15-013 358 CHESTERFIELD RD BP- 2011 -0306
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map :Bloc 15 - 013 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 -0306
Project # JS- 2011- 000504
Est. Cost: $3978.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 091496
Lot Size(sq. ft.): 41643.36 Owner: GUYETTE GEORGE E
Zoning: RR(100) Applicant: PELLA PRODUCTS, INC
AT. 358 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772 -0153 WC
GREEN FIELDMA01301 ISSUED ON :101412010 0:00:00
TO PERFORM THE FOLLOWING WORK.- INSTALL REPLACEMENT WINDOWS
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 10/4/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
i of Northampton
- -- •--� -" Building Department
212 Main Street
Room 100
Northampton; MA 01060
l-- - -phW46 413- 587;1240 `Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1,1 Property Address V CSQ�d `t
�ee�•S , f`�l [�
O iq5-�
2.1 Owner of Record
aecXae- cnwtt d
Name (Print) T, �r ��"" ,�, Cube 1 ilin2 Add S:
(�eS I�th2� 0 -0( �GC'y- mu
tko�C Telephone y
Signature
2.2 Authorized Agent:
bmi id S! k 4 5.1 n t . 1tfs M r>a na . C feen_Fi A . ft* 01
Name Print) Current Mailing Address:
2
Signature Telephone
Item Estimated Cost (Dollars) to be
completed by emlit appi scan t
1. Building
2. Electrical �� �.:..,':•': :.ifi.;,_.<;'' >"..
3. Plumbing
4. Mechanical (HVAC) F .. ..... ,. .
5. Fire Protection
6. Total 1 2 3 4 5
.. ....... .... .... ......:.. ......:: '.: ..:.,, .:nom•
I
a
:.:: ...... .. .`.. �v f �....:' .w' � >. :: .: � :. �' .c.. v .`.. i :•; k: v vn. �- :'1:i v:'��.i::::
s
,E
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
Setbacks Front
Side L: R: L: R:
Rear C�
Building Height
Bldg. Square Footage % C�
Open Space Footage %
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces
Fill:
volume & Location
A. Has a Special Permit /Variance /Finding a er been issued for /on the site?
NO 0 DONT KNOW YES
IF YES, date issued: I
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW ® YES
IF YES: enter Book i Pager and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW ( 2 ( YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained 0 , 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 0 NO
IF ES,_ 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.
s
5 3 E sce. HIS X05 I1
New House [] Addition ❑ Replacement Wiruiows Alterations) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [r-3] Decks [❑ Siding [p] Other [C1)
Brief D cdption of Proposed
work: c�c c�fla 8 wick .l-, WM. V�t1 f k - An��� !Jo SM�c-�vc
C�Cxr9tS
Alteration of existing bedroom Yes No Adding new bedroom Yes �_ No
J
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
MWARWIM, "01
a. Use of building: One Family t/ 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
I, , as Owner of the subject
party 1 .3
property
hereby authorize :�Zdyct% 1n C
to act on my behalf, i nall matters relative to worlt authorized by this building permit application.
(;eo- SIaVwA 0aN�c'aC- - a .CL a d ,� n 10
Signature of er Date
I, R,(bf S ��. _ _ _ _ as Owner /Authorized
Agent ereby declare that the statements and information on th& foregoing application are true and accurate, to the best of my knowledge
and belief.
S under the pains and penalties of perjury.
Pnnt N e
Signature of Owner /Agent Date
iS._.
8.1 Licensed Construction Superviso +A , Not Applicable 0
Name of License Holder �� W� \ ��P�1 �( r(1 nq Jq C 1 t
License Number
o II3II11
Address (} C, �� _ Expiration Date
Signature Telephone
Not Applicable ❑
roc . I y 2Z
Company Name Registration Number
1 �.�n eel- r -�rP,� �,Id,�L1Pti n� �n i 3l0 u 11 2 =::
Address Expiration Date
Telephone 5
R
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 buildin p permit.
Signed Affidavit Attached Yes....... No...... ❑
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 helshe 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 Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature - -
To Whom It May Concern:
as property owner, give
permis O n to our contractor, Pella Products, Inc., to
obtain a building permit for the installation of windows
or doors in my home, located at
Please
accept this letter in place of my signature on the
permit application.
Thank you,
T �
Please Print Name
Homeo er's Signature Date
Pella Products, Inc.
155 Main Street
Greenfield, MA 01301
Phone: 413- 772 -0153
Cell: 413 - 834 -8799
To: Building Inspector
From: David White — Installation Manager
Date: January 19, 2009
SUBJECT: Building Permit Applications & Designees
Pella Products Incorporated is in the business of replacing windows and
doors for our customers. Our process includes providing a building permit
for each and every project.
I am a licensed Construction Supervisor. Building permits will be applied
for using my CSL #091496 and our HIC, # 142279. Please find a copy of
my licenses below.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information / / Please Print Legibly
I 1) Name ( Business /Organization/Individual): ��� ry � C/ [ t t �3 f rI C
�S� �� % ��n � �r
Address:
City /State /Zip: re"- T, L / Aw 0 130 f Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. employer I am a em to er with !�) 4. ❑ 6. I am a general contractor and I ❑
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. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 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.❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. Other F
comp. insurance required.] 1_')vo r S
*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.
I am an employer that is providing workers' compensation insurance for my employees. Below is, the policy and job site
information.
Insurance Company Name: 7 � / �7 u l' CE n
Policy # or Self -ins. Lic. #: G N'/ 0 I 7��/ _3 Expiration Date: 45�)
Job Site Address: ? I'le CA City /State /Zip: kQ eds , M R 0 1-6- 5:z,
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 insu coverage verification.
I do hereby cert' under the pains and pe sallies of perjury that the information provided above is true and correct.
Si nature. \ q Date: d
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 #:
BERKSHIRE INS Fax:14135684284 Aug 6 2010 8:11 P.01
AC-ORM CERTIFICAT OF LIABILITY INSURAN DATE(MMlDD
8/6 2010
PRODUCER (413) 773 -99X3 FAIL. (413) 774 -3872 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Massone Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
117 Alain Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P,O. Box 638
Greenfield MA 01302 -0638 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA Continental We steru
Pella Products, Inc. INSURER B:
ATTN: aohn Be INSURER C:
155 Mama Str INSURE D:
Greenfield MA 01301 -3258 INSURER E:
- THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTVVITHSTANDING ANY
REQUIREMENT, TE" 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.
UM ITS SHQVM MAY HAVE BEE Cf:D 13Y PAID CLAIMS POLICY EFFECTIVE POLICY EXPIRATION
lNBR DD, TE OF INSURANCE POLICY NUMBER DATE DATE M LIMITS LIMITS YP
GENERAL LIABILITY EACH 0Cr.IJI3R9NCE 1,000,000
DAMAGE 7 300,000
X COMMERCIAL 13ENERALIL01LITY 0RENTEO Q $
A CLAIMS MAV, OCCUR CPA020470113 1•11/2010 1/1/2011 MEDEXP one $ 15,000
$ 1,000,000
GENERAL AGGREGATE S 2, 000, 000
pgonLICTS GEML AGGREGATE LIMIT APPLIES PER: _ S 2
X POLICY PRO- LOC
AUTOMOBILELIABIUTY 00MOINED.SINGLELIMII $ 1,000,000
(Ea acodvd)
ANY AUTO
A ALL OWNED AUTOS MAA0 2 04 7 0213 I/]./2010 1/1/2011 BODILY INJURY a
(Per Person)
rX SCHEDULED AUY06
HIRED AUTOS BODILY INJURY (Par xcidanq NOW'OWNED AUTOS
PROPERTY DANIA% 3
(Per accident)
GARAGE UAWLITY AUTO ONLY- EA ACCI06W $
P1 ANY AUTO OTHER THAN EA A
AUTO ONLY: ACR3 S
EXCE881JMBRELLA LIABILITY
OCCUR 0 CLAIMS MADE AGGREGATE S
4
DEDUCTIBLE
4
NTI N q _ OTH-
A WORKERS COMPENSATION AND X
EMPLOYERS' LIABILITY E.L. EACH Its NT f 500,000
ANY PROPRIETORIPARTNERIEXECUTIVE 5 0 0, 0 0 0
OFFICERANEM5�EXCLUDED? NCA020470513 1/1/2010 1/1/2011 E.LDISEASE -EAEMP
If yes, dPSctibe under EL DISEASE- —1-J—T is 500,000
SPECIAL PROVIVatIS below
OTHER
DESCRIPTION OF OPERAYIONSILOCAT10NWVMCLES IMLuCIONS ADDED BY ENDOROEM15IN111SPECIAL PROV1810N5
Operations usual to the Bales of windows & Boars.
CERTIFICATE HOLDER CANCELLATION
(413)736-3390 8HOULC ANY OF THH ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of Northampton EXPIRATION DATE THEREOF, THE 188UIN0 INSURER WILL ENDEAVOR TO MAIL
212 Ma in Street 10 DAYS WRITTEN NOTIC)= TO YHE CERTIMCATE HOLDER NAMED TO THE LEFT, BUT
Northampton, MA 01060 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR L"ILITY OF ANY KIND UPON THE
INSURER, ITS AOENTB OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Norma Laforest /SPG
ACORD 25 (2001108) O ACORD CORPORATION 1888
INS025 (Oias).aae Pose 1 01`2
358 CHESTERFIELD RD' BP- 2010 -0619
CIIS 4: COMMONWEALTH OF MASSACHUSETTS
M s:I3ioc is - 013 CITY OF NORTHAMPTON
I.0t_ -0 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate� BUILDING PERMIT
Permit # BP- 2010 -0619
Project # JS- 2010 - 000901
Est. Cost: $1379.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: IDEAL HOME IMPROVEMENT INC 091207
Lot Size(sq ft.): 41643.36 Owner: GUYETTE GEORGE E
Zoning: RR(100)/ Applicant IDEAL HOME IMPROVEMENT INC
AT. 358 CHESTERFIELD RD
Applicant Address: Phone: Insurance:
142 BOYLE RD (413) 863 -2128
GILLMA01354 ISSUED ON: 1212212009 0:00:00
TO PERFORM THE FOLLOWING WORK .-INSTALL ATTIC INSULATION
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 12/22/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
Department use only
City of Northampton Status of Permit:
Building Department Curb CutfDriveway Permit
212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 -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
This section to be completed by office
1.1 Property Address
& e h es f&Ae J J Map Lot Unit
Zone Overlay District J,'e�S M 4 0/ 0-S 3
' Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record 1:
Name (Print) j Current Mail'
X13 - -� :, _J5 iL
Telephone
ignature
2.2 Authorized Agent
Na (Print) Current Mar&V Address:
<-'� CA
SCnaj6re 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) / f7 9 Check Number
This Section For Official Use On
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buidings 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
Setbacks Front
Side L: R: L: R: _
Rear
Building Height
Bldg. Square Footage %
Open Space Footage _ %
(Lot area minus bldg & paved
p arkin g)
# of Parking Spaces
Fill:
volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pagel and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW ® YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , 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 0 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 Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Al. 4
SECTION 5- DESCRIPTION OF PROPOSED WORK !check all aoulicable)
New House [] Addition ❑ Replacement Windows Alterations) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [Q Siding [E3] Other [CD]
Brief Description of Proposed /�j
Work: y�"'1 � C(
Alteration of eAsting bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes _1,/
Plans Attached Roll - Sheet
sa. if New house and or addition to existing housi complete the followin
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. Massc heck 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
1 ' ` eO 6 (k L as Owner of the subject
property -
hereby authorize J ecWS F - //, S
to act on my behalf, in all matters retattve to "Of authorized by this building permit a lication.
Signature of Own Date
I ' s LA s as Owner /Authorized
Agent hereby declare that the statemen s and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under painr� penalties of perjury.
7tz- w�
0
nat re of owner/Agent Date
J.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licen ed Construction Su rvisor. Not Applicable ❑
Name of License Holder : /Il ' 9 1, 1 0
0
License N ber
Add s � 1 / {� F-> � Date
V� .4 1 � O�b3 °_ud F
gnat Telephone
9. R e ' tered Ho M2 Im v men Cont ract = Not Applicable ❑
(.� V)LQS �cS 1196 1 7 L O 1�
Company Name I Registration Number // Y
/ 40� (& I., k Address ' Expira 'on Date
Telephone . 18
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 162, § 26C(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 buildin rmit_
Signed Affidavit Attached Yes....... No...... ❑
11. - Home Owner Exemi don
The current exemption for "homeowners" was extended to include Owner - occupied Dwellinzs 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 10835.1.
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 Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
The Commonwedth ofMossachuseft
-i Department of IndoshWAccidents
f
Office of Investigations
r
t r 600 Washington ,Street
Boston, AM 02111
www.mass gov1d a
Workers' Compensation Insurance Affidavit: Builders/ ContractorsMectricians /Plumbers
Applicant Information Please Print Legibly
Name (Businesstorganizatior l ividual): 6�e .C_-.- W i4C— 1 f 4 eg Q V Me N i
Address:
City/State/Zip: l`% �'� �i 13 Phone #: 41 - 3 1 L4 e
Are you an employer? Check the appropriate box: Type of '
1. E I am a employer with _ Z 4. 0 lam a general contractor and 1
employees (full and/or part-time).* have hired the sub- contractors 6. C] New construction
project {emu rred ):
2. ❑ I am a sole proprietor or partner= listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employes and have workers'
tx>m ance•I 9. [� Building addition
(No workers' comp. insurance comp. insar
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 -[] Plumbing repairs or additions
myself_ [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees- [No workers' 13.010iher nSLt /G tw,
comp- insurance required -]
*Any applicant that cbccks box # l mast also fill out the section below showing dtar workers' corrquasstion policy infornmtioa
t Homeowners who submit this afdavit in&amug they = doting all work sod dum hire outside contractors mist Mbmit a new affidavit aulicatiag such.
*Contractors drat check this brae must attached an adder sheet showing the mine of the snb-cw nrs and state whetber or not those enddes have
employees_ If the subaoutractoo have employers, they rest provide their workers' comp. policy number,
lam an employer that is provltMV workm Bdow h the pokey mrd job site
information. i�l
Insurance Company Name: a
Policy # or Self-ins. Lic. #: ��ti ��- f �� Expiration Date:
Job Site Address: / T It keeds City /State/Zip: m o_i os3
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 $2250.00 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 c under the a nd peamUm ofpedkq *hart ,tke urfarn on provided above is trace and correct
i x t� 2 re s -
Phone #: l
OJ)Za use only. Do not write in d* area, to be congdeted by tlty or town vfik -iat
City or Town: Permitl.License #
Issuing Authority (circle one):
1. Board of Health 2. BuMing Department 3. Cityffown Clerk 4. Ell Inspector 5. Plumb Inspector
6, Other
Contact Person: Phone #: