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11A-062 (2)
t.4 The Commonwealth of Massachusetts Department of Industrial Accidents U Office of Investigations 600 Washington Street Boston,Mass 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Businesss/Organizatton/lndividual):_ 11 M of 1 r'll�) n S Q AtonC, LV Address:_ .J CQ�) — -e , City/State/Zip: 40./ Phone#:_ Are ou an employer?Check the appropriate box: Type of project(required): 1 I am an employer with 1— 4.C)I am a general contractor and I 6.U New construction 2.©employees(full and/or part time).* have hired the sub-contractors �,p Remodeling I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8.0 Demolition working for me in any capacity. employees and have workers' g p Building addition [No workers'comp.insurance comp.insurance.$ required] 5.QWe are a corporation and its 10.❑Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.(]Plumbing repairs or additions myself [No workers'comp. right of exemption perm MGL insurance required]t c.152,§1(4),and we have no 12.17 Roof repairs employees.[no workers' 13. Other e-I��e comp.insurance required.] *Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers'comp,policy number. I am an employer tit at is providing workers'compensation insurance for my employees Below is the policy and job site information. ` Insurance Company Name:_ d i4 C �a n er il)f'��-ecs TDS lllt-4 n C P ,a`n t� Policy#or Self-ins.Lic.#-. , U 8 Q 112 Expiration Date: Q Job Site Address: _9 L-eOnc,,A Skc'Q,QA City/State/Zip:LPPAS- rnA n(0'C_,'3 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 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 $250.00 a day against violator.Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certi under the pains and penalties ofperjury that the information provided above is true and correct. Signature- Date: Print Name. 7n Anso pc,-6Ce_, Phone#• yid b�-,Sc��OdOC7 Official use only Do not write in this area to be completed by city or town official City or Town: Permittlicense#: Issuing Authority(circle one): 1.Board of heath 2. Building Department 3.City(rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact person: Phone#• SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / l Not Applicable ❑ Name of License Holder:\1\,) cs- 100 i-�a License Number 130 souk y, ad�Lj mi% Olm Address I Expiration Date 41 WOO Signature Telephone 9.kegist ed Home Improvement Contractor: Not Applicable ❑ A(Yw'C,C,gC\ I k-k or's 11S1'3a Company Name Registration Number 13o Address Expiration Date Telephone4� 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...... ❑ I L- Home Owner Exemution 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 51 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 Selz. CO j)}�-QcA SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El Or Doors I—I Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[p] Otherp l nsv t w o n Brief Descriptionof Proposed R"r 5e-w; � }hrOq%\C AA (noMt' ool N� )n Qv�)c� nOcK Work: S�CocS-.Jell . ins kCAZ- G4 is 60*6' Alteration of existing bedroom Yes Y No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes _L_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,_ .Sklso n as Owner of the subject property hereby authorize _ rnQ,r a n n S ca.114 i o'nS to act on my behalf,in all matters relative to work authorized by this building permit application. S22. co",+ CCA- 1 a re of Owner Date I, Dog r I r L a ,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. �+mPr�cA�, ns �I�Qtvrs Print Name c 1 �AmecicAn 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: _-J R: ii� L:= R:L—= Rear Building Height Bldg.Square Footage ` j —I Open Space Footage _ % (Lot area minus bldg&paved parking) #of Parking Spaces r-----i -' --� Fill: -------------------- —,�------.__---------------- ------------------------- (volume&Location) — A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW IV% YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW O YES O IF YES: enter Book I Page I and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Sal YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained O , Date Issued: C. Do any signs exist on the property? YES O NO O IF YES, describe size, type and location: F D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O 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 O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only P FC�� , °? City of Northampton status of Permit: Building Department Curb Cut/Driveway Permit -n r 212 Main Street Sewer/Septic Availability.... JUL 9 .; _ Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans.: DEPT RI HAMnONAIA u`_T':pone 413-587-1240 Fax 413-587-1272 Plot/Site Plans ------ - 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 9 Le-ono,c-J 5+rQe-} Map Lot Unit L elt4s I MIA 01 6S 3 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Suson One-ill q Leonolyd st�-&P.} , L ,PJs M 01C)S3 Name(Print) Current Mailing Address: can 4-c-Qe,� Telephone C,3--)-3 - `1o`2C9 Signature 2.2 Authorized Aaent: QM2r� Ln_ � lnS}p�i1 ��oY.S I3o �.c�l�p Sk OU44CUJ(04 n-A Name(Print) Current Mailing Ad ss: 01 1 iA(y%ac�CcQQ (ns�QllQkkoc\s 41?,-SSa-oa0o Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 3,O0'�s. L{(.p (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 6. Total=(1 +2+3+4+5) Qp Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2016-0030 APPLICANT/CONTACT PERSON AMERICAN INSTALLATIONS LLC ADDRESS/PHONE 130 COLLEGE ST SOUTH HADLEY01075 (413)552-0200 PROPERTY LOCATION 9 LEONARD ST MAP I IA PARCEL 062 001 ZONE URA000) 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: INSTALL ATTIC INSULATION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 106178 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF013MATION PRESENTED: 4--'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 e i Delay S k of 13 uil ng-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. 9 LEONARD ST BP-2016-0030 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-Block: I I-062 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit# BP-2016-0030 Proiect# JS-2016-000062 Est. Cost: $3005.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group AMERICAN INSTALLATIONS LLC 106178 Lot Size(sq. ft.): 72745.20 Owner: ONEILL SUSAN Zoning: URA(100)/ Applicant: AMERICAN INSTALLATIONS LLC AT. 9 LEONARD ST Applicant Address: Phone: Insurance: 130 COLLEGE ST (413) 552-0200 WC SOUTH HADLEYMA01075 ISSUED ON.711312015 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION 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 7/13/2015 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner