Loading...
11A-065 `.: BP- 2011 -0410 GIS #: COMMONWEALTH OF MASSACHUSETTS '6 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit # BP-2011-0410 Project # JS- 2011- 000678 Est. Cost: Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 15246.00 Owner: JEFFWAY ROBERT W & CELESTE R Zoning URA(100) Applicant: JEFFWAY ROBERT W & CELESTE R AT. 47 FRONT ST Applicant Address: Phone: Insurance: 37 FRONT ST (413) 585- 8819�� LEEDSMA01053 ISSUED ON :121912010 0:00:00 TO PERFORM THE FOLLOWING WORK DEMOLISH HOUSE 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 12/9/2010 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner File # BP- 2011 -0410 ` N APPLICANT /CONTACT PERSON JEFFWAY ROBERT W & CELESTE R ADDRESS/PHONE 37 FRONT ST LEEDS (413) 585 -8819 Q PROPERTY LOCATION 47 FRONT ST ..� MAP 1 IA PARCEL 065 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ti9 ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid T_ypeof Construction: DEMOLISH HOUSE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF RMATION 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 / 1 41 AIF li Y 10 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: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of structural Plans phon6.4 3 -587 -1240 Fax 413 -587 -1272 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 /,r1 Fr,4 �r ee Map Lot Unit `T Le&I.S / 1-/ 14 Zone Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: a c .3 hmn� I-efd i m 01 3 ame i ) ' Current Mailing Address: Y-/ 3 —.k TS —Ifflq ` Telephone Signature 2.2 Authorized Anent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by rmit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) J Check Number This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings 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 tilled in by Building Department Lot Size 3'D `7 35 7 Frontage o?d X200 Setbacks Front 61T 316- Side L: /7 R: 30 L: SF R: 30 Rear Building Height 3a Bldg. Square Footage �a / % 3 1p �7 Open Space Footage % (Lot area minus bldg & paved ?43P3 7'7 A x p arkin g) # of Parking Spaces �;2 °z Fill: volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW ® YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO � DONT KNOW Q YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained ® , Date Issued: C. Do any signs exist on the property? YES © 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 VY 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 © NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ® New Signs [I3] Decks [p Siding [p] Other [El Brief Description f Pro sed P4 eA p/ - ?Ae / Work: �� �i��n n� 1k/,'1, s P .��,LQ__ and rxi.S�m�nl a� �F7F���� St,. �aracfe "Dremar/) 0J , � sd. Opt. e Sso r { Sfru(ht Alteration of existing bedroom Yes J No Adding new bedroom Yes y1 No 0 Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing 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 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. Signature of Owner Date I, J(. as Owner /Authorized Agent hereby declare that LhO statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. L Print am �i /0 v Zo Signature of Owner/ ent Date SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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 per The undersigned "homeowner" certifi es responsibility for compliance with the State Building Code, City of Northampton Ordinances, S to c Z ing Laws and State of Massachusetts General Laws Annotated. Homeowner Signature i0/27/2010 06:24 41 35686625 CJD MCAST PAGE 02/02 Per your request, the Comcast service drop has been removed from the address listed below as of 10 /26/10 tech 1315. 47 Front Street Leeds, MA Nate Ryan 10/15/201n 09:21 4137883143 VERIZOPI PAGE 01 ireriz [ r 365 State St. Springfield, Ma. 01103 413 - DATE 9� 01 C RE: Demolition @ . Dear i Tlfis letter is to inform you and any interested parties that Verizon telephony: services have been di; ;connected for purpose of demolition of building located at x-19 r%) .54 i i Sincerely, P CJ i i i Oct 15 10 11:11a Water 4135871576 p.l CITY OF NORTHAMPTON, MASSACHUSETTS pT �ti DEPARTMENT OF PUBLIC WORKS 125 Locust Street A e Northampton, MA 01060 -2066 413 -587 -1570 Fax 413 - 587 -1576 Edward S. Huntley, P.E Director October 15. 2010 Louis Hasbrook, Building Inspector Municipal Office Annex 212 Main Street Northampton, Ma 01060 Dear Mr. Hasbrook: The water service at #47 Front Street has been shut at the curb stop and the water meter has been removed from the premises as of 9/29/2010. Please contact me if you have any questions. Sincerely, David Sparks Superintendent of Water Cc: Ned Huntley. Directo- of Public Works Jim Laurila, City Engineer nationalgrid The power of action: Reservoir Woods 40 Sylvan Rd Waltham, MA 02451 October 15, 2010 Bob. Jeffway Fax: 413 -665 -2339 RE: Service Removal for Building Demolition. Attn: This letter is to confirm that, per your request; National Grid has removed the electrical service and meter at 47 Front St, Leeds on 9/29/10. If you have any questions or need further assistance, please feel free to contact me at (508) 357 -4661. Sincerely. P ulaw.14 . �3ec�, 7 {4 nationalgrid Cimomer Order Fulfillment Central & NVestern MA Office 508- 357 -4661 8 Fax 315 -460 -91.49 t;t,becc IR w(r. us.rtgriri.com Oct 20 2010 9:57 City of Northampton DPW (413) 587 -1576 p.2 CITY OF NORTHAMPTON, MASSACHUSETTS . DEPARTMENT OF PUBLIC WORKS 125 Locust Street Northampton, MA 01060 413- 587 -1570 Fax 413 -587 -1576 E ward S. Huntley, P.E. Director October 20, 2010 Mr. Louis Hashrook, Building Commissioner 212 Main Street, Room 100 Northampton, MA 01060 Dear Mr. Hasbrook, Mr, Bob Jeffway of 47 Front Street in Leeds approached me about demolishing a house on his property and capping the sewer service after the demolition. I have no problem with this, providing I am called for an inspection later. Please feel free to call me if you have any questions or concerns. Thanks. Sincerel. ohn Hall Sewer Department Foreman Cc: Bob Jeffway file 780 CMR: STATE BOARD OF BUILDING REGULATIONS AND STANDARDS ADMINISTRATION FOR SINGLE- AND TWO- FAMILY DWELLINGS 5111.13 Approval in Part. The building official 780 CMR 5113 CONDITIONS OF PERMIT may issue a permit for the construction of 5113.1 Payment of Fees. A permit shall not be foundations or any other part of a detached one- or issued until the fees prescribed in 780 CMR 5114.0 two- family dwelling before the construction have been paid. documents for the whole detached one- or two- family dwelling have been submitted, provided 5113.2 Compliance with Code. The permit shall be that adequate information and detailed statements a license to proceed with the work and shall not be have been filed complying with all of the pertinent construed as authority to violate, cancel or set aside requirements of 780 CMR 51.00 through 99.00. any of the provisions of 780 CMR 51.00 through Work shall be limited to that work approved by the 99.00 or any other law or regulation, except as partial approval and further work shall proceed only specifically stipulated by modification or legally when the building permit is amended in accordance granted variation as described in the application. with 780 CMR 5110.8. The holder of such permit Permits presuming to give authority to violate or for the foundation or other parts of a detached one- cancel the provisions of 780 CMR 51.00 through or two - family dwelling shall proceed at the holder's 99.00 or other ordinances of the jurisdiction shall not own risk with the building operation and without be valid. The issuance of a permit based on assurance that a permit for the entire detached one- construction documents and other data shall not or two- family dwelling will be granted. prevent the building official from requiring the correction of errors in the construction documents 5111.14 Posting of Permit. A true copy of the and other data. The building official is also building permit shall be kept on the site of authorized to prevent occupancy or use of a structure operations, open to public inspection during the where in violation of 780 CMR 51.00 through 99.00 entire time of prosecution of the work and until the or of any other ordinances of this jurisdiction. completion of the same. 5113.3 Compliance with Permit. All work shall 5111.15 Notice of Start. At least 24 -hour notice of conform to the approved application and the start of work under a building permit shall be given approved construction documents for which the to the building official. permit has been issued and to any approved amendments to the approved application or the 780 CMR 5112 DEMOLITION OR approved construction documents. REMOVAL OF STRUCTURES 5112.1 Service Connections. Before a detached 5113.4 Compliance with Site Plan. All new work one- or two- family dwelling is demolished or shall be located strictly in accordance with the removed, the owner or agent shall notify all utilities approved site plan. having service connections within the structure such as water, electric, gas, sewer and other connections. 780 CMR 5114 FEES A permit to demolish or remove a detached one- or 5114.1 General. A permit to begin work for new two - family dwelling shall not be issued until a construction, alteration, removal, demolition or other release is obtained from the utilities, stating that building operation shall not be issued until the fees their respective service connections and appurtenant prescribed in 780 CMR 5114 shall have been paid to equipment, such as meters and regulators, have been the department of building inspection or other removed or sealed and plugged in a safe manner. authorized agency of the jurisdiction, nor shall an All debris shall be disposed of in accordance with amendment to a permit necessitating an additional 780 CMR 5111.5. fee be approved until the additional fee has been 5112.2 Notice to Adjoining Owners. Only when paid. written notice has been given by the applicant to the 5114.2 Special Fees. The payment of the fee for the owners of adjoining lots and to the owners of wired construction, alteration, removal or demolition for or other facilities, of which the temporary removal is all work done in connection with or concurrently necessitated by the proposed work, shall a permit be with the work contemplated by a building permit granted for the removal of a detached one- or shall not relieve the applicant or holder of the permit two- family dwelling. from the payment of other fees that are prescribed by 5112.3 Lot Regulation. Whenever a detached one- law or ordinance for water taps, sewer connections, or two- family dwelling is demolished or removed, electrical permits, erection of signs and display the premises shall be maintained free from all unsafe structures, or other appurtenant structures, or fees of or hazardous conditions by the proper regulation of inspections, certificates of occupancy or other the lot, restoration of established grades and the privileges or requirements, both within and without erection of the necessary retaining walls and fences the jurisdiction of the department of building in accordance with the provisions of 780 CMR 51.00 inspection. through 99.00. 5114.3 New Construction and Alterations. The fees for plan examination, building permit and 12/28/07 (Effective 1/1/08) 780 CMR - Seventh Edition 511 23 -,� // CITY OF NORTHAMPTON, MASSACHUSETTS DEPARTMENT OF PUBLIC WORKS 125 Locust Street �E Northampton, MA 01060 mx' iF 413 - 587 -1570 Fax 413 - 587 -1576 Edward S. Huntley, P.E. Director CCT 2 1, 2010 October 20, 2010 Mr. Louis Hasbrook, Building Commissioner 212 Main Street, Room 100 Northampton, MA 01060 Dear Mr. Hasbrook, Mr. Bob Jeffway of 47 Front Street in Leeds approached me about demolishing a house on his property and capping the sewer service after the demolition. I have no problem with this, providing I am called for an inspection later. Please feel free to call me if you have any questions or concerns. Thanks. Sincerely, ohn Hall Sewer Department Foreman Cc: Bob Jeffway file 47 FRONT S BP- 2011 -0410 GIs # 69 _ - -- COMMONWEALTH OF MASSACHUSETTS Map _..- iIIA Block. ,065 CITY OF NORTHAMPTON Lot: ,001 Category: ,demolition Permit #- J Bp -2011 -041 -- BUILDING PERMIT Project # JS- 2011- 000678 E st. Cost: Fee Charged: $35.00 Balance Due: $.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Expires: Use Group: Homeowner as Contractor Lot Size(sq. ft) 15246 - - -- Zoning: iURA(100 - Owner: JEFFWAY ROBERT W & CELESTE R )/ Units Gained: Applicant: JEFFWAY ROBERT W & CELESTE R Units Lost: 1 AT: 47 FRONT ST Dig Safe #: ISSUED ON. • AMENDED ON. EXPIRES ON. TO PERFORM THE FOLLOWING WORK: DEMOLISH HOUSE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Electric Gas Plumbin2 uildin Underground: Underground: Underground: Excavation: Service: Meter: Footings: Rough: Rough: Rough: Foundation: Final: Final: Final: Rough Frame: Fireplace /Chimney: D. P.W. Fire Health Insulation: Meter: Oil: Final: House # Smoke: Treasury: Water: Alarm: Assessor Sewer: Sprinklers: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Signature: Fee Type: Receipt No: Date Paid: Check No: Amount: demolition REC -2011- 001661 03- Nov -10 2391 $35.00 212 Main Street, Phone:(413) 587 -1240, Fax:(413) 587 -1272, Email:lhasbrouck @ northamptonma.gov GeoTMS© 2010 Des Lauriers Municipal Solutions, Inc. �s�i i s o F 0 0's oo P� Cv T GO o: Po e 1�� a 1s Gafi �tiS� Oe'� p 9 O �t 1 �t�aCtO��e4 p' P '� 4�'b5Jo ob �'� 54 °t Go e S� �F 5 5 `�` - SP Z l'c 0 t3� G� 0O' �, ye C 5 Tr�� � Tr e C� °{ i, r 5 NO.11° Q SO 1o s'4 � 1 1ra1. 40 � ���'' ce' tee 01 of ;Q oko ���G a��te• li �_.,����'+� ��e 0 o de d b� 1`b • e� aeb� ��to to e p -A 4 O' d CD n 7:5' CD CD O- D 4 CD 0 C, CpD Q N 4 cr CD CD `* @ Oo CD D a r a G) CD t� %r _ �. " , ', CD Cp m ( p � L t4 fi N O O N The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations ' 600 Washington Street Boston, MA 02111 www.massgov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 1 ,, .E t�( �� ��'/ X Address: v ' 1 ?-Z, :. C� %:7,i lw_� ,,-e x City /State /Zip: Phone - #: `r I y '' �/ ` A Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4.. [] I am a general contractor and I 6. E] New construction employees (full and/or part-time).* have hired the sub - contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have. no employees These sub - contractors have .g. F� Demolition working or me in an capacity. employees and have workers' g Y P tY• $ . 9. ❑Building addition [No workers' comp. insurance comp. insurance. required.] 5. We are a corporation and its 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption 'per MGL 12.E] Roof repairs insurance required] t c. 152, § 1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *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. :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 provide their workers' comp. policy number. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ,, , s j Insurance Company Name: f�- / ! { V 1 i ✓ y Policy # or Self-ins. Lic. #: 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 Section 25A of MGL c. 152 can lead to the imposition of crimin4l penalties of a - fine up to $1,500.00 and/or =year imp=isonmei t� as as civil penaalttes 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 havestieations of the DIA for insurance coverage verification. I do hereby certify under the pans and penalties ofperjury that the information provided above is true and correct. Suture: �.. ?,1i r Dater 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 #: 14- 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, also states that "every state or Iocal 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 insuran 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 - insuran 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 permif/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 o (i.e. a dog license or pe rmit t bum leaves e tc. said _erso n is NOT required.to_ complete_this.affidavit - - --- - - - - -P -=---- - -� P -- 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 df Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617- 727 -4900 ext 406 or 1- 877- MASSAFE Revised 11 -22 -06 Fax # 617- 727 -7749 www.mass.gov /dia 47 FRONT ST BP-2011-0410 GIS #: COMMONWEALTH OF MASSACHUSETTS ME Bloc I IA - 065 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Categor: BUILDING PERMIT Permit # BP- 2011 -0410 Project # JS- 2011- 000678 Est. Cost: Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor. License: Use Group: Homeowner as Contractor Lot Size(sa. ft.): 15246.00 Owner. JEFFWAY ROBERT W & CELESTE R Zoning: URA(100) Applicant: JEFFWAY ROBERT W & CELESTE R AT: 47 FRONT ST Applicant Address: Phone: Insurance: 37 FRONT ST (413) 585 -8819 (� LEEDSMA01053 ISSUED ON: TO PERFORM THE FOLLOWING WORK DEMOLISH HOUSE 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 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner