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38B-319 (2) tTtb ?1�Tr7 � r { EAST ELEVATION RER M ER E SLEEPING AREA EAST ELEVATION 331-11 314" _. _ 91-6- in GARAGE io NEW STURERU7M DWELLING 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 cant'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 IndustrialAccidents _ Office of Investigations I Congress Street, Suite 100 �+ Roston,MA 02114-2017 �? www'.mass.gov/dia Workers' Compe sation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Informat n Please Print Leaibl Name (Business/Organizati)n/Individual): Address: 2 Cr v ALL �4 City/State/Zip: '"v Phone#: 5 Z7-61 Are you an employer?ChE ck the appropria e box: Type of project(required): 1.0 I am a employer with 4. 0 1 am a general contractor and I 6. New construction employees (full and/or part-time).* have hued the sub-contactors ❑ 2. I am a sole proprietor r partner- listed on the attached sheet. 7. Remodeling ship and have no empl yees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. 0 Building addition [No workers' comp.in urance comp.insurance. required.] 5. � We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 11. Plumbing re airs or additions 3.0 I am a homeowner do' all work p myself. [No workers' c mp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 mu t also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affida it indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must ttached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors hav employees,they must provide their workers'comp.policy number. I am an employer that is prove *i-workers'compensation insurance for my employees. Below is the policy mad 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 r quired 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 e violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA f ante coverage verification. I do hereby cert' under the p and ena ties of erjury that the information provided above is true and correct. �3Signature: Date Phone#: Official use only. Do not w 'te in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle on ): 1. Board of Health 2. Build ng Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Su rvisor: Not Applicable ❑ Name of License Holder: License Number Address Expi ation p to Sig a u Telephone 9.Realistered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number G / Zo / t5 Address Expir tion Date v \ Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6)) Workers Compensation Insuranc affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of th building permit. Signed Affidavit Attached Yes.... .. ❑ No...... ❑ 11. - Uome Owner Exemption The curreXexption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2 families and to alloeowner to engage an indi��idual for hire who does not possess a license, rovided tha owner acts as su erv80 Sixth Edition Section 1083.5.1. Definition of HotrneowLn Person(s)who own a parcel of land on which he/she resides o �ends to reside,on which there is,or is intended to be,a one tiro family dwelling,attached or detached siructu ccessory to such use and/or farm structures.A person vho const is more than one home in a two- ea rrod shall not be considered a homeowner. Such"homeowner"shall submit to th uilding Official.on a for ceptable to the Building Official,that he/she shall be responsible for all s h work erforme nder the bull ermit. As acting Constructi in Super-visor your pres qice o)p. c job site will be required from time to time,during and upon completion of the wo m for which this permit i. st Also be advised that V rith reference to C er 152(Wo?r ' Compensation) and Chapter 153 (Liability of Employers to Employees for injurie not resultin Death)of the Massachus General Laws Annotated,you may be liable for person(s) you hire to perform w)rk for u under this permit. The undersigned"ho �ner'°certifies and assumes responsibility for comp i ��ith the State Building Code,City of Northampton Or an ces,Slate and L/o�cal Zonin- Laws and State f Massachusetts General Laws Annotated. Homeo er Signature �' SECTION 5-DESCRIPTION OF PROPOSED WORK check all applicable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[Q Brief De ,,scrip n of Proposed Work: (.,Q) i 1 r �T1�J G <^ vv(ji\ d Ci , 5 Alteration of existing bedroom Yes No Adding new bedroom Yes 'Q No Attached Narrative Renovating unfinished basement Yes _Z!�:, No Plans Attached Roll -Sheet sa. If New house and or ad ditio,n 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 iew construction. 1 L8 C� 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 S wer 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 hereby authorize to a on my behalf, i II matters r lative to work authorized by this building permit application. Sigiliature of Owner Date 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 pene Ities of perjury. Print ame Signature of Owner/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 °Ir Open Space Footage 17o' (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 0 DONT KNOW 0 YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document#', B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO C) 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? YES 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. : I� [` \ City of Northampton Status of Permit: Department use only �__--- — Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability 25 2015 Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans Et ctric, Plumbing&Gas Ir4W6rdes 13-587-1240 Fax 413-587-1272 Plot/Site Plans Northampton, MA 01060 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 d l-�V �`ry Map Lot Unit Zone Overlay District c rC'G o Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nam (P�ri�nt,)(/�� Current Mailing Address: ,Zlid/�� Telephone Signature 2.2 Authorized Agent: Name(Pri 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 Z o© v,j (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 Z;UG C) 6. Total=(1 +2+3+4 +5) i 000 Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2015-0884 APPLICANT/CONTACT PERSON TIMOTHY STOKES ADDRESS/PHONE 20 TURKEY HILL RD WESTHAMPTON01027(413)695-2264 Q PROPERTY LOCATION 50 OLIVE ST MAP 38B PARCEL 319 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out c Fee Paid Typeof Construction: CONVERT PORTION OF GARAGE TO STORAGE/WORK ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure - Buildiny,Plans Included• Owner/Statement or License 083602 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFqRMATION 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 De h ' n Delay Signature of Buil mg 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. 50 OLIVE ST BP-2015-0884 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 38B-319 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-2015-0884 Project# JS-2015-001722 Est. Cost: $15000.00 Fee: $90.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: TIMOTHY STOKES 083602 Lot Size(sq. ft,): Owner: RAHM LINDA K Zoning:URB Applicant: TIMOTHY STOKES AT. 50 OLIVE ST Applicant Address: Phone: Insurance: 20 TURKEY HILL RD (413) 695-2264 () WESTHAMPTONMA01027 ISSUED ON:312612015 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONVERT PORTION OF GARAGE TO STORAGENVORK ROOM 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 3/26/2015 0:00:00 $90.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner