31A-268 (6) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
10 Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please P,{r-i�n�t,Legibly
Name (Business/Organization/Individual): <�, T�D U'
Address: 00 k ok M l CA R
City/State/Zip: S -�) f—k<kd Phone #: C)
Are you an employer?Check the appropriate box: Type of project(required):
1.M I am a employer with 4. ❑ I am a general contractor and I 6. [ New construction
employees(full and/or part-Time).* have hired the sub-contractors
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. T Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t 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 their workers'comp.policy information.
I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: V► l I Y 1 d1S ' �U
Policy#or Self-ins.Lic.#: ,U R-1- ()p5(d0q 7,(��3 Expiration Date: co
Job Site Address: 4-1 1 !2t c%--b q-R z 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 penaltles ofperjury that the Information provided above is true and correct
Siznature [� �— 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 Applicable ❑
Name of License Holder: C"�� `� C'�-` z:�c S c—�^ 4 2
License Number
Address A Expiration Date
Signat Telephone
9.Realster+od Home.Imm-yarront Cont—radon Not Applicable ❑
Company Name Registration Number
Address r Expiration Date
_�ti M 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....... l5k No...... ❑
Wme Ow r,Exemy"40
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 108.35.1.
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 pen-nit 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 EJ
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks PK* Siding[p] Other[EJ
Brief Description of Propos Q M` , a � +JA- —I e C� , ►\e-
Work: ��1aCr w/ lQr,-k-- o�S rcky'jo. f\le:AJ
Alteration of existing bedroom Yes_ No Adding new bedroom Yes �_Nom
Att Renovating unfinished basement Yes No
Plans Attached Roll -Sheet YES
6a.If Newhouse and or addition to 0AMIrin hgus rii6,06 6114 to th4-'6IIdWino:
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
I, rA O A- � ��{%����- �- ��� f- as Owner of the subject
property
hekao tyhaif,e
to in all matters relative to work authorized by this building permit application.
f
Signatu-rrofowner Dake
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.
Print Name
Signature wner/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 -6
Frontage
Setbacks Front
Side L: �(2� R: ,Z L: R:
Rear [t
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved `f'
parking)
#of Parking Spaces 2
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO � DONT KNOW O YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO
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,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YE£ O NO �.
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
J
ity of Northampton
ilding Department
JUN 6 MOW 212 Main Street � 77i
Room 100 _
Electric Plumbing&Gas Inspect hampton, MA 01060
MA t 87-1240 Fax 413-587-1272
t
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
4'-4 D r 7 , Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A 9AM r� 5,T, [t✓tt.cc. W!A C) 2
Name(P' Current Mailing Address:
911 E-70 o31 Z
Telephone
Sign ture CA iz,
2.2 Authorized Aaent:
<:�; i!n C,
Name(Print) Current Mailing Address:
Signaft Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building •Z (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) Z O(-S , 0� Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File# BP-2014-1301
APPLICANT/CONTACT PERSON SCAPES BUILDERS&LANDSCAPING LLC
ADDRESS/PHONE P O BOX 469 DEERFIELD (413)665-0185 Q
PROPERTY LOCATION 47 DRYADS GREEN ST
MAP 31A PARCEL 268 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out & �
Fee Paid TOW
Construction: REPLACE EXISTING DECK(SAME FOOTPRINT)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 105802
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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
Demolition Delay
Signs ure 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.
47 DRYADS GREEN ST BP-2014-1301
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31A-268 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: renovation BUILDING PERMIT
Permit# BP-2014-1301
Project# JS-2014-002189
Est. Cost: $20060.00
Fee: $120.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group:— SCAPES BUILDERS & LANDSCAPING LLC 105802
Lot Size(sq. ft.): 8276.40 Owner: ZUCKER ADAM&HEATHER ABEL
Zoning. URA(100)/ Applicant: SCAPES BUILDERS & LANDSCAPING LLC
AT: 47 DRYADS GREEN ST
Applicant Address: Phone: Insurance:
P O BOX 469 (413) 665-0185 O WC
DEERFIELDMA01373 ISSUED ON.61612014 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE EXISTING DECK (SAME FOOTPRINT)
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 6/6/2014 0:00:00 $120.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner