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cx The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
" y 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: A 4a�&*M_,e
City/State/Zip: k1 O GD6 O Phone M 4(13 3
Are yo an employer?Check a appropriate box: Type of project(required):
1. am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. F-1 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 or me in an capacity. employees and have workers'
g y p �'• 9. E] Building addition
[No workers' comp. insurance 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 11. mbing 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.
$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: A tfr CP
Policy#or Self-ins. Lic. #: 614v&4 O 1Y1(4— 6—IV Expiration Date:
Job Site Address: 440 IhA c�'f - -City/State/Zip: � " 0 *4 a
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 pain d penalties ofperjury that the information provided above is true and correct.
Sip-nature: / 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: (-70X W( CICr
License Number
>3
0/00) 3/9/c o 1,6
Addresl Expiration Date
Signature Telephone
9.Re istered Homeamp�ovement Contractor Not Applicable £
Company Name Registration Number
& MA/wAW lJ� n�r for �fsn ,�lfl o(�da 26Z c cG
Address Expirafioh 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 Attache 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 buildinL 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 (]
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding [❑] Other[❑]
Brief Description of Proposed
Work: �p nLou a()
Alteration of existing bedroom Yes)_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement No
Plans Attached Roll -Sheet
sa;If Newhouse and oir add'itidn W ezis€ng housing,: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
I as Owner of the subject
property or
hereby authorize
to act on my behalf, in all matters rela ive to work autho ized by this building permit application.
�n /��► nfrQ/�
Signature of Owner Date
I, �hereby '� as Owner/Authorized
Aglare that the state n s 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.
6'&�Law' /1 h
Print Name
Signature of Owner/AV 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 L.—JI
#of Parking Spaces
Fill
(volume&Location)
A. Has a Special Permit/Vahamce/Rndingever been issued for/on the site?
�� ��
NO �~� DON7KNOYY YES �~��
�
|F YES, date issued�
IF YES: Was the permit recorded at the Registry ofDeeds?
NO � J DON7KNO\V Y[5
��
IF YES: enter Book Pagei and/or Document#L
�� ��
B. Does the site contain a brook, body of water orwetlands? NO �0� DDNT KNOW ��' YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained «—\ Obtained �~� Date�~� �~� ' .
��
C. Do any�gnsex�ton the pnoper�? YES «�� NO
)F YES, describe size, type and location:
D. Are there any proposed changes toor additions of signs intended for the prnpert 0 y� YES NO
IF YES, describe size' type and location: �
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orioi1 part ofa common plan
JONN
' that will disturb over 1acre? YES NO U
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
'"� >s' !]epartmeht use onix ,
City of Northampton Status of Permit i r
qSectr1c, Building De partment 212 Main Street NM 11u.111
AL 3 2014 Room 100 VlfaterlUkte�tAvailabihty Northampton, MA 01060 Two sets of Structural Plan$.UwS,irspectio one 413-587-1240 Fax 413-587-1272 o;;
1'AA 09080 Othef5 ecl
r L ]
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 comPletetl by office
Map Lot Unit
a NGtn�C�en S7'
Zone Overlay District
lU�i ��nr gunk Or ob a
Elm St Distrid CB Distract
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�il-�-ro n a� f-{Q�I�O�r� �1� lufJlGfm btu►'► �,�,�.0 06a
Name(Print) Current ailin drew: -?/Q
On lnfi- C/L Telephone (r `�
Signature
2.2 Authorized Agent:
V 1odUstkl [2! obu
14a-me(Print) Current Mailing Address:
113- - a
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
�6 6 . 0
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) OU Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/lnspector'of Buildings Date
21 HAMPDEN ST BP-2015-0123
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38D-017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit# BP-2015-0123
Project# JS-2015-000223
Est. Cost: $16986.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: YANKEE HOME IMPROVEMENT INC 89442
Lot Size(sq. ft.): 11499.84 Owner: BUTTON GEORGE H JR&BEVERLY J
Zoning. URB(100) Applicant: YANKEE HOME IMPROVEMENT INC
AT. 21 HAMPDEN ST
Applicant Address: Phone: Insurance:
82 INDUSTRIAL DR, UNIT 2 (413) 341-5259 O WC
NORTHAMPTONMA01060 ISSUED ON.•713 012 01 4 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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:
FeeTyue: Date Paid: Amount:
Building 7/30/2014 0:00:00 $35.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner