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38D-029 BP- 2011 -0491 GIs #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Perrnit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit # BP- 2011 -0491 Project # JS- 2011- 000806 Est. Cost: $30000.00 Fee: $180.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: KEVIN NETTO CONSTRUCTION INC 1317 Lot Size(sq. ft.): 10715.76 Owner: NETTO KEVIN C & JOVITA B Zoning: URB(100)/ Applicant. KEVIN NETTO CONSTRUCTION INC AT: 292 1/2 SOUTH ST Applicant Address: Phone: Insurance: 90 Southampton Rd. (413) 527 -3168 Workers Compensation WESTHAMPTONMA01027 ISSUED ON :121112010 0:00:00 TO PERFORM THE FOLLOWING WORK.- UPDATE 2 BATH ROOMS,KITCHENS,ENTRY DOORS,BASEMENT WINDOWS & PORCH LANDINGS 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 12/1/2010 0:00:00 $180.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0491 APPLICANT /CONTACT PERSON KEVIN NETTO CONSTRUCTION INC ADDRESS/PHONE 90 Southampton Rd. WESTHAMPTON (413) 527 -3168 PROPERTY LOCATION 292 1/2 SOUTH ST MAP 38D PARCEL 030 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: UPDATE 2 BATHROOMS,KITCHENS,ENTRY DOORS,BASEMENT WINDOWS & PORCH LANDINGS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 1317 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOYMATION PRESENTED: Approved 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 Demolition Delay c7e�� It o 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 granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. Department use only City of Northampton, 'Status of Permit ' ;Jui(dinc Department Curb CutlDnveuvayPniiriit 212 Main Stru Senn SepticRyaitabilify Room 100 WatedWellAvaiiability " �, `� Nrthampion, M.^ 01060 Two Sets of Structural Plans - p 3o1 413' 587 - 1240 Fa-A 13 - r - 87 - 1272 P16USitePlans 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 Map Lot Unit -Zone Overlay District Efrri St District CS District SECTION 2 - PROPERTY OWNERSH1PIKUTr 7ORIZED AGENT 2 -1 Owner of Record Name (Print) Current Mailing Address Q \Qa1 - Telephone Signat 2.2 Authorized Agent: Name (Print) Cur l r ` ent Mailing Address: Signa re Telephone SECTION 3 - ESTIMATED - CONSTRUCTION COSTS Item I Estimated Cost (Dollars) to be Official Use Only completed by permit aDolicant 1. Buiidina (a) Building Permit Fee 2. Electrical (b) Estimated'Total Cost of Construction ;from- (6 ) 3. Plumbing I Building Permit Fee 4. Mechanical (HVAC) I 5. Fire Protection 6. Total= (1 T 2 ; 3 _ 4 5) Check Number This Section For O iiciatUse Onl Date: Building Permit Number: Issued: Signature: - - — -- Build --- -- — � 8uiiding Commissioner /fnspectoror. ui mc5 -" Date r ection 4. Z' 0 N I N G At', information ML--t Be Compiet-ad. Pe—rit Car, Be Denied Due To incom.plete Inforr Exi Proposed Require-6 by Zoni� BuildinL Department Lot Size Setbacks Fron Rear Building Height Bldg. Square Footage ------ % Open Space Footage % (Lot area mirus bids! & payed tiaridnz A. Has a Special Pennit/Yariance/Rndkng ever been issued for/on the site? ��, �~\ »~~� MO I DON7'KNOVY YES \^� /F YES, date bsued: � IF YES: Was t permit recorded at t Registry nfDeeds? �� NO �� DON / xnvW 0 ,c, IF YES: enter Book � Page' / and/or Oocument#� B. Does the site contain a brook, body of water or wetlands? NO DONTKNOYY 0 YES 0 IF YES, has permit been or need to be obtained from the Conservation Commission? Needs to be obtained � Obtained a ned /~� Date Issued: ' ^ `�� ^ �~/ ' ' ^ v ��` C. Do any �gnsexist on the property? YES �_/ NO ��. IF YES, describe size type and location: D. Are there any proposed chances to or additions of signs intended for the property ? YES �-\ NO t'7) IF YES, describe size type and location: _ E. Will 'the construction activity disturb (clearing, grading vadon, or filling) over 1 acre orish part ofacommon pian that M|/ disturb over 1acre? YES � ) NO �Q) �� Vy '|FYES.����No�6����hS5��0��r K��ge�nfP6nn�hnm the DPvV��qu/ed. ' S =C T ION 5- DESCPIP;ION OF PROPOSED WORK fcheck all afloiicabie) New House ❑ Addition Replacement Windows 1 Alteration(s) Roofing j Or Doors �I Accessory =1c c '� Siding [r I g. Demoiit;on Never . ;grs iC] Ciecks [i , �: Other Y I I 1 1 Brief Descnp5on of Prcpesed \ \ Wcr : — 4L "ltcfaiion or existing bedroom Ye �� N Agding nc'N bedrGGn Yes _� No �,i-:ached Narrative Rencvatina unfinished basement Yes �_ No j Plays nrached RGIf - Sheet _. I 5a. ff Neuu house and oraadiiion.to exisana housing. COMDfete- thd,:f6ug a- Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of SathrcGmS c. Is there a carace attached? d. Proposed Square footage of new constrJction- Dimensions Number of stores? Method of heating? Fireplaces or Woedstoves Number of each C. Energy Conser. Compliance. Masscheck Enera Compliance form attached? h. Type of ccnstr uoticn i. Is corstrucuon within 100 L- of wetlands? Yes No. Is =rstruction within 100 yr, flcodpiain Yes No ;. Decth of basement or cellar floor below finished grade k. Will building ccnform to the Building and Zoning regulations? Yes No . I I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER Al TrIORYZAMON =TQ- BE COMPETED WHEAT - OWNERS -AC-ENT OR CONTRACTOR APPUE EURBIf11D . INGPERM� ( i 1, 2N , q n • l y '(� �0�� 1 V�� as Owner of the subject property hereby authorize 1�V\r f to aC cn my behalf, in all m ters reiadve to wort( authorized by this building permit application. I Signatur of Owner D\-= �V yyN N as OwnerlAuthcrzed =gem nere-cy GEC +are tat the and infiom"atiCn on the treacinc ap.cllcaticn are true and accurate, to the gesi GT my knowlecce and belie*. Signed under the pairs and penalties of penury- I 7 Yk fi� - �• _ ©mot\ ��'e.. ' = ..n dame I ZEC T ION a - CONS TRUC MON SE3VICES Lice nsed Lens`iruc SiuoerAscr i Not App i Name of License Holder License Number ;ocress O,O� —i Expiration Date 5 nature Telephone i. Re Horne; lmmovsmerri- Contractor Not Applicable ❑ :omoanv Name Registration Number .ddress p\p!bj Expiration Date ` Telephone �j�Z- �y��p� ECTION TO- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L c. 152, rcrkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result the denial of the issuance of the building permit. fined Affidavit Attached Yes ------- is r No ------ ❑ I The current exemption for "homeowners" was extended to include Owner - occupied Dwellings ofone (I) or two(2) families and to allow such homeowner to enaa!ze an individual for hire who does not possess a license, provided that the owner acts as supervisor. CIVIR 780- Si-rth Edition Section 10335.1. Definition of Homeowner Person (s) who own a parcel ofland 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 faun structures. A person who constructs more than one home in a two -vear 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 verformed under the buildinz hermit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion ofnhe work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter Lli- (Liability ofEmployers to Employees for injuries not resultir z in Death) of the Massachusetts General Laws Annotated, you niav 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 Sate Buiidin2 Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature Tile C0;17177tonr+'e -"h of?ifassacitlLSer :s _ DeJ ^; ,'fZel.': c71 ::"Ia�_�CCZ» :rS of Ir_ i'rsri a:zo ?ZS _ - 6 V T N.-zz, on Sneer - - _ Boston, 2111 -1 0311 nass.g ov1dig NIVork:.rs' COMDeusafi Insurance - Affliulavit: Builders; 'Coutractors,EIectricians, r:bers A,nwicaut inforr:ai `\\ - Please Lea, Ci n.'State;'Zip Phone F2. you an employer' Check the appropriate box: Type of project (required'): I am a employer wi h 4 . 17 I am a general contractor and I �-- 6. ❑ New �n w consucon 1 e: u,loyees (full andlorpart- time).* have lured the sub-contractors Iisted on the attached sheet. 7. �! Remodeling I am a sole proprietor or partner- ship and have no employees These sub - contactors have S. ❑ Demolition worming far me in any capac.ry. employees and have workers' o I I 9. Buildin add_don rNo work co=. insurance comp. insura - 1e t�Pd D. We are a corporation and its 10.]_] Electrical repairs or additions ❑ I am a homeowner doll all work ofncers have exercised their 1 I.❑ Plumbing repairs or addi��ons myself o workers' comp_ right of exertion per -MGL 1 Roof repairs p (� : airs isurance required.] t c. I=2, § I(z'), and we have no employees. [-N workers, 131 Other I corgi. baTarance regiLlred.] 'Any apnlic :t that checks box =1 nu:st aiso 511 out the section beiow show-ing their woricers' conmensation policy irforrrtion. 1-iomeowners who Suornit this affidavit indicants thev are doirg all work aid then hire outside contractors must subrnit a new affidavit indicating such. =Contractors :ha: check this box must, artached an additional sheet showi. v the name ofthe sub- grcactors and state w e:ner or not those entities eve e:nplo if the sic - contactors have enmlovees, thev must provide their worke. -s' corm. policy number. I am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Com- pany ' ame: �t Expiradon Date: Job Site Address Zkcyw) City /State;'Zip: Attach a copy of the workers' compensation polio declaration page (showing the policy number and expiration date). Lail uro - J "\ T T t 1 e secure coverage as regmreu unde Section 2: A _. or t ✓1GL C. 52 Can Lead i0 t,.e i:u '2LGSiIIGn or Cr "%a� T pezalAe$ of a tine un to S 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 5250.00 a day against m e violator_ Be advised that a copy of this statement may be forwarded to the Office of Invest Qations of t he DLz for insurance coverage verification. I do hereby cerrify under the pains and nalties ofperjuty that the information provided shove is true and corr ecr- Siz n-a*c -e Date: Phone = a. � I O� " ieial use only. Do j:ot write in this area, to be completed by city or town ojjicia-I City or Town: Permit/License Issuing authority (circle one): j 1. Board of Health 2. Building Deparanent Ci-v;IF Cler - Electrical Inspector =. P 'umbin_ Iaspecior 6. Other 1 i Contact per or: P sere Fi:c f /BP- 2011 -0491 F, !'PLICANT /CONTACT PERSON KEVIN NETTO CONSTRUCTION INC A DDRESS/PHONE 90 Southampton Rd. WESTHAMPTON (413) 527 -3168 PROPERTY LOCATION 292 1/2 SOUTH ST 1� ! :11' 3 81) PARCEL We 00 1 ZONE URBO 00)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE FORM FILLED OUT F. e P,iid Permit Filled out T - ;,co Construction: UPDATE 2 BATHROOMS KITCHENS ENTRY DOORS BASEMENT WINDOWS & V , i�(] I LANDING AMENDED 2 /11 /11- SHEETROCK OVER PLASTER & REPLACE INTERIOR DOORS 11, w ( no struction _ ) i 1 Structural interior renovations _ Id ition to Existing essory Structure I_ flans Included: _ "I ner/ Statement or License 1317 sets of Plans / Plot Plan 7 !.LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON I ,UNION PRESENTED: oved Additional permits required (see below) .-INNING BOARD PERMIT REQUIRED UNDER:§ •rmediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan 1NG BOARD PERMIT REQUIRED UNDER: § iing Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed r 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 : A S i ( Building Official Date * are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of P: Development for more information. Department use only j City of North2mpton Status of Permit j Buildinc Department :Curb GutlDrivesivay.Pem it 212 Main Stream: 'SewerlSepticAwaitabiliiy i i.. Room 100 Water/Well Availability l� ha.mpton, Mr. 0106G Two Sets of Sttuctiiral Flans phone 413 -587 -12 -4Q Fax 410- 587 -1272 PlottSftetiPlans OtCier Specify ; APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Prooerty Address This section to be completed by office Map Let Unit zone Overlay District Efrri St District CS District SECTION 2 -PROPER TY Y OWNERSHIPIAUTHORIZED AGENT 2 -1 Owner of Record Name (Print) Current Mailing Address \037 Telephone Signatu 2.2 Authorized Agent: y 0 1 Na (Print) Current Mailing Address. \Da Signat te Telephone SECTION 3 -ESTIMATED CONSTRUCTION COSTS Item + Estimated Cost (Dollars) to be Ot Use Only completed by permit aoolicant 1. Building vs (a} Building Permit. Fee 2. Electrical (b) Estimated' Total Cest of Construction.from (6) 3. Plumbing I Building Permit Fee 4. Mechanical (HVAC) 5 Fire Protection I 6. Total= (1 +2+3+4+1 Check Number This Section For Official: Use Onl _:. -Date Building Permit Number Issued: Signature: I Building Commissioner /Insoec or or unamcs - Da1e Section 4. ZONING All information Must Be Compieted. Permit Can Be Denied Due To Incomplete Infornnation Existing Proposed I Required by Zoning This coi=n to be filled in by Buildin2 De-nartment Lot Size Frontage _ _ - _. __ ____.__ _.µ _ +i_ _ _. _ __ - - �^ __', w .. _ .._ . Setbacks Front Side L: R: L. R: ------- Rear Build Heiah Bldg. Square Footage % Open Space Footage % (Lot area minus bldg & paved oarL-ng) # ofParkine Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for/on the site? K?I) - NO k4y DON7 KNOW 0 YES 0 IF YES, date issued:— IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON7 KNOW 0 YES 0 IF YES: enter Book Page and/or Document # ADN B. Does the site contain a brook, body of water or wetlands? NO k,,��y DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: A I K2Ni C. Do a signs exist on the property? YES 0 NO V-y IF YES, describe size, type and location: ?C D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, excavation, or filling) over I acre or is it part of common plan that will disturb over 1 acre? YES NO XD" 0 1 101 IF YES, then - a - Ncrt S M from the DPW is required. I - S =^ TION b- DESOPIPTiON OF PFOPOSED WOFK (check all aoclicabie I I ( I New House f'J � Addition Q Replacement Windows Alteration(s) ( � Roofing i I Or Doors 1 1 Accessory'Idg. n Demolition S igns j._] — 1 Siding I � N ew ..; rs � Decks (� jG; Othe t 'K Brief Desonrton of Proposed ,\\ I Work: Alteration of ex.stinc bedroom Yes No Addina new bedroom Yes No � —ached Narrative Fenovatina unfinished basement Yes No Plans A Ua cneg =oil - Sheet 5a. If New (louse aria ar adaitian. to exrstina-hcUSina, cbMb[.ete t ;e fo rra winc: 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 a'ttached? i d. Proposed Square footage of new construction. Dimensions e. Number of stones? f. Method of heating? Fireplaces or Woedstoves Number of each c. Energy Conservation, Compliance. Masscheck Energy Compliance form attached? h. Type of wnstruciion i. Is construc�on within 100 1 1L cf wetlands? Yes No. Is construction within 100 yr. flccdpiain Yes No j. Depth of basement or cellar floor below finished grade k. Will building ccrfom to the Building and Zoning regulations? Yes No. I. Septic Tank City Sewer Private well City niter Supply SECTION is -OWNER AU- THOR1Z4T1O N- T.C�BECOMPEETEDHWHEN -_ -; OWNERS - AGENT ORCO[i TRACTOR APPLIES E LD(NtG- PERMIT I, �r Nyp as Owner of the subject proper , 'y herby authonzze �i��C' 1Je_ �c��cvc�co� ,— to act on my behalf, in all maters relative tc work authorized by this building permit application. Signatur of Owner \ Date as OwnerfAuthcrted A l ceni nerecy ceciare t hat the sic emenz5 and infcm�at;on on u e fore V cing = CpiicailCn are tPIE and accurate, 'late, to th ^ �eSt pf m;! (nOwledce end belief. 1 � Signed under the pains and penalties of penury. � rnrt Name SEC ON 8 - CONS T RUCTION SERVICES 2.1 L versed Construction Suoerr_ =or i Not Appiicable 0 i Name of License Holder V \'(^� _ (':� M License Plumber E,- .^,iration Date ;ic ature Telephone 1. Rectistered Homelrt>nrcletrtertL'Gorttsac €ate, - s . = m Not Applicable ❑ :omr)anv Name Registration Number .ddress —� Expiration Date Telephone 5A ECTION 1:0- WORKERS' C€3MFENSAMON tNSURANC>= AFFIDA AT 4M.G L c. 152, § 25C(fil) +orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result the denial of the issuance of the building permit. fined Affidavit Attached Yes....... lZj No ...... ❑ _.�a>i e, 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 enzage an individual for hire who does not possess a license, provided that the owner acts as supervisor. C -MR 780. Sixth Edition Section 10335.1. 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 helshe shall be responsible for all such worst 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 15 (Liability of Employers to Employees for injures not resulting in Death) of the Massachusetts General Laws Annotated, von may be Iiable 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 _ - fie Co. 0� - �Irssacilacse :s - D °D•'- ' %£;71en£ OJ f 01 Ir esz g atia ?zS �.._ _ 6, S. Boston, 31-10211-7 110rli-rS' ColnDensa:.:on Insurance Affldavit: Builde r si "CortraCtors, r.bers �>jaiicant 7nforr::aLion PIease Print Le�. .A.11L...JJ. Cir�,'Stat�;'Zip: Cn \ Phone y \3- �a131�a Are you an employer' Check the appropriate box: Type of project {required): 4- ❑ I aria a general contractor and I 1. I a* a e p lover with - * have hired the sub- contracto_� 6 `env cors�ucaon employees (till and/or part - time ). � _. ❑ I am a sole proprietor or parmer- listed on the a-.ached sheet. 7. Remodeling s hlp and have no employees These sub- contractors have g- C Demohrion wort ing for me in any capacity. employees and have works' yer g n I _ 9. Q D .�uIdin� adcitioy [moo workers' come. insurance comp. msurance.> ""T", 5. F1 We are a corporation and its 10.17 Elecuical repairs or additions 3. ❑ I ant a homeowner doing all wort: officers have exercised their 11.❑ Plumbing repairs or additiors myself [-\ workers' comp - right of exemption per MGL [� l:. 7 Roof repairs insurance requ red.; c. 12, § 1(4'), and we have no employees. [- workers' 13.7 Other I coma. insurance required -] 'Any applicant that checks box =1 rns: also ail out the section beiow showing u.eir worke -s' cotnDensaaor. policy irforrraaon- Hor -eow , ie s who subrrur this affidavit indica&z thev are doing aA work and then hire outside contactors must submit a new amdavit indicating such. 'Contactors that check this box nust arac.'zed an additional sheet showing the aanr of the sub - contactors and state w setae: or not those eaaees ra e- mlovees- I: zhe sub - contactors have e rmloyees, they must provide their work,. -:s' corm- policy number. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job sue information. Jns;i -?rice Corrpanv' ame: Policy or Seii ins. Lic. T: \AZC \D " `� Expiration Date: Job Site Address: o��la���, t`8^� City /Stare /Zip: Na Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure - secure coverage as recurred under Section 25_" of MGL c. 1=2 can lead to t`e imposition of cr `a? pen- es of fine up to S1.500-00 and /or one -year tmpnsonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine cf � to = �fJ.f)� 2 day aCainst rh e violator- Be advised that a copy of this statement may be forwarded to the Office of Invesrgarions of the DLz for insurance coverage verifeation_ I do hereby cerrifv under the pains d penalties of perjury that the in { ormarion provided above is rare and Corr ecL �i aCL-e: Date: Phone i ✓ :vial use only. Do not inrire in this area, to he completed by ciry or town ofj7cial City or Torn: Permit , 'License Issuir:z Authority (circle one): I. Board o_`$ealih '. Buiicinu Deparr._:ent y . Cirv; CIerlc -' E iectrical Insaector 5. ? umbiL, laspector 6. Other i Uont.^.cr Person Phe re _ i�