18C-141 (35) The Commonwealth of Massachusetts
.Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
Name(Business/Organization/Individual): Bonde Construction
Address: 205 Park Street
City/State/Zip: Easthampton,MA 01027 Phone.#: 413-529-2176
Are you an employer?Check the appropriate bog: Type of project(required}:
1.0x 1 am a employer with 2 4. [] 1 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 proprietor or partner- listed on the attached sheet. 7. modeling
ship and have no employees These sub-contractors have S. E]Demolition
world for me in an ci employees and have workers'
� Y� �'- t 9. []Building addition
f No workers'comp.insurance comp.insurance.
required.] 5. [] We are a corporation and its 30.0 Electrical repairs or additions
3_❑ I am a homeowner doing all work officers have exercised their 11.0 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.f No workers' 13.f]Other
comp.insurance required.]
*Any applicant that checks bolt#1 must aisa fill out the section belawshowing their workers'compcasation policy informatiom
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 mutt attached an additional sheet showing the name of the sub-contractors and slate whether or not those entities have
employem if the sub-contractors have employees,they trust provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees Below is thepolicy and joh site
information. .
Travelers'Insurance
Insurance Company Name:
3B985388UB 3/13!2016
Policy#or Self-ins.Lic.#: Expiration Date:
Jolt Site Address:. j��Q,F'�- , .F%I �..� City/State/Zip: Al';e�� y V 64,-,
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
Investitrations of the DIA for insurance coverage verification.
I do hereby cerfift under the pains and penalties of perjury that the information provided above is true and correct.
Si ature:
t k Date: ' 1 1
Phone#: 413-529-2176
Of ecia/use only. Do not write in this area,to be completed by city or town offzciaL
City or Town: Permit/License#/
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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 %
aDt area minus bldg&paved
#of Parking SeEM
Fill:
(volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DONT KNOW Q' YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW % YES 0
IF YES: enter Boon Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW er-YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES a NO �--'
IF YES, describe size, type and location:
E. Will the construction activity disturb(cl ring,grading,a cav acre,or filling)over 1 a or is it part of a common plan
that viii disturb over 1 acre? YEE V NO (9y r
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 6-DESCRIPTION OF PRQE=D WORK(check all applicable)
New House ❑ Addition ❑ eacernenttWWindows Alterations) � Roofing
Or Doors Accessory Bldg. ❑ Demolition ❑ New Sigma Decks (❑ Siding V) Other jq
Brief Description of Proposed 7"t'Z % 1-S
Work:
Alteration of e)asting bedroom Yes ✓No Adding new bedroom Yes Flo
Attached Narrative Ronovating unfinished basement Yes No
Plans Attached Roll -Sheet
rrrs rr��
on. If New house and or adfrl w to exMiria housing. Coll pLefe the fcftKing:
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. Mas3check Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 it 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.
1. 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, 1 Vo l–A J( JaA.�2-- ,as Owner of the subject
property
hereby authorize
to act on be ,in all matters rel authorized by this building permit application.
Signature of Owner Date
l — A bn ye" _ MxL ,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
ature of erl
Date
City of Northampton Status of Pent:
---- Building Department Curb Cut/Driveway Permit
212 Main Street Sew dSepticAvailability
Room 100 Walw/We ll Availabllity
NOV 1 7 >?� orthampton, MA 01060 Two sets of structural Plans
� o e 4 3-587-1240 Fax 413-587-1272 Plot/Site Plans
DEPT pc c�JlLGtNG INSP' Other Specify
APPLJCA Wo TRUCT,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
�LaMtx�Ci"�(' Map Lot unit
"jIweam vo, Zone Overlay District
+t�f£��-ti►st�PTZ 1 Elm St.Dhddde CS ptstri
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam�nt) Current Mailing Address:
Telneepho
Signature
2.2 Authorized Ascent:
>A a F
Name(Print) Current Mailing Address:
4%3 5ZA-Z�l`T rte_
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (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 Check Number Ovb
This Suction For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building CommissionerAnspector of Buildings Date
File#BP-2016-0674
APPLICANT/CONTACT PERSON MARK BONDE
ADDRESS/PHONE 205 PARK ST EASTHAMPTON01027(413)535-9529 Q
PROPERTY LOCATION 56 FIRETHORN -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 97 ca
Building Permit Filled out
Fee Paid
Tvpeof Construction:_REPLACE KITCHEN CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 67758
3 sets of Plans/Plot Plan
THE FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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
Demolitio ay
T
Signs ure of Buildin O ficial 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.
56 FIRETHORN -680 BRIDGE RD BP-2016-0674
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-2016-0674
Project# JS-2016-001126
Est. Cost: $5000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK BONDE 67758
Lot Size(sa. ft.): 1497897.72 Owner: LATHROP COMMUNITY INC
Zoning: Applicant: MARK BONDE
AT. 56 FIRETHORN - 680 BRIDGE RD
Applicant Address: Phone: Insurance:
205 PARK ST (413) 535-9529 O WC
EASTHAMPTONMA01027 ISSUED ON.11/19/2015 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE KITCHEN CABINETS
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 11/19/2015 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner