35-088 (2) City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
s of the work: o u C S f)
Address /�
The debris will be transported by: M 0. a '�
The debris will be received by: c 'ja,�
Building permit number:
Name of Permit Applicant rl c-
Date Signature of Permit Applicant
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 bum 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
rr� Cc Office of Investigations
d 1 Congress Street, Suite 100
b
Boston, MA 02114-2017
www.fnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Cont.-actors/Electricians/Plumbers
Applicant Informat on Please Print Legibly
Name (Business/Organization/Individual): C-
Address:_ Po (3c�x 5/ y L>5 , , /I7 p
City/State/Zip: c, t,,e ,, 0 /0,3.2 Phone#:
Are you an employer? Check the appropriate boa: F7, e of project(required):
1.❑ I am employer with 4. 1 am a general contractor and I
employees (full and/or part-time).* have hued the sub-contractors ❑New construction
2.❑ I am a sole proprietor or partner- Ag"I fisted on the attached sheet. Remodeling
ship and have no employees These sub-contractors have . Demolition
working for mein any capacity. employees and have workers'
insurance. 9. E]Building addition
[No workers comp.insurance ,,,comp.
required.] 5. We are a corporation and its 10.0 Electrical repairs or additions
3.El 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.;KRoof repairs
insurance required.] c. 152, §1(4), and we have no
employees. [No workers' 13.7 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.
lContractors 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: 1,1(23 +,� J r City/State/Zip: HoCf n t-e M
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 un!�e C the pains and penalties of erjury that the information provided above is true and correct.
Signature: �'"'-.� . _ .. Date:
� r
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#:
r
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable £
Name of License Holder: M• i� �— `� ~r PS
License Number
71 d 60
Address Expiration Date
Signature Telephone
9.Registered Home Ima�ovement Cori'fractor: _. Not Applicable £
Company Name Registration Number
Address Expiration Date
F-0 5-1 y (;05 Telephone y(3 0750�7�9b 3 l�
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 es....... £ No...... £
I :Home Owner Egehiption
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 ssum s responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and 1 n ws 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 F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [❑ Siding[O] Other[O]
Brief Descri p do of ro o�ed
Work: '1 t �;A; �- >)IOO�-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
fia. If New house and or addition to existinq.houslriA, complete the followinct:
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? /10 /► �
d. Proposed Square footage of new construction. A/3' Dimensions A
e. Number of stories? /
f. Method of heating? fi«tr .���' Q `l Fireplaces or Woodstoves&Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? /JO
h. Type of construction 8061
i. Is construction within 100 ft. of wetlands? Yes --X—No. Is construction within 100 yr. floodplain Yes__g_,No
j. Depth of basement or cellar floor below finished grade t4 A
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
1. M.C%,A f i Da 6 as Owner of the subject
property
hereby authorize
to act on my behalf, i 1 matters relative to woN authorized by this building permit application.
Signature f Owner Date Eh�01&r
1.A��e�M Q r+ 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.
,M:
Print Name
Signature of Owner/Agent Date
r .
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 F-LZ
Building Height
Bldg.Square Footage 0/,o
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces ETI
A. Has a Special Permit/Vahance/Rnding ever been issued for/on the site?
�.� �~�
NO 0U DONTK�W �� YES ��
|F YES, date isoueU
IF YES: Was the permit recorded at the Registry ofDeeds?
NO 0 DON7 KNOW 0 'ES
Do
IF YES: enter Book Page and/or cum ent#
B. Dues the site contain a brook, body of water nrwetlands? NO DON7 KNOW 0 YES 0
IF YES, has a permit been o,need tobe obtained from the Conservation Commission?
Needs to be obtained �-� Obtained »~� , Date Issued:
�� ��
C. Do any signs exist on the property? Y[5 x�� NO
|F YES, describe size, type and location:
NO
D. Are there any proposed c h anges t uor additions nf signs intended for the property? YES 0 «T�
|F YES, describe size, type an diocatiun: '
E. Will the construction activity disturb(clearing, grading on,or filling)over 1 acre orioit part nfa common plan
' that will disturb over 1acre? YES NO KV@
va/
|F YES,then o Northampton Storm Water Management Permit from the DPW iorequired.
/
L51- 14 C
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ilding Department
MAY $ 212 Main Street Seyver/SeptiGAvalfaE�lllty �F, f a
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pton, MA 01060 Two 8efsrcit 5#ructuFal I?tar�s
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`pgctrJ4� - 87-1240 Fax 413-587-1272 PIof/SiYe Plan's", A' f ; `}
Otfrerk,peclfy`°3 i h q 2i
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
-
}. Overlay District
a
r
Elm St t)istrlct CB D�stnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1,,✓Owner of Record: /� J /� I r_
`i C- .4'-C„ I �"` *1 V/ /7�cJ/� �r%R e 194 Ha1'//�+s0 Al�'
Name(Print Current C tiling Address:
0 5,
Telephone
Signature
2.2 Authorized Agent:
Name(Print) 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 vo (a)Building Permit Feb
DO
2. Electrical (b) Estimated Total Cost of
Construction'from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection LL
6. Total=(1 +2+3+4+5) Check Number
This Section For Official'Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector'of Buildings Date
1203 BURTS PIT RD BP-2015-1148
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -088 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-2015-1148
Project# JS-2015-002158
Est. Cost: $2500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MICHAEL PHILLIPS 082683
Lot Size(sq. ft.): 10149.48 Owner: DAMON MICHAEL&DIANA
Zoning: Applicant: MICHAEL PHILLIPS
AT. 1203 BURTS PIT RD
Applicant Address: Phone: Insurance:
P O BOX 514 (413) 268-0193
GOSHENMA01032 ISSUED ON.512012015 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:
FeeType: Date Paid: Amount:
Building 5/20/2015 0:00:00 $35.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner