18C-141 (25) The Commonwealth of Massachusetts
Department of IndustrWAccidents
Office of Investigadons
1 Congress Street,Suite 100
IV Boston,MA 02114-2017
www.rnassgovl dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Ekd icians/Plumbers
Piet t
Name akisineworg ionandividum): ., —
Address: _, b 5 5-rll
Ci lState/2i ; Q "lPhone hl:
Are you an employer?Cheek the appropriate box: Type of project(requh ed):
1.M-ram a employer with 4. 31"am a general contractor and
employees(full and/or part-time).* have hired the sub-contractors Q New construction
213 I am a sole proprietor or partner- listed on the attached sheet. 7. GitLftodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity. employees and have workers'
coin insurance.t 9• Q Building addition
[No workers' comp.insurance P•
required.] 5. Q We are a corporation and its 10.Q Electrical repairs or additions
3.13 1 am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.[3 Roof repairs
insurance required.]t c. 152,§1(4),and we have no 13.Q Other
employees. [No workers'
com .insurance required.
•Any applicant that checks box 111 must also&u out the section below showing their workers'compwsafion Policy informati(n.
f Homeowners who submit this affidavit indicating they are doing all wwk and them hire outside oontcactaas must submit anew affidavit indicating such.
=Contractors that eheckthisbox must attadiedan additional sheet showing the mine of the sub-contractors and state whether or not those entities have
employees. V the sub tars bave employees,they must provide their wodwrs'comp.policy number.
law an emptoyerr dW is jwovifirrg workers'congmnaden inatraace for nV emiployeez Bdow is t]lie policy and ob sRe
information.
Insurance Company Name:, "'rWAWSAI , ? M119::i•
Policy#or Self-ins.Lic.#:_ L)bbz!% %99 Expiration Date: i n-15
Job Site Address:�Ll 62A"FSAPA.F _t-,i�l, 1 City/State/Zip:�i�
Attu a copy of the workers'compensation policy declaration page(showing the policy numb 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 cerW y muler dw panne and penalties oi'p+erhwq that the information p'rovi&d above I trite and aatr+ect.
Signature: Date:
«.
F����;e7r use only. Do not write in this urea,to be completes!by city or town o,�i ekd,
or n Permit/License#
ority(circle one):
� 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumb%Inspector
son: Phone#:
SECTION 8-CONSTRUCTION SERVICES
8.1 11 ..tensed C 021nig S'im a. � _ Not Applicable ❑
Ucense Number
r,,,... Expiration Date
Si elephone
Not Applicable ❑
omt�anrt Name ta 2.
egistration Number
AddEress Expiration Date
SECTION 10•WORIKEFV COMPENSATION INSURANCE AFRDAVR(M.G.1..c.162,0 25C(8))
Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit Vitt result
in the denial of the issuance of the bufidin pemrif.
�;4ned Affidavit Attached Yes....... No...... ❑
The current exemption far"homeowners"was extended to include OM1er-oc9MM 8211_a of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a license,gMIft UM tbg glM_acts
7A Mh 9MM 1090 MM-1.
0202410 of llMttstwner Person(s)who awn 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.
Such"homeowner"shalt submit to the Building Official,on a form acceptable to the Building Official&Met,hg&k Ali be
resooesible,� [nor_AD M"work gtdg=M ygder the bM=nerrr&
As acting Qnftntft ftMIkK your presence on the job site will be required from time to time,during and upon
completion of the worts 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 lure 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 Sipatw*
SOON 5,-,MMIPT11ON S?E EHQtQ=W=JoblA 2111 BRRV abue)
Now House �] Adlltion ReDRm eMff ndows Alteration(s) C:] Roofng 0
Accessory Bldg. ❑ DonolIfion ❑ New Slgns P-0 Decks C3 Siding IM Other M
Brief Description of Proposed
Work: ramjj9s= kwmmA 1b=k9==
UPS
Alteration of existing bedroom YesNo Aging new bedroom Yes
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
a. Use of building:One Family Truro 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, floodpiain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
1. Septic Tank City Sewer Private well City water Supply
SECTION Is-OWNER AUTHOFMTO t-TO BE C OMPLETO WHIt
OWNERS A0ENT OR CONTRACTOR APPLIES FOR SU LDING PSPJA T
1, & t-A l( Jars .. ,as Owner of the subject
property
hereby authorize
to ad in tiers red. authorized by this building permit application.
Si awe of Owner Date •-
I ,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 enalties of perjury.
�:A Wk
Print Name
-r
e of , Date
Section 4. ZONING All InforMtIM Must Be Compieted.Permt Can Be Denied Due To incomplete information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Fr(mtw
Seftcks Front
Side L R 1. ,r„" .. R
LEK
Building Height
Bldg.Square Footage Ri,
Open Space Footage %
(Lot area minus bldg&paved
Parking)
#of Parkin S
Fill:
♦alume&Location
A. Has a Special Permit/Var lance/Finding ever been issued forlon the site?
NO 0 DON'f KNOW Q— YES 0
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW YES O
IF YES: enter Book ! Page and/or Document#
B. Does the site contain a brook, body of water or wetland? NO O DONT KNOW &---YES
IF YES, has a 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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading, cav ,or filing)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YE. 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
I
w"
ampton
[� rtment
Q 212 M feet
t
00
Nort�t1nt n
01060` 3 r
4 d* J
.cl p►umb� on.�A �F 413-587-1272
��tr No�tt'amPt
APPLICATI TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-$ITE INFORMATION
1.1 Pronertv ddress: -54 C j?A15 VS4E- - t0 be t�.ditl d y�
a c.c*Arnk*-tc Lot
zone «ar D
Omni. 0%Kp ,Via% Eft ft DWW Cattrt
SECTION 2-PROPERTY OWNERSWIAUTHORIZED AGENT
2.1 Owrter.of Raix":
11 a ffty"t I kA 1124
Name en�Melling Ore
Telephone
2.2 AggI91M Agent:
& �
Name(Pant} Current Msftg Address:
Signature Telephone
Item Estimated Coat Pollars)to be Official Use Only
1. Building (a)Building Permit fee
2. Eledrical (b)Estimated Total Cost of
Construction from j6j
3. Plumbing Bt"no Permit Fla
4. Mechanics(HVAC)
S. Fire Protection
6. Total 1 +2+3+4+-5) Check Number
nft 900 For OW U"2
Building Permit Number: D849
Issued:
Signature:
Suiidng Commissionemnspedor of Buildings
Date
File#BP-2015-0809
APPLICANT/CONTACT PERSON MARK BONDE
ADDRESS/PHONE 205 PARK ST EASTHAMPTON01027(413)535-9529 Q
PROPERTY LOCATION 24 CRABAPPLE-680 BRIDGE RD
MAP 18C PARCEL 141 001 ZONE
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: CONVERT 8 X 12 ROOM INTO HEATED LIVING AREA& REPLACE KITCHEN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Buildine Plans Included:
Owner/Statement or License 67758
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved 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
lay
„/,7
Signat of uilding 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.
24 CRABAPPLE-680 BRIDGE RD BP-2015-0809
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18C- 141 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-2015-0809
Project# JS-2015-001571
Est. Cost: $15000.00
Fee:$90.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK BONDE 67758
Lot Size(sq. ft.): 1497897.72 Owner: LATHROP COMMUNITY INC
zoninjz: Applicant. MARK BONDE
AT. 24 CRABAPPLE - 680 BRIDGE RD
Applicant Address: Phone: Insurance:
205 PARK ST (413) 535-9529 O WC
EASTHAMPTONMA01027 ISSUED ON:212012015 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 8 X 12 ROOM INTO HEATED LIVING
AREA & REPLACE KITCHEN
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 2/20/2015 0:00:00 $90.00
212 Main Street,Phone(413)587-1240, Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner