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32A-241N me ra r y, C7 I- w h 1 lz;)rs�o QiT`-, S NvO6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self -insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each - year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 7-2010 www.mass.gov/dia u. The Commonwealth of Massachusetts Print i Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston, MA 02114-20I 7 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: rf e �i Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I - - employees -(full and/or part-time).* have -hired the sub -contractors - 2.� I am a sole proprietor or partner- listed on the attached sheet. - - ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.1 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. � New construction 7. Remodeling S. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section 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. 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 employees. 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. Insurance Company Name: C�iilQ E'(� 6Ck_J(GA-re (d ft- &A )L — Policy # or Self -ins. Lic. #: � ZS 1 �0 1 Expiration Date: A s_ Job Site Address: Y�S ��t��� � PPS` 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Phone #� 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 Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Name of License Holder: Supervisor: z ��� fJ "Ju Not Applicable ❑ 6 � — 019 � License Number, Address Expiration Date SignatureTelephone 9. Reallatered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address Telephone Expiration Date 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....... V No...... ❑ 1 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 Land State of Massachusetts General Laws Annotated. Homeowner Signature �.4 r'. 1 .`l`'., A Vie � ., SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) 21 Roofing ❑ Or Doors 1:1 Accessory Bldg. ❑ Demolition ❑ New Signs [tom] Decks [Q Siding [t3] Other [ol Brief De R on of Proposed Work: (11G11P.�C/' °]c� 0,, i�eoG J kdM-Mo(eatr e tblf�-FyrfinM. Scw�de��, Alteration of e)asting bedroom Yes V No Adding new bedroom Yes N Attached Narrative Renovating unfinished basement Yes 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. floodpiain _ 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 property � (� herebyauthorize kA to act on my behalf, in all ma relative to work authorized by this building permit application. 9--7A--I2 Agent hereby declare that the statements and information on tl and belief. Signed under the ms and penalti s of perjury. Us--{ ,) Print Name Date Yes No , as Owner of the subject , as Owner/Authorized application are true and accurate, to the best of my knowledge of Owner/Agjit 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 (5d� Setbacks Front Side Rear L: �(a R ? Ya T� Lt L:�_ \ Building Height v f0pou to \ Bldg. Square Footage % '� C Open Space Footage (lot area minus bldg & paved % \ # of Parking Spaces \ Fill: volume &Location \ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW O YES O IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW © YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW © YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained A , Date Issued: C. Do any signs exist on the property? YES o NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO 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 t IF YES, then a Northampton Storm Water Management Permit from the DPW is required. FAX JOURNAL REPORT TIME / 09/04/201 ^=86:00 NAME - ' ��N� ~ . --~ � FAX � SER.# BROL0F369914 NO. DATE TIME FAX NO./NAME DURATION PAGE(S) RESULT COMMENT BUSY: BUSY/NO RESPONSE NG : POOR LINE CONDITION / OUT OF MEMORY POL : POLLING RET : RETRIEVAL PC : PC -FAX use �""pT;pFBUI'�`"t"" MA01060� City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 413-587-1240 Fax 413-587-1272 s of Permit: Cut/Driveway Permit sr/Septic Availability ►r/Well Availability Sets of Structural Plans 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 i i S Wbe-s}feo Map Lot Unit rid rVMMe" 0 I M 01 D (00 4 ," Zone Overlay District Elm St. District CB District SECTION 2. PROPERTY OWNERSHIP/AUTHORIZED AGENT 2A Owner of Record: I homAS �calra, cc }} C� � t;e T I�tir- aw�ptUN M Name (Print) Current Mailing Add ss: Telephone rgnafure 2.2 Authorized Aaent: U04- Name (Print) Current Mailing Address: L,is Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ;A660 (a) Building Permit Fee 2. Electrical U,DO (b) Estimated Total Cost of �b Construction from 6 i 3. Plumbing 1,C.o0 Building Permit Fee g Q Q a 4. Mechanical (HVAC) 5. Fire Protection 6. Total = 0 + 2 + 3 + 4 + 5) © 00 Check Number This Section For Official Use Only Building Permit Number: Date Issued: !i U v Signatur Building Commissioner/inspector of Buildings Date 115 BRIDGE ST BP-2013-0162 GIs #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 241 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Pernut: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP-2013-0162 Project # JS-2013-000261 Est. Cost: $30000.00 Fee: $180.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin. JUSTIN HOEHN 099332 Lot Size(sq. ft.): 130244.40 Owner: HORTON THOMAS & SARAH K Zoning: SC(81)/URC(19)/ Applicant: JUSTIN HOEHN AT. 115 BRIDGE ST Applicant Address: Phone: Insurance: 233 WIISDOM WAY APT 1 (413) 475-3133 GREEN FIELDMA01301 ISSUED ON.8/13/2012 0:00:00 TO PERFORM THE FOLLOWING WORK. RECONFIGURE FOR HANDICAP ACCESS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Underground: Service: Meter: Rough: Rough: House # Driveway Final: Final: Final: Gas: Fire Department Rough: Oil: Final: Smoke: Building Inspector Footings: Foundation: Rough Frame: Fireplace/Chimney: Insulation: 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 8/13/2012 0:00:00 $180.00 212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272 Louis Hasbrouck — Building Commissioner