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32A-004 (4)
Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership., association,corporation or other legal entity,or any two or more of the.foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 7-2010 Fax# 617-727-7749 www.mass.gov/dia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant fnformat on / Please Print Le6ibly Name (Business/Organization/Individual): r Address:-:?A/ 31 ©•c�c� �•C/,�.�i 'vf � �`�i� City/State/Zip: Phone #: F il Are you an employer? Check the appropriate box: Type of project(required): .❑ I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have hued 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.❑ 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' 131-1 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out flee 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. 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 certif under the pains an Wallies of erjury that the information provided above is true and correct. Signature: 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 S.Plumbing Inspector 6. Other Contact Person: Phone#: I SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. i Not Applicable ❑ f Name of License Holder: c^� License Number Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Expiration Address z,<wz /, /`i�/f Old � Telephone /�3 �' !�25^ 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 W doors Alterations) Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [o) Decks [p Siding[0j Other[Q Brief Des . ti n of Proposed ly Work: "i ,dC/TCAV;, _,,A1e % e4S,--2,s-T,,C'-J Alteration of existing bedroom Yes I/ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _No Plans Attached Roll -Sheet 6a.If New house and or addition to existing 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 I, tsi kl_ej ' I . �'l< as Owner of the subject property hereby authorize C.T`�?�' (I(`�4? K y to act a y ehatf,in all matters elative to work authorized by this building permit application. Sig re Owner Date 1, P l f U�UW( •� l':L. �- 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. �'��k' ►� ti J L 2 �� Print Name / ,e S L Signature of Owner/Age 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 O DONT KNOW er YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW er YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained 0 , Date Issued: C. Do any signs exist on the property? YES ® NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,exca ation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO F IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit L_ R'Ta O V E q13 ilding Department Curb Cut/Driveway Permit � u 212 Main Street Sewer/Sephc Availability Room 100 WatedWeli Availability 6i � hampton, MA 01060 Two Sets of Structural Plans phone 87-1240 Fax 413-587-1272 Plot/Site Plans Electric,Plumbing&Gas InspeckW6 Other Specify on, lutu UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 :t +, This section to be completed by office ► �,! C� Map Lot Unit Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ C.-Lt/k- Nam ' t) Current Mailing Address:Llt , iL l y 114 �1 ^� Telephone Signature rig l n : i � lf�� J e'_ Name(P Current Mailing 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 oocD. — 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing 6 s _ Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) p a . Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings Date File 4 BP-2015-0394 APPLICANT/CONTACT PERSON PETER R HERONEMUS ADDRESS/PHONE 247 LONG PLAIN RD LEVERETT PROPERTY LOCATION 14 WALNUT ST MAP 32A PARCEL 004 001 ZONE URC(106)/ 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: RENO KITCHEN BATH NEW WINDOWS&ROOF New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 058899 3 sets of Plans/Plot Plan THE FOL 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 Del y Sign re 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. 14 WALNUT ST BP-2015-0394 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A-004 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-2015-0394 Project# JS-2015-000681 Est. Cost: $63500.00 Fee: $381.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: PETER R HERONEMUS 058899 Lot Size(sq. ft.): 12980.88 Owner: SHOTLAND JEFFREY D&PETER SYLVAN &JAMES P SYLVAN Zoning: URC(106)/ Applicant: PETER R HERONEMUS AT. 14 WALNUT ST Applicant Address: Phone: Insurance: 247 LONG PLAIN RD LEVERETTMA01054 ISSUED ON:1011612014 0:00:00 TO PERFORM THE FOLLOWING WORK.RENO KITCHEN, BATH, NEW WINDOWS & ROOF (no framing changes) 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 10/16/2014 0:00:00 $381.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner