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24C-076 (6) BP-2024-0921 24 MASSASOIT ST COMMONWEALTH OF MASSACHUSETTS Map:Block:Lot: 24C-076-001 CITY OF NORTHAMPTON Permit: Alts Renovations Repair PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Permit # BP-2024-0921 PERMISSION IS HEREBY GRANTED TO: Project# 2nd floorreno 2024 Contractor: License: Est. Cost: 76000 BRIAN WORGESS 106973 Const.Class: Exp.Date: 03/31/2025 Use Group: Owner: PAMELA ROSEN Lot Size (sq.ft.) Zoning: URB Applicant: BRIAN WORGESS Applicant Address Phone: Insurance: 680 BAY RD (508)680-6271 AMHERST, MA 01002 ISSUED ON: 07/19/2024 TO PERFORM THE FOLLOWING WORK: CREATE A PRIMARY SUITE OUT OF 2 BEDROOMS ON 2ND FLOOR 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/./P Fees Paid: $570.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Office of the Building Commissioner ' I� c, ifl The Commonwealth of Massa use , l v 41 Board of Building Regulations a d Sta•dard�-4 ip FOR 1, R f 8 0.', UMr PALITY Massachusetts State Building C , SE O� r. Building Permit Application To Construct, Repair, R• : : iritb Iemol Ta Rev•.ed Mar 2011 One-or Two-Family Dwelling t"'To'O/NsA This Section For Official Use Only ti'40 C7%oM9 Building Permit Number: 3$")-H_ 91( Date Applied: e:oioki 145 /7/Z-- 7-18-agy Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: _ 1.2 Assessors Map& Parcel Numbers Pro SSa so S , 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Public 0 Private 0 Check if yes❑ Municipal Won site disposal system 0 SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: 1 A 1 PawlLI 't prise• f AwdrettJ klooSte[Yv1 in/ /iof4R�10-a,l , fYl4 O106O Name(Print) f City,State, ZIP � 0? y rn6sSel Sot�i S4 (ql�) (pis- 1 J(s-�' pqm r` se,4egmoli is co/Ih No.and Street Telephone Email Address J SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 0 Addition 0 Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify: _ Brief Description of Proposed Work': 1C-Ce... +-G o. peg rna cm S 1( e o c) - D4 2 (7t c. oo S ,nvJ T' CctcayJ E- I' - Q SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building $ SOl Ooo 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ 0 Standard City/Town Application Fee 5,LOO 0 Total Project Cost3(Item 6)x multiplier x 3. Plumbing $ of 000 2. Other Fees: $__._ 4. Mechanical (HVAC) $ 3/ 00o List: 5. Mechanical (Fire $ Suppression) '0 Total All Fees: } ^� " Check No. / skheck Amotuti.' 51 Cash Amount: 6.Total Project Cost: $ / coo 0 Paid in Full 0 Outstanding Balance Due: hl SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS - /O 6 R7-Z 03 3 20-2-C £ (� i Vi fJ vJ�oe CS License Number Expiration Dat Name of CSL Holder e i3A , O` , List CSL Type(see below) U No.and Street �.! Type Description ()al I`t ,S 4 (I Y) 4 0 r or)-2.or)-2. 0 Unrestricted(Buildings up to 35,000 Cu.ft.) Restricted 1&2 Family Dwelling City/Town,State,ZIP) R y M Masonry RC Roofing Covering WS Window and Siding /G SF Solid Fuel Burning Appliances (S035 /Q—cpz?) 6y;grtle 7-gl erS I Insulation Telephone Email address Ou, 1 riji D Demolition 5.2 Registered Home Improvement Contractor(HIC) t•neo Q►►� , I i L IoING�S5 10�Zoe l3 o HICr Co►�panx Name or IC Registrant Name HIC Registration NumberEx i Date U1qki K , , , 6rran le 7515)-c„‹16cicic)1, ,442 No and Street Email address 1-1 eh -f, ✓n/9- Woo (.co )d6�o-4,Z / 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 I` 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 to act on my behalf,in all matters relative to work authorized by this building permit application. ...y 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 st of my knowledge and understanding. a(\' N W oro e S5 L ��en e y_pco/Z y Print Owner's or Authorized Ant's Name(Electr nic Signature Dafe NOTES: 1. 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. 142A. Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.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" -41 __ SECTIONS. ( ()\sIItt ( TIt11SIIT\ I( I \ 5.1 Construction Supervisor License(CSL1 j l(�2�<::S .6 F fJ �� nhcr l..rtt•mtwt U_f. Sam:oft vI II.,Lk ,/ I�,t( �I I tx l.ce ixi.:, • \•. nd sir,' ',,I,c Deuxirrton ,1i( l .r ,- a 11-) Fl C)r 002.. 1 nre,trtctrxitl)wlJtn r_t.r I_<,WOeu It t R I(tstricted Inc..-I;unrl t)ttellm, ___i t KC I(u.ttin. (o%Crttt` __________ - ___ %I s \I tntim and N!J1,. ._. Si .did Fuel(Fuming lrrlianccs 1 (;ic_i—,:: 2-f Jr ,Pot— r. I Inautautm . __...1—. _.. I m,Ll,,JJrc,, L Lil a::/ 1/ Demolition __...__ ._ _ 5.2 Registered Home Improvement Contractor(HIC) zznWI- G z�3t gr\I V J 0 �2 S ' / ?' Iik III(; .Nature,•r,III( Regiurant\artte r Ni 0.i — 0 PK-- t fran) - 7�f54%--. 1di, ,cc \,�_and ut,' t mill jJJresi C_it•• I owwn,State,/IP 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.., l3/ No 0 SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED W HEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize g('A/1/ I• O( to act on my behalf,in all matters relative to work authorized by this building permit aication /1 Pamela Rosen &Andrew Kloostermanb July16,2024 `tom'__ _ Print t)'.,ner-'s-Name i Electronic Signatutrl j — — [}�c SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION Ely 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 .st of my knowledge and understanding. , Of`A/V 0 Idooles Print TM net',or \uthoriredt's Nagle th:Iccc snit:Signal[. :o Al• _ l)arc NOTES: . _.____ _____. I An Owner%%ho obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(111C)Program).will not have access to the arbitration program or guaranty fund wider M.6.I c I42A.Other important information on the HIC Program can be found at ca Information on the Construction Supervisor License can be found at����\t n;t- ,.;n�, 0..1�L _�_ _ 1\hewn substantial work is planned,provide the information below i t'tal floor arm tsq. 11.1 _ .__(including garage.finished basement attic..decks or porch) (gross living area i sq 11.1 . _ .. - _ I Iabitahk room count Number of fireplaces Number of bedrooms Number of batlirmuns Number of half'baths I YPe of ltcaimi.!\>•teirt Number of decks porches I ype of emoting '•y,tctn Enclosed ()hat "I utal Prolix( 'stitiare I-ovtace•'may he substituted for"I otal I'roiect( 0•1" i hc:t. t,nuni'mstahh 4V) '11a„at.iit ,rit, I3ctard ul 11uiidtnt: Reuidatttui, and Standard, i r tR !`4 III S'( It,;hi 1 FN. °a :_ f \iacachu,eu Simi. Buildw ( ,+clr. 780 lAIR 1 ' 1 liuticlrne I'rnntl ,\ppltk:ation I i)(-twist r'Lt. Repair. Renovate Or I)crn,,tiih a a,:0,'-1 tf..r:.)r (hne- r,r 7itr,-I await 1),teiIg:�' ihis section 1 or Otiicial I ( ,Pi Ittuldmg I'cnntt Number I)atc Applied ituaunt_ i)lli.t tl I I'r,r \.rt r, •;;r.:,.r_ 1)::^.: Si ( I'IOh is SI I C. INfOR IAi-U)5 1.1 Propert Address: 1.2 Assessors Map& Parcel Numbers ;rr !.la Is this un J,...i`Ied street r n0 \1lp\t:o;,rl.:r I'.,. ;\::rr`cr 1.3 Zoning Information: 1.4 Property Dimensions: ;) .in, ,oI ; . 1/4 Arra(sg lit Fromaitilir 1.5 Building SetbacI I Ct) __ 1 mm Yard 1— Side Yards Rear Yard Required Pmcided i Required Provided Required I'roridcd '�1.6 Water Supply:INt.G I_c.40.§54) t 1.7 Flood Zone Information: t.8 Sewage Disposal System: —' i ?one OutsiJ:I',o�d lone? Public.❑ 1'risatc❑ i __ Cluck i f ❑ : Munlnpat Eton sire.disposal system 0 __ SECTION 2: PROPERT\ O1kSeRSHIP' 2.1 t)ss nee'of Record: s \amc I Print) I I.u}.'tatc./Il' \l' and•,1..1 telephone I rre:�il AJ.ir v� ` ��_. SECT 1ON 3: DESCRIPTION OF PROPOSE i) 1%ORK- (check all that apply) Nas Construction 0 ! sating Building 0 : ',)cuter 4)ccupicd 0 Repairs(s) 0 . Altcrationtsl 0 Addition 0 __ I)t.mt litinn 0 .',t.t... r Bldg 0 {cumber of Units Other 0 Specify Brief Dcs:rips on tll I'rt,pnse'd 10 vrl, 1 ' y- ,a. ... is . 1 c .. ` . __ . . i ° SUCTION 4: FSTINI:\TEl)CONSTRtl CTION COSTS Item , I snmatal l'u lti (Alicia) Use Only t Libor and t ik:I I:II, I f3utlJur /,^ OOG 1 Iiuthhut! Ponta et: . Indicate hht,t tee 1,detct,nutecl ❑Standard ( it; Tuna Application Fek i k.tiic.;l 5_._ . QQ. OQ(� ._.__ 0 Total Project to,i'(Item h)\multiplier I'I�:rnhri,, c i$ Q� 2 Other Fees. S 4 Mcei,.utiell I II‘i At. 1 is 3f i ,o t 1.Is1' :t..1+.ogee1 II:r; c I Ili I'1,11 111 1 Ce (het.). '`+tr t.'Iie I Amount feat Amount 'Total Project ( utit '(0l CVO n Paid in Full 0 t!til.a.m,iiin. It-tl tn,:e 1hie A`ORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 07/17/2024 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Susan Fleury NAME: King&Cushman PHONE FAX (A/C No.Ext): (A/C,No): PO Box 447 E-MAIL sfleury@hilbgroup corn ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC N Northampton MA 01061 INSURER A: Auto-Owners Insurance Company 18988 INSURED INSURER B: Seven Sisters Building Co..Inc. INSURER C: 680 Bay Rd INSURER D: INSURER E: Amherst MA 01002-3543 INSURER F: COVERAGES CERTIFICATE NUMBER: CL2471725430 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR ADDL-SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MWDD/YYYY) (MWDD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000.000 DAMAGE TO CLAIMS-MADE XI OCCUR PREMISES(EaENTED occu ence) S _ MED EXP(Any one person) $ 5,000 A 20056737 02/09/2024 02/09/2025 PERSONAL&ADV INJURY S GENL AGGREGATE LIMITAPPLIESPER GENERAL AGGREGATE S 2.000,000 POLICY n PRO- 2,000,000 JECT LOC PRODUCTS-COMPIOPAGG S OTHER $ AUTOMOBILE UABILITY COMBINED SINGLE LIMIT S (Ea acuoent) ANY AUTO BODILY INJURY(Per person) $ OWNED -SCHEDULED BODILY INJURY(Per acadentl S AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per acoCentl $ UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE S DED RETENTION S WORKERS COMPENSATION PER OTH. AND EMPLOYERS'UABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE NIA E L EACH ACCIDENT S OFFICER/MEMBER EXCLUDED'? (Mandatory In NH) E L DISEASE-EA EMPLOYEE $ If yes.describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SAMPLE ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) Tho ACORD name and logo are registered marks of ACORD The Commonwealth of.Mlassnchusetts Department of Industrial.-accidents 5' 1 Congress Street.Suite 100 Boston, MA 02114-2017 )s'w►t:ntass.Roi/die 11 en kers' Compensation Insurance Affidav it: Builders!('ontractorsit:IrctricianviPlumhers. to lii.FILED% ll It I Ill Pl•:RSII F1l(;At iIIORI I Applicant Information Please Print t.eoiihls Name mUNMCSSOIE.11111.111011 Ilid t'lduall: _OiZl O / V\ ✓,E C G5 S Address: (OF() aiq R.), City/State/Zip: p of l-}tr51; f 1i1(4- 0(WZ Phone 4: ( ) .trrc yea an rmpluyrr?II leek the appropriate Ma: Type of project(required): 1.0 I am a employer with employees I full and iu part-time t.• 7. ❑New construction 20 lam a sole proprietor of purtnership and have nu employees working for me in tt. ['remodeling any capacity.[No workers'comp.nisi/nines: required.) 9. ❑Demolition 301 am a homeowner doing all work myself-[No workers'comp.insur nee required.)' 10 Q Building addition 4.0 I am a homwwner and will be hiring eontra tors to conduct all work on my property. I w ill ensure that all eo tractor>either hase workers'compensation msurmet or are sole I I CI Electrical repairs or additions proprietors w ith no employees. 12.0 Plumbing repairs or additions 5.{71 I am a general contractor and I base hoed the sob-contractors listed on the attached sheet. 13 Roof repairs These sob-contractors hare employees and hire workers'cramp.Insurance. 6.ErV.a are a corporation and its olleers have exorcised their nght of exemption per%K.L c. I4. Other 132.§114).and we base no employees. No workers'comp.insurance required.) 'Any applicant that chocks box al mum also fill out the section below showing their worker'compensation policy information. t Homeowners who submit this aflid sit indicating they are doing all wvet and then hire outside contractors must sutntut a new utTtdav it indicating such. :Contractors that check this bxnx must attached an additional sheet showing the name of the sob-contractor,and state whether or not those onuses hasc employees. If the sub-contractors lore cm{,lo}ecs.they must pn•sidc their workers'comp polio)numb.) l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_ _ Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation police declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c- 152.§25A is a criminal violation punishable by a fine up to SI.500.(X) and/or one-year imprisonment,as well as 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 of this statement he forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif•under lb pains and penalties of perjury that the information provided above is true and correct. Signature: g• W ( Z� ` // ['hone C: $c � 0 — rl ) � Date: Official use only. Do not write in this area,to be completed by city or town official ( itv or l uss n: Permit/License Issuing.tuthorits (circle one): I. Board of Health 2. Building Department 3.('il rl-own Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone 4: City of Northampton oaYN�M >o: S S i � Massachusetts A�?S , •— . `i DEPARTMENT OF BUILDING INSPECTIONS 9 . ' 212 Main Street • Municipal Building J� ca • ,d ; 4 Northampton, MA 01060 s3'j. TD‘' 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: 6e— 1� JA) d. ji- 9114 A 141bu4rS4 -7--/- Agfe 4--v-4/0--0 Location of Facility G G The debris will be transported by: Name of Hauler: &OW WeX61-5-5-- Signature of Applicant: /..- - Date: D7 /60 2 The Commonwealth of Massachusetts )* =!/ Department of Industrial Accidents Es 1 Congress Street,Suite 100 `It. �;„i, n.. Boston,MA 02114-2017 t5t,t..t. www mass.gov/dia 11 of kers' ('ompensation Insurance Affidavit: Builders/Contractors/BectricianslPlumbers. TO HE FILED N•ft'N THE:PERMUTING ING AUTHORITY. Applicant Information i'lease Print Lesiiblc Naive I l3usnc.�Organ►ratton Iudi\iduall:� Address: City/State-Zip: Phone#: Are cart an cmpktyrr?('\eek the appropriate hot: Type ol project(required): i.0 I am a employer with employees(full and'or part-timcl.• 7. a New construction 20 I am a sole proprietor on partnership and bays no engsioyeca winking for me in g- o Remodeling any capacity.[`o workers'comp.i nsuraane'e required.) 9. ❑Demolition .101 am a homeowner doing all'work myself.[No workers'comp.insurance required.)' 10 Q Building addition 4.0 I am a homeowner and will be hiring evturadora to conduct all work on my property. I will ensure that all currdaetun either have workers'compensation insurance or ate ale I I.a Electrical repairs or additions proprietors w ith no employees. 12.0 Plumbing repairs or additions .s0 I am a general contractor and I have hired the sub-cuntractors listed on the attached sheet. 13 Roof repairs These sib-cuntrsetors have employees and lint c workers'comp.insurance.. h.Q We are a corporation and its officers have exercised their right of exemption per NMI V. I tl.a Other 152.. 114?,and we have no employees.[No workers'comp.insurance minimal 'Any applicant that checks lux sal must also till out the section below showing their workers'compensation policy information. r Homeowners who submit this at1icktvit indicating they arc doing all work and then hire outside contractor must submit a new affidavit indicating such. :contractors that check this box muss attae Iwd an additional sheet shuts ing the name of the subMco itr'actur s and state whether or not those 1.711111es hate o npluyecs. If the sub-contractors hate cn tlo)eet.they mint hnn iJe their stokers'wail, policy nwntst. I am an employer that is providing workers'compensation insurance for my employees. Below is the polio'and job.site information. Insurance Company Name: — _ — Policy#or Self ins.Lie. #:_ _ Expiration Date: —� Job 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 MGL c. 152.§25A is a criminal violation punishable by a tine 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 tine of up to S250.00 a day against the violator.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 abase 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: PermitiLicense# __ issuing Authority(circle one): I. Board of health 2.Building Department 3.('ity;Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other ('intact Person: Phone#: 1---- , ,9q al„,,50, 4_ . . __ II c5� r/U I BEDROOM BEDROOM III I 1 HALL BATH 3 'i 71.171111Th / BEDROOM BEDROOM 40.% 4,1\\ lfrs SECOND FLOOR PLAN 1 3'-2 f" 11 '-6 1" ' 2 _ --,---� - 2 /- i -ra- 3'-2" / , DRESSING ROOM 36"xte 4'- 1 0" - 1 I- - -1-j \ i \ i \ \ i \ 5'-9" .-1\ ` U r, 1 Q'-7 2" PRIMARY BEDROOM 1 L ^ � ., / PRIMARY BATH I w / DETAIL f / �� ti ,_ SHOWER 5 -0 f--- _:., 1 ~--\ 34" x 60" 4P il M / / (0) -6 0>_._i .. I 4., .1, , it= L_________ r- ,,-- ►J ' 1 11-lti f� 281-4 /- PROPOSED SUITE 7/12 A SCALE: 3/8" = 1 '