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35-229 (6) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLibly Name (Business/Organization/Individual): E h S SC's d t Cie s �L L Address: Ll - SG-Ik'14br.8 1 t2. 2&0 City/State/Zip: 74 Q _6LLi--h M A a (SG Phone #: T`,l— Z 2 i3 Are you an employer? Check the appropriate box: Type of project(required): 1.[?f am a employer with Lf 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. E] 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 g, ❑ Demolition working for me in any capacity. employees and have workers' insurance.$ 9. ❑ Building addition [No workers comp.comp. insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 l.❑ 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. t Homeowners 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. I Insurance Company Name: Ga t 0. ( ''l.S Lt—Q l C "t C d Policy#or Self-ins.Lie. #: II CA 02(2 4 7(f — )3 Expiration Date: Job Site Address: ��-y (%e✓d-4, ei Q City/State/Zip: F-1 r%4-oc-t c e MA 0/6 C,)_ 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 ce!ti Q under the pains and enalties of er'ury that the information provided above is true and correct Signature: ._ Date. . Phone#: -7 f (CA ° 2-E Q 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#: This section to be filled out in home and signed by customer Property Owner Must Complete and Signs this Section if using a Builder k 1q1 V 1, Z°/`•/ /, / ��5� as Owner of the subject property herby authorize CMSR SERVICES, LLC to act on my behalf, in all matters relative to work authorized by this building permit application for(address of job) (42 Signature of Owner Date -------------------------------------------------------------------------------------------------------------------- This section to be completed by CMSR SERVICES, LLC staff Owner or Builder (as Agent of Owner) Must Complete and Sign this Section I, <) C,K f A)d C -C4-,A as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application for(address of job) are true and accurate, to the b6st of my knowledge and belief. Signed under the pains and penalties of perjury Print Name r gigpdture of Owner/Agent Date _ '� Office of Consumer Affairs and Business Regulation 0/ - 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 162011 Type: LLC Expiration: 12/26/2014 Tr# 234265 CMSR SERVICES, LLC. SEAN NOONAN 482 SOUTHBRIDGE ST SUITE 268 AUBURN, MA 01501 Update Address and return card.Mark reason for change. Address D Renewal E] Employment F-] Lost Card SCA 1 0 2OM-05111 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen-isor License:C34N82W3 JOHN M MCARD $ q 89 Tatiytewa Lade Weroedber MA Of6ft !xpiration Commissioner 1112812016 Unrestricted-BURdings of any use group which coo"M less*an 35,000 cubic feet(9910)of enclosed space. Fatiure to posses -a Current edition of the Massachuseft State auliding Code is cause for revocation of this iioense. For DPS U=Wng information vL-& www.Maas.Gov/DPS - 0 ��QJi Office of Consumer Affairs//and Business Regulation 10 Park Plaza.- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration. 162011 Type: Supplement Card CMSR SERVICES, LLC. Expiration: 12126/2014 JOHN WARDLE 482 SOUTHBRIDGE ST SUITE 268 AUBURN, MA 01501 Update Address and return card.Mark reason for change. scn 1 0 1 0 Address [] Rw wai [] 19mployamt [ Lost Card SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: J D k, Nk Nt L A-r A (t; CS— Cfo�o 4 3 License Number t .Tarv� 1�w' I &vu' �Jv✓ s � ��ti Q (�6Z ►�f2 /Zo 5 Add ss Expiration Date Signatur Telephone 9.Realstered Home Improvement Contractor: Not Applicable ❑ 005�2_ Serytceg LL(-- W)100 Company Name 1, - Registration Number 1'-V7_6 Z u Address i- I Expiration Date XU.urvl( 50 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"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 Wi ows I Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [M] Decks [C[ Siding[E-31 Other[aj Brief Description of Proposed Work: ✓e-14 0ye- CL"%u L�O0 V lit vv LX— Alteration of existing bedroom Yes \'� No Adding new bedroom Yes \-�No / Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa. If New house and or addition to existing housina, complete the followina: 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 1, (.S as Owner of the subject property . hereby authorize CMS r- Jeer tlt Ge S LLC to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date /l.Jvp /tiacA 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. �4✓t �• r'VUG l�-Ce�1 Print Name f� / 6110 ft 1-1 Signature of er/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 Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO ® DONT KNOW YES IF YES, date issued: IF YES Was the permit recorded at the Registry of Deeds? NO ® DONT MOW O YES IF YES enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO a DONT MOW ® YES O IF YES, has 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 kj IF YES describe size, type and location: D. Are t here any proposed changes to or additions of signs intended for t he property? YES ® No IF YE$ describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavoon, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO V IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only pn City of Northampton Status of Permit: D —V .-- Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability JUN 10 2014 ;I Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans Ele trio, RU„i:.,, c: . in-, 413-587-1240 Fax 413-587-1272 Plot/Site Plans Nortlrn;,I'- MA 710th 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 (t_0 f;OLI �(2 rr� Ltev)t Map Lot Unit rlo re it,e-, il" A o i0v)- Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: CLv122 i OosS t l.ctoe, Name(Print) — Current Mailing Address: Telephone Signature 2.2 Authorized Anent: Name(Print) Current Mailing Address: 3"' P -7-7 t4 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building H 1 0 d0 v 0C (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) a COO Check Number This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date 16 BAYBERRY LN BP-2014-1324 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35-229 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate�y: REPLACEMENT DOOR BUILDING PERMIT Permit# BP-2014-1324 Project# JS-2014-002228 Est. Cost: $12000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CMSR SERVICES LLC 082043 Lot Size(sq. ft.): 45302.40 Owner: JORDAN HAROLD R&RENEE ROSSI JORDAN Zoning: Applicant. CMSR SERVICES LLC AT. 16 BAYBERRY LN Applicant Address: Phone: Insurance: 482 SOUTHBRIDGE ST STE 268 (774) 210-2513 WC AUBURNMA01501 ISSUED ON.611112014 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT DOOR 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 6/11/2014 0:00:00 $35.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner