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24C-059 (4) The Commonwealth of Kassachusetts Department of:industrial Accidents s Office of Investigations 600 Washington Street Boston,MA 02111 n,wn%mass.gov1dia Workers' Compensation Insurance Affidavit: Build ers]Contractors/Electri cians/Plu mbers Applicant Information Please Print Le ibl ' Name(Business/Organization/Individual): ✓ r? k ��� ✓-} h'1.it Address: Foo,\,oyt.ch-{ VI1`ec,C�0W \LCIatJJ City/State/Zip: 5Q �"1 4 01 u`lP5ane.n: `-�)� —Sa�--��, 3 Arc YOU an employer? Check the appropriate boa: Type of project(required): 1.E�� �4 am a employer with 3 4. [] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole pi oprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8, C(Demolition working for me in any capacity. employees and have workers' 4. �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 l l.❑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' I3.❑Other comp. insurance required.] Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Hometowners 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 employers. 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. f Insurance Company Name: % Policy#or Self-ins.Lie.#: LJC(_ SCb J�C>\ 4 H_4'3 a O1 Expiration Date: (-Q— tp .loh 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. 1 do hereby certify under the pains and penalties of perjury 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: Perinit/License# Issuing Authority(circle one): I. Board of Health 2.Building;Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, 554, 1 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 15OA. Address of the work: The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant ':t�2 "— Date Signature of Permit Applicant SECTION 8-CONSTRUCTION SERVICES 8.1 619erlsCQnstruction Supervisor. Not Applicable 0 Igme of Licomm Holder: W\w-2\L- dS 3Li License Number Addresss� Expiration Date Signature Telephone 9.ftletemid Home tmdroveemeM Cant or: Not Applicable 0 �VA-IL+-1C--\--\ 9—, \h--e---tS 1 -3- gASI Company Name Registration Number Address Expiration Date Telephone 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...... 0 11. - Home Qwner Exemption ��.I�W.IIq��4 ���1 I■- 1 FYI 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.CUR 780. Sixth Edition Section 1083-5.1. 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 h%he sho be responsible for all sucb works.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 Vgy 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 acdtcable) New House ❑ Addition ❑ Replacement Windows Alteration(s) � Roofing r�--11 Or Doors [_] Accessory Bldg. ❑ Demolition LJ New Signs M Decks [❑ Siding 13 Other[[� Brief DescriptIT of Proposeq"`) Work: k -')'ecc:,� Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement _Yes Z No Plans Attached Roll -Sheet 6a.if New house and or addition to existing housing, complete the foliowina: 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, � u(7 , j71", �� ( � as Owner of the subject property , hereby authorize �+ v n,� 'A a \J '4""7 w C to act o y beh in all matters relative to work authorized by this building permit application. Signature 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 penalties of perjury. Print Name 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 % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location)'* A. Has a Speciat Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW O YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW U YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO a DONT KNOW O YES O IF YES, has a permit been or need It obtained f m the Conservation Commission? Needs to be obtained O Obta e O , Date Issued: C. Do any signs exist on the property? YES NO Q IF YES, describe size, type and loc on: D. Are there any proposed change o or additions of signs ' tended for the property? YES 0 NO O IF YES, describe size ty 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 vAH disturb over 1 acre? YES O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. r � �s ._ n � � Kp� _...... .. .. ... .� r# „'., F... 4r w `-i 6 *+1� D ., Department use only ity of Northampton Status of Permit: SEP 2 3 2015 ulding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Electric,Plumbing&Gas inspections Room 100 Water/Well Availability Northampton,MA 01 060 hampton, MA 01060 Two Sete of Structural Plans phone 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 W o©- c.'4v-� Map Lot Unit V10/L*nc"',P 1 c, VM o o t, Zone Overlay District Elm SL Distrlct CS Dlstrlat SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 22.1. Owner of R rd: Name(Print) Current Mailing Address: Telephone Signa re 2.2 Authorized Ascent: Name(Print) Current Mailing Address: .5 r k ✓t- d-�3 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION trOSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building � _ (a)Building Permit Fee la. RO CS 2. Electrical (b)Estimated Total Cost of LQ O c) Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) per,.0 -- Check Number Q This Section For Official Use Only Building Permit Number: Issued: Signature: Building Commissioner/inspector of Buildings Date File#BP-2016-0394 APPLICANT/CONTACT PERSON MARK SARAFIN ADDRESS/PHONE 42 Pomeroy Meadow Road SOUTHAMPTON01073 (413)527-7812 PROPERTY LOCATION 85 WOODLAWN AVE MAP 24C PARCEL 059 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid w0- Building Permit Filled out Fee Paid Tvneof Construction: REMODEL 2ND FLR BATHROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building-Plans Included: Owner/Statement or License 053434 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 mo 'tio ela Si re Buildi f icial 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. 85 WOODLAWN AVE BP-2016-0394 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C-059 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-2016-0394 Project# JS-2016-000627 Est. Cost: $18000.00 Fee: $117.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK SARAFIN 053434 Lot Size(sq. ft.): 10323.72 Owner: PAPORELLO LORI L Zoning: URA(100)/ Applicant: MARK SARAFIN AT. 85 WOODLAWN AVE Applicant Address: Phone: Insurance: 42 Pomeroy Meadow Road (413) 527-7812 Workers Compensation SOUTHAMPTONMA01073 ISSUED ON.912412015 0:00:00 TO PERFORM THE FOLLOWING WORK.REMODEL 2ND FLR BATHROOM 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 9/24/2015 0:00:00 $117.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner