��
IF YES: enter Book Pagel-
a and/or Document#
�� ��_��
B. Does the site contain a brook, body of water orwetlands? NO ���7 DONT KNKNOW �~� YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained ~�x—� Obtained �~\~�� Date
'
�
'
�»+~�
C. Do any signs exist on the property? YES K } NO J��L
IF YES, describe size, type and location:
D. Are there any proposed changes toor additions of signs intended for the property7 YES 0 NO -�y
iF YES, describe size, type and location:
L- -_-___'--_---------------.
E Will the construction activity disturb(clearing,grading excavation,or filling)over 1 acre orioit part ofo common plan
' thut will disturb over 1acre? YES NO -DO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^ ~
,�. � _ r r 5 Departmeht use onl�r ,- i
City of Northampton r
Building Department CurB Cut/Drfvevay Perrrlit r 4
k s
212 Main Street S,ewerlSepticRvaifabllity ' r
on. Room 100 !Nater/WeiCAvailablllty r
EN Plumbing MAOio� rthampton, MA 01060 Twosefs ifs#ructurai"Ptans '
mp
Mortha p one 413-587-1240 Fax 413-587-1272 Plof/Slts Plaps . ,
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OtherzSpec�fy r �, l
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
This section fo be completed by office
1.1 Property Address:
Lot Unit
�a9 - '
Nt h"c►v��� ��^ I d IQ�p hdver lay D►sfrrct
Elm
Stlli Qstnct CB Dlstnct
. SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
N Current Maili g Address:
Telephone
Si re
2.2 Authorized A ent:
1_77 hD
Name( (nt) Current Mailing Address:
R
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be " Official Use Only
completed by ermit applicant
1. Building ��N t -� (a)Building Permit Fee
CPO
2. Electrical �w (b)Estimated Total Cost of
Construction`from 6
3. Plumbing h 5�, — Building Permit Fee
4. Mechanical(HVAC) .J
5. Fire Protection / .SGT
6. Total=0 +2+3+4+5) ' 6 Svc)� Check Number
ENO
This Section For Official Use'Only
Date
Building Permit Number: Issued:
Signature:
Building Comm issioner/Inspector'of Buildings Date
File#BP-2014-1070
APPLICANT/CONTACT PERSON BRIAN CAMPEDELLI
ADDRESS/PHONE P O BOX 823 EASTHAMPTON (413)539-3685
PROPERTY LOCATION 229 GLENDALE RD
MAP 49 PARCEL 001 001 ZONE
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out e 4L 1 `�
Fee Paid
Typeof Construction: PARTIAL INT DEMO NEW ROOF WINDOWS SHEETROCK, KITCHEN&BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 082616
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFPRMATION 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 Stone Water Management
o ' ' Delay
Si re of Buil ff ial 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.
229 GLENDALE RD BP-2014-1070
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 49-001 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-2014-1070
Project# JS-2014-001839
Est. Cost: $26500.00
Fee: $159.00 PERMISSION IS HEREB Y GRANTED TO:
Const. Class: Contractor: License:
Use Group: BRIAN CAMPEDELLI 082616
Lot Size(sq ft.): 42601.68 Owner: CAMPEDELLI BRIAN
Zoninfz: Applicant: BRIAN CAMPEDELLI
AT: 229 GLENDALE RD
Applicant Address: Phone: Insurance:
P O BOX 823 (413) 539-3685 WC
EASTHAMPTONMA01027 ISSUED ON:412212014 0:00:00
TO PERFORM THE FOLLOWING WORK:PARTIAL INT DEMO,NEW
ROOF,WINDOWS,SHEETROCK, KITCHEN & BATH
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 4/22/2014 0:00:00 $159.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner