31A The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov1dia
Workers' Compensation I nsu r anceAff i davit: Builder s/Contr actor s(Electr icianstPl umbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
I icyve c'Q_(T-K
Address: Mey
City/State/Zip: Phone
Are you an employer? Check the appropriate box: Type of project(required):
1.[2!R am a employer with 4. 7 1 am a general contractor and 1 6. 7 New construction
employees (full and/or part-time).* have hired the sub-contractors
2.E] I am a sole proprietor or partner- listed on the attached sheet. 7. 7 Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 1 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 131� Other
employees. [N o workers
comp. insurance required.]
Any apps icwt that checks box#1 must also fill out the rection 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.
$Contractors 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 providetheir 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: h illi Mirf kAl
Policy 9 or Self-ins. Lic. #: to Expiration Date: 10
Job Site Address: 00_e_ City/State/Zip: o mv\PV0 o ti D
Attach a copy of theworkers' 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 hereh c rtify der the pain alties of perjury that the information provided above is true and correct
Sianaturel 7 ___41 Date: IN
Phone#: i3 5 3 2 -5T-113
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 5.Plumbing Inspector
6. Other
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.
Address of the work: .�\ a-�
The debris will be transported by: P�-Qo L- kc-
The debris will be received by:
Building permit number:
Name of Permit Applicant pa t b my)LJZ'N
Date Signature of Permit Applicant
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: l Not Applicable !
Name of License Holder: ,{�� 0-s-
Licensee Number
Address Expiration Date
Signature Telephone
9.Registered Home Improvement Contractors NotApplicable !
R`l St PrT ST CA--r'�- L?.K..) o A-�
Company Name Registration Number
Lcr k I \^6 � 2C7
Aress Expiration Date
Telephone G lQ 53 �1�
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......
11. - Home OWner Exemption
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 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 applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 57Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [❑ Siding Other[QJ
Brief Des�,gr'iption of Proposed _ n
Work: {"�rn�t►_ c�R riles lCc��t.�b ,,l74( �7AmA � 3I{J�3
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
8a. if New house and or addition to!existinca 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
l .�c`F F 12Z—it4-4\SmE 3> as Owner of the subject
property
hereby authorize 0)P"ZA
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, Mom MtaY 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.
gned under the pais penalties of perjury.
V t Name
M hie 1-0 ft}
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 Heights Nµ
Bldg. Square Footage % ...,.,. _
Open Space Footage _, %
(Lot area minus bldg&paved
parking)
#of Parking Spaces -- rv-
Fill: F
(volume&Location)
A. Has a Sp ial Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW a YES 0
IF YES, daa issued-
IF YES: Was the permit recorded at the Registry of Deeds?
NO r-10 DON'T KNOW 0 YES 0
IF YES: enter Book .uA „~µ .„._.,.... Pagew. .. and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 Date Issued: _. w
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NOO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excmvation,or filling)over 1 acre or is it part of a common pian
that will disturb over 1 acre? YES 0 NO -(;�r
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Department use.t7nly
City of Northampton F,, ,,-.
s.,of'Pen.nit:,
Building Department Cut/Driueway Permit212 Main Streetr/SePtlb, Vailabilily>
Room 100Watt?r/1Ielllluairability
Northampton,.MA 01060 Two;Setsof'Structura►Plans1`
phone 413-587-1240 Fax 413-587-1272 ProtLSite Plans
er S cifj!
APPLICATION TO CONSTRUCT,ALTER, REPAIR, ENOVATE OR DE OLIS H A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION NOV 2 8 2018
1.1 Prooertv Address: This sectio to be completed by office.
DEPT.OF BUILDING INSPECTIONS i 15~ /
Q_-c) NORTHAMPTOIM!l1�41060 Lot: Unit
I )1)1zafi Iq M PTbrj MR
Zone Overlay District
Elm St.District- CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
F 1`Q c�/ G Lrv1 sTE 7�'\ YYl>A'itl� 2� �N per, v 11'►q
Name(Print)
Current Mailing Address:
Signature
Telephone
2.2 Authorized Agent:
M W3 MA&)Lt cok 6NGPEsc < �ct� � � �to�3
Name(Print Current Mailing Address:
Signature _T
Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building
tl7 Z SU (a) Building Permit Fee
I
2. Electrical (b) Estimated Total Cost of
3. Plumbing
Construction from 6
Building Permit Fee
4. Mechanical(HVAC)
5 Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2019-0638
APPLICANT/CONTACT PERSON BAYSTATE RESTORATION GROUP
ADDRESS/PHONE 69 GAGNE ST CHICOPEE (413)532-3473
PROPERTY LOCATION 31 MAYNARD RD
MAP 3 IA PARCEL 151 001 LONE URB(100
THIS SECTION FOR OFFICUL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fge Paid
Building Pprmit Filled out
Fee Paid
T)mNf Construction: FIRE REPAIR ON GARAGE ROOF AND SIDING,REPLACE DAMAGED STUDS
New Construction
Non StWctural interior reaQvLtions
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 056785
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)
le�
PLANNING BOARD PERMIT REQUIRED UNDERI
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
D=oliti2n Dcla*
Sightle-o'fBuil dmg(5fflcial 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.
31MAYNARDRD BP-2019-0638
GIS#: COMMONWEALTH OF MASSACHUSETTS
—Map�Rlmk;31A- 151 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
CategM: REPAIR BUILDING PERMIT
Rgrut# BP-2019-0638
Project# JS-2019-001040
Est.Cost:$10250.09
Fee:S§6.OQ PERMISSION IS HEREBY GRANTED TO
Cqnst,CWs:
Contractor, License.
Use fir,mR: BAYSTATE RESTORATION GROUP 056785
Lot size(sg.ft.): 7927.92 Qwner., OLMSIE&2 MFEREY S&JULIE G
Zoning:URB000V Applicant: BAYSTATE RESTORATION GROUP
AT: 31 MAYNARD RQ
Applicant Address: Phone: Insurance:
69 GAGNE ST (413) 532-3473 WC
CHICOPEEMA01013 ISSUED ON.-1211012018 0.-00:00
TO PERFORM THE FOLLOWING WORK.-FIRE REPAIR ON GARAGE ROOF AND SIDING,
REPLACE DAMAGED STUDS
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 Nl!aLtm0j Fireplace/Chimney:
Rough: ot 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 Occugangy Signature:
FeCIERe: Date Paid: Amount:
Building 12/10/20180:00:00 $66.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner