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31A-047 BP-2024-0632 249 CRESCENT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 31A-047-001 CITY OF NORTHAMPTON Permit: Addition PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit# BP-2024-0632 PERMISSION IS HEREBY GRANTED TO: Project# ADDITION 2024 Contractor: License: Est.Cost: 415000 MICHAEL MACDONALD 60750 Const.Class: Exp.Date: 05/19/2025 Use Group: Owner: CHEN,HENRY&SKYLER TREAT Lot Size (sq.ft.) Zoning: URB Applicant: MICHAEL MACDONALD Applicant Address Phone: Insurance: 7 SHAW LANE (413)250-8943 HADLEY, MA 01035 ISSUED ON: 05/17/2024 TO PERFORM THE FOLLOWING WORK: EXPAND 3RD FLOOR, 2 STORY ADDITION 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: Final: Final: Final: Rough Frame: Gas: Fire Department Driveway Final: Fireplace/Chimney: Rough: Oil: Insulation: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: 1/2_ Fees Paid: S2,698.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Office of the Building Commissioner cep r, , ,,...a c,c,6..4,0 , r------ ---________-1 li i ' • 1 ftr Nia i f ` j s MAY 1 2024 sts The Commonwealth of Massachusetts 'r Board of Building Regulations and Standards ; -:,.1. F( Massachusetts State Building Code, 780 CMR -pd.,ar-suit f"_, rl, t,,ruqkia.ALITY ,. 0106if Building Permit Application To Construct,Repair, Renovate Or Demolish a 7i'et'/.red Mar 20// One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: 6 P. �-e/� Y i )— Date Applied: 44--7, os s i /Z 5-r7 2,029 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 249 CRESCENT ST, NORTHAMPTON MA 31A-047-001 l.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Pr erty Dimensions: R 11068 69.86 Zoning District Proposed Use Lot Area(sq fi) Frontage(II) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 20 30 15 8.5 20 75 1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Private❑ Zone. _ Outside Flood yesO Zone'? Municipal 0 On site disposal system 0 Check if yes SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: HENRY CHEN, SKYLER TREAT NORTHAMPTON, MA Name(Print) City,State,ZIP 249 CRESCENT ST 571-294-7617 '"henryechen@gmail.com No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building® Owner-Occupied III Repairs(s) 0 Alteration(s) 21 Addition LID Demolition 0 Accessory Bldg.bd Number of Units Other 0 Specify: Brief Description of Proposed Work2: EXPAND EXISTING 3RD FLOORWITH NEW WALLS AND ROOF STRUCTURE, 12'X12' 2-STORY ADDITION TO THE BACK OF THE HOME REMOVE WOOD DECK SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1.Building S 350,000.00 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical S 20,000.00 0 Standard City/Town Application Fee Cl Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 15,000.00 2. Other Fees: $ 4.Mechanical (11VAC) $ 30,000.00 List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ /�Check No. 13) $ heck Amot ;to ash Amount: 6.Total Project Cost: $ 415,000.00 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS-060750 5/19/2025 MICHAEL MACDONALD License Number Expiration Date Name of CSL bolder 7 SHAW LN List CSL Type(see below) U No.and Street Type Description HADLEY, MA 01035 U Unrestricted(Buildings up to 35,000 cu.R.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 413-250-8943 1MSMBUILDERS@GMAILCOM I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 121690 10/28/2024 MICHAEL MACDONALD HIC Registration Number Expiration Date HIC Company Name or IIIC Registrant Name 7 SHAW LN 1MSMBUILDERS@GMAILCOM No.and Street Email address HADLEY,MA 01035 413-250-8943 City Town,State,ZIP Telephone SECTION 6: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 la No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize MICHAEL MACDONALD to act on my behalf,in all matters relative to work authorized by this building permit application. HENRY CHEN 4/2/2024 Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. MICHAEL MACDONALD 4/2/2024 Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the!ITC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at ww•w.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms __ Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" City of Northampton r • ff Massachusetts ti . '4 HS L DEPARTMENT OF BUILDING INSPECTIONS y 212 Main Street • Municipal Building 1 !O� Northampton, MA 01060 L. CONSTRUCTION DEBRIS AFFIDAVIT (FOR ALL DEMOLITION AND RENOVATION PROJECTS) In accordance of the provisions of MGL c 40, S54, a condition of Building Permit Number is that all debris resulting from this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A. The debris will be disposed of in: Location of Facility: USA WASTE The debris will be transported by: USA WASTE Name of Hauler: MIKE MACDONALD Signature of Applicant: Date: 4/2/2024 CITY OF NORTHAMPTON SETBACK PLAN MAP: LOT: LOT SIZE: REAR LOT DIMENSION: REAR YARD SEE ATTACHED SURVEY PLAN SIDE YARD SIDE YARD FRONT SETBACK FRONTAGE * _ N 04'32'W w 87.80'— stockade teats _'- ASSESSORS PARCEL 10 .- 31A-047-001 HENRY CHEN a SKYLER TREAT W 2 1 'X SEE PLAN480CK966, P46,PAGE AGE 8 :� s LOT AREA e Y 11,068± SQ. FT. 0 S OS'38'2Y E I t 1 .12.39' Remove existing deck •�`f`..., a Proposed 12'.12'2- story odd'rtlon II.1 a s' \ 6s Q 0 ii PI :::.- :\\\\\\\\n" 4 le I ee L-J O r 2 69 8Y 70.03' a —S O416'00"E 69,86' 70.55' 89.96' CRESCENT STREET "EXISTING CONDITIONS" PLAN OF LAND IN NORTHAMPTON, MASSACHUSETTS PREPARED FOR HENRY CHEN AND SKYLER TREAT SCALE: 1-,-20. MARCH 29. 2024 LEGEND i31,t( HAROLD L. EATON AND ASSOCIATES INC. O FOUND IRON PIN 888I � 2 )" REGISTERED PROFESSIONAL LAND SURVEYORS • IRON PIN TO BE SET 235 RUSSELL STREET - HADLEY - MASSACHUSETTS e UNMARKED POINT 413-584-7599 413-585-5976 (fax) email - hleotonCool.com 0' 20' 40' 60' 1' 1111111111111 1111111111 1 IiH (I�!!1 b �,- II I—i-1 IlIIUIIII� ', ,'I Ii11111o. l l Mik illhI:1llhiW 1Ft lilies lil Iit ar 1 1mi 1 Ip t w 1 . ,.� �I IMI 1 11 •IIIII�11111�IIII�IIIN�ll i I II III I II,IIIIIIIII..11111,111F.1 1 , .. b 4- _ i!1 I i IT, w i .T.agi 1 T I.ta.61,r i !.«. -, 11111111 II .I ffrff II..1111 ill IMMINIMY a I!' 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' JAN 2024 • ��,..�.,�,..�,.�.,•�..•�;..•�.•�.�,.,•��..•�,,..•�,,..•�..�,..�..�...��..•�.•�..•�,r.•�..•�,,...�,..•�..•�.:�,,.'�,..� CEILING FRAMING IIIM»o• •LLD'',M w4 .b.a'- ••", rtarcfr exrsnnrG neirauoRa rnr D.I A o AGG w!A b•PIS►.:.• We.w*A4a DAM/•Hr ru'z aeLL WPC..u: 0.CM22 GILL M.]•..A.1•044 I Z �/Y KC'NOC< Y,.•L M,CWiGrpA 4P O &04 OP r NA,. 1i OULT41P.C40A f` MI 1,A14GK•,FC. MW/.HT A+G SAWN RJD MOW.GA•NO AA••]48•LOrO . MTAL.1A6.4`.f. II e.IFro ANO I,O{ILATION F . s• Y•OJPu Or SAVE 44.4044.0 II I�•,R•�,1���V�V0/I • MKs]p ap9 BACKER Rooms } `••••G• ,. -''' TIMI1111IIfl11HN i A..Mo....4..w•I� A M 2y �..TA.A•A•A•AAA•A•A•A•A, 3 rowww.a:vHn.SO.,w I _ -- ---- :•:w�...t o. I__ 0I1'tat C.LlMG MILD,N• i ]�,C4 YJ LMRtA 44. Ttw _ Df1 tAl PL41� tit OWL SO.* vl,.WA.tY�Q•4L 1 ...4.144.44.0.40 MOMS rvt.'LP tYLL P.C.* N4 '. 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FINAL WINDOW SIZES AND P<ANUFACTURER 1.... SHALL BE DECIDED BY OWNER•CONTRACTOR Q AMER AporioN IS CONSTR�.CTED T{ a REMOVE 8L DER STALL p05 E II'.re'LVL SEM A ` 6 AND REMOVE WALL THEN PA'C 4 Z lr lr v �o 4 ♦— .:I a •4 f •,, 4 REMOVE SONG I,'. . DECK 1 . t�,l I' T*.K.4 D.&DNa o-*eeoP...AL.. 2 S IYMTL=CNTONILL wo66 Q .W DFW4L 4 ♦ _ I o.o.O. (NR� 000 CtL enu N 4TN V Y et. O O.TW4L I z,.. .'4, ♦ L PLEASE NOTE �m ANON ALL D/MENBIONS ARE TO BE FIELD VERIFIED SINCE 6'O' j G.o' EXACT OVERALL DIMENSIONS MAY NOT BE EXACT REMOVE DECK.eiAne6 li n'o AND THE FACT THAT EXISTING BUILDINGS ARE NEITHER n•-y d Fea- veg.,- PLUMB NOR BQ h4RE AD,LIST ALL DIMENSIONS AS Pa.n4TaN*o.wm.wN ADDITION - SECOND FLOOR PLAN NEEDED TO FIT FOR THE NE//CONSTRUCTION. EXISTING CONDITIONS 4 DEMOLITION• i U :ZDI ` I SSA`!ASOvi I F 8(RI N46 DAMNS,CONSTRUCTION. 11 I THE NM)WALL SHALL GS CONSTRUCTED 60 10 BAND J016T I T I NEW DRYWALL ALIGNS urn.mt.6TING WALL .11111,111 9 El REMOVi AL1.SIDNG 1Rna Ex:STING FOUNDATIONX CA 1.11 TRIFLE.,=lo JOISTS IIIIIIIIi _ az y is Otr . TTM+c4L x.WWI U EFFON w •y 2=10 BOOR JO'STS•'6'c.c. Tr���. M'L.+OFSP1=4 6DM6 p 6 uiv 4 n.x•DPy4LL w••r.0 » a �.Tloe•u'o.e. MID SPAN 0.0CKNiG ! 9 2OeN CALL ent.LI nlLLATLTI 9 V vY ORYW4.L a \ . —..._ -_-_-- APED•s4rn® I 'RIPL6?a•0 J018'e k [1 I .w j .�.� .l VI T T �( i. 6 FIELD VERFY i.-..ir FIELD V6R�FY q ADDITION - FIRST FLOOR PLAN ADDITION - SECOND FLOOR FRAMING PLAN !i Ex.S•NG F',.80ATION acaveT o ,•.i-. .1,....,..�. TWO ► 2.a DAND iDeT P �e' .InavEL a®� Q17 ereTNG FouNDATIoN Ww^• a e l �crr, TRIPLE a I0 ro 6T6 ♦ 1/4'.1'-0' 9 0.�Poe*JP•o w OCR o e*e RPLE P.. z MA"7 FT.LONG "'• O 6,4 P.T.POST ---• D110 FLOOR.O•STS•16`0.4. EZ4N�'4'SEDUM= n0 SPAN BLOCKING Q uJEGNT Teo 06.EICAIT S4.6'a 8'TOP .6 SASE STE IS 2 FOOT SOUARF LOAD CAPAG:TY IS.000 LDS. 'RIPE.[2.f0 JOISTS P06 UP u✓6x6 P.T.POST .. ... . CHECK T THIS DMENS ON. l 1 1 I, { x r xCCT 6• '2•,O. 6• THE NSI DRYWALL ONTO THE NEW III FIELD VER,0Y .y T-RT THE bXID WALL 16•DRYWALL. ALIGN SO THE EXISTING DRYWALL.SEE MOVE �pl��.l�l/�I PAST PLOPS NOTES.vERIFY SY SOME FIRST FLOOR FRAMING PLAN FOUNDATION PLAN DIbTRucrve eoRIN�INTO WAu Ai,V16.24 PLEASE NOTE ALL DIMEN8/0N8 ARE TO HE FIELD VERIFIED SINCE EXACT OVERALL DIMENSIONS MAY NOT SE EXACT AND THE FACT THAT EXIBT/NG HU/LDINGS ARE NEITHER PLUMS NCR lQIA4RE AD.WT ALL DIMENSIONS AS 0Q ,", NEEDED TO FIT FOR THE NEW CON87RUCTIDAL • 26-0 g Y o r---�-y s to it \ \ \ \ - ao' so'.ea' sc'.ea' so'•.o ra' N-_ r--.•-•••�t y t --t e--� k \ \ (U JED Dd +ROCtf L � q ' 9' e y z Fr Qi. J va GUEST Z MEDIA ROOM o e W 'r z BEDROOM } 1 o i Q as OV R - HALLWAY m Q A `A 19 t Z III emrt:: j r"--. .. "."'"'T 3. v o 4 ' OFFICE "'' -a.STORAGE \ I c .. -- L t A IL. \ \ ao'..r� es�,.7'oyI \ \ \ ti acarsarn T" 1 Q GC auwer 6 I/4'•I'-0' SW', 1 1t[OM s s' sy' 0 :r_,y e.0. 0 AO/2023 aa"T 1 / 36-0' e 1=1(...- f t File #26 APPLICANT/CONTACT PERSON:MICHAEL MACDONALD 7 SHAW LANE HADLEY, MA 01035(413)250-8943 PROPERTY LOCATION 249 CRESCENT ST MAP:LOT 31 A-047-001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: ?ERMIT-_APPLLCATLON_CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Building Permit Filled out Fee Paid $30.00 Type of Construction: EXPAND EXISTING 3RD FLOOR AND ADD 2 STORY ADDITION ON BACK OF HOUSE PER ATTACHED PLANS New Construction Non Structural Renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan Driveway Grade% THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: Approved 1/ Additional permits required(see below) For all projects that need additional reviews Cw��.E as checked below,please see the Office of Planning&Susta inability Permit page or scan here - 1. PLANNING BOARD PERMIT REQUIRED UNDER:§ r 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: § 350 - % 3 (.7/(2) Finding Special Permit Variances v(t SIGYATtx2i. 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 �� Demolition Delay // & LI 8-2ozy Signature of Building 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 ranted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning& Development for more information. File No. 7--Co Ck 4' y 30. 0 ZONING PERMIT APPLICATION (350.4.4) Please type in this fillable PDF or print and hand-write all information and return to thO3uilding Inspector at the Building Department (212 Main St.) with the $30 filing fee by check and money order (payable to the City of Northampton) or credit card (in person only). Name of Applicant:Michael MACDONALD Email: 1 MSMBUILDERS@GMAIL.COM 1. Address:7 SHAW LN HADLEY MA Telephone:4132508943 2. Owner of Property:HENRY CHEN, SKYLER TREAT Address:249 CRESCENT ST, Ll1I ST, NORTHAMPTON Telephone:571-294-7617 3. Status of Applicant: Owner u Contract Purchaser Li Lessee Other (explain)CONTRACTOR 4. Job Location:249 CRESCENT ST NORTHAMPTON MA Parcel Id: Zoning Map#3I19-01/7-001 Parcel# District(s): In Elm Street District In Central Business District (TO BE FILLED IN BY THE BUILDING DEPARTMENT) 5. Existing Use of Structure/Property:SINGLE FAMILY HOME 6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary): EXPAND EXISTING 3RD FLOOR WITH NEW WALLS AND ROOF STRUCTURE 12'X12' 2-STORY ADDITION TO BACK OF HOME remove wood deck 7. Attached Plans: Sketch Plan 111 Site Plan 111 Engineered/Surveyed Plans El 8. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO LJ DON'T KNOW El YES 111 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 111 DON'T KNOW 111 YES I 1 IF YES: enter Book Page and/or Document# 9.Does the site contain a brook, body of water or wetlands? NO I6 I DON'T KNOW El YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained El Obtained , date issued: (Form Continues On Other Side) t 7/2023 10. Do any signs exist on the property? YES Ell NO El IF YES, describe size, type and location: Are there any proposed changes to or additions of signs intended for the property? YES El NO 111 IF YES, describe size, type and location: 11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan of development that will disturb over 1 acre? YES NO l l IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION This column reserved for use by the Building Dept.only. EXISTING PROPOSED REQUIRED BY ZONING Lot Size 6954 6954 Frontage 69 69 Setbacks Front Side L: 8.5 R: 8.5 L: 8.5 R: 8.5 L: 8.5 R: 8.5 Rear 80+/- 75+/- Building Height 35 38 Building Square Footage 3471 3871 %Open Space: (lot area minus building & 7768 7768 paved parking) #of Parking Spaces 5 5 #of Loading Docks O O Fill: (volume & location) Driveway Grade% 5% 5% 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. 4/2/20 � ' Date: Applicant's Signature NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning requirements and obtain all required permits from the Board of Health,Conservation Commission,Historical Commission and Architectural Boards,Department of Public Works and other applicable permit granting authorities. 6/7/2023 The Commonwealth of Massachusetts t''===7 =.,, Department of lndustrial.Accidents 3Rt= I Congress Street,Suite 100 :,.= -" Boston. ,1f:A 0?l/4-201 www.mass.goWdia Workers'Compensation Insurance Aflidasit: Builders/'ontractorti/Eketricians/Plumbers. to 1#:E t1.FU 51 tTH 1 HF.PERM I I l INC AUTHORITY. Aanlicant Information Please Print Leeibts Name tHusittcs Organization. gTMICHAEL MACDONALD,DBA MSM BUILDERS S. Atoms: 7 SHAW LN City/State/Zip: HADLEY,MA 01035 pie#: 413-250-8943 Are yea an rmpbyet?('ierk tie appropriate bow project Typeof (required) t.®I am a employer with 1 cmpluaaes(full ardor part-time)-• 7. CI New construction 20 I am a sole pnipm:tut or purtnerahip and have no employee,w otkmg rot roc in S. ®Remodeling Any..rpavtta-INu%mixt,'rump.tmuranai maimed{ 9. 0 Demolition ?..0 I sin a liontizawinct diwny all work myxll.{No winker.`comp imuratue regnant)" 10®Building addition 4 Q t am a hunsa>w nee and*di 6c hiruu,nntun.tor,to conduct all work on ma mopesta- I aril �"'� ensure that all comma-ton either have k `con ns ipcatjcvi insurance tat ate mile 11.�J Electrical repairs or additions prupneturs wain no ampluaxn 12.0 Plumbing repairs or additions 5.173 I atn a general.umttxtur anal I has c hired the soli-cunuactun tested on the attached art 130 Roof repairs ihasc soli-cuntractats hasa etnpluycea and has a workers"comp.ttninunce.. 14.0Ot er n D Vac We a crrrprxattun and its of kayo have oxen at.a d thou right of exemption pet kith.c. 15'2..ii41.and we halt no employees.(No workers'comp-inaurance minimal 'Ana applicant that clt.Yks box aI aunt also till out the section below alto%ing then wurkcrs"coniptmatttrun policy utfurmatatwt $Homeowners who submit this*Minn indacating thkcy at d<nng all work and then hut outside contra torn must suhn it a new atftdas at tedi.utang such *C.untractun that check the.box roust attached an additional.hest,bus*tnr the moat:of du:-auk-ctmtrs.iters arul mate w he-thcr or nut thew cathlac.lust empkarr. It the wlrcunuastor,hose otjsloa no.trues taus,ptui aJc that ,,,otkcra':.,rip tads..Ilunatyt I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site information. Itr,ur,nrc otttpany Name: ATLANTIC CHARTER INSURANCE COMPANY Poitc} =or Self ins.Lie.#: WC100099912 Expiration Date: 5/12/2024 Job Site Address: 249 CRESCENT ST City/State/Zip: f SIa Zip: NORTHAMPTON,MA Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MILL c. 152.*25A is a criminal violation punishable by a fine up to SI 500.00 and'or one-year imprisonment.as well its civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator.A copy oftins statement nsay be forwarded to the Office of Investigations of the DIA for insurance coverage serthcation I do hereby certify under the pains and penalties of perjury that the information provided above ' true and correct �o z y Ss atom: Date: phone#: 413-250-8943 Official use only. Do not write in this area.to be completed by city or town official City or Town: Permit/license k Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other i Contact Person: Phone l$: