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32A-205 The Commonwealth of Massachusetts �;;� _ Department of Industrial Accidents J ) „4 - ' Office of Investigations 600 Washington Street br , Boston, MA 02111 -. .. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): t I , ` Z v C o As IT Address: d t � 7 f Ott C (? cr ( Q (,) City /St. e /Zip: 6 sib uql I v fllphone 4 #: 5 9 7 v ' i ST _ ■ --- Are y. an employer? Check the appropV ate box: Type of : re ro'ect (required): © 4. am a p J ( q ) 1. u I am a employer with 4❑ I general contractor and I g employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- These sub - contractors have ship and have no employees 8. ❑ 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. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Pl robing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Qloof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13. ❑ 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Q / 1 1 . jtLfv �i/ /11,s- Policy # or Self -ins. Lic. #: 4.-611C 7 0 / / 6 .5 6- 0 / z 0/ /Expiration Date: [ f 2--0 i �---- Job Site Address: ( C3U «t' 11 e l. G k 6 i{ /State /Zip: Gl Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under th "pai nd penalties of (I erjury that the information provided ove is ue and correct. Date: / 3 Signature: I / t Y � v i ' [ fir 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 #: . . 4 SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable ❑ Name of License Holder : t J F7, 0 3 o 4 L Numbe i e/ - r Address ration to I. 7 -y6. _ Si ur e elephone .•:;::76; it ied., o ''orover en' orif l i Ate !; : # " 1: Not Applicable ❑ Company Name / Registra 'on Nu ber r - 0 - a-t .��r � - �� GEC r/ - � > Address � ` � Expir tion D e � / � , Q� :i 0 SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT{MG L c X52, § 25C(6)) ; Workers Compensation Insurance affidavit ust be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the buil ' permit. Signed Affidavit Attached Yes No ❑ W ,' 1 pion The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he/she resides or intends to reside', ,on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two -year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • J SECTION 5 -: DE O PROPOSED WORK (checkaliapplicable) „ New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing 111,.." Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [(] Siding [D] Other [0] Brief Descri tion of Propose -t . o pos P— - i ftsf 4ec.) � Sitg (h h ' 15 hJ- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 5" . e' 'eius id r • di 1 ;1ezistiW of sth '®m ®ete he :.at OWtfl : 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 S ECTION 7a OWNER.AUTHORIZATION . 4 T O, BE COMPL / , OWNERS AGENT Ott CONTRACTOR.:APPLIES 0.0. LDING PERM1T ; I, FeCtirc Ck. iw- , as Owner of the subject property hereby authorize . T (A,i`� �'L .g C t to act y behalf, in all matters relati t work aut oriz b is building ermit ap lication. Signature of Owner ate as Owner!• -. Agent hereby declare that the st ments and info tion on the foregoing application are true and accurate, to the best of my nowledge and belief. A Signed under t ins and penalties • •* 'ury. lu 1 g id Print Nam rif 1 Il k k Signature o 0 r /Agent 1 Date . ,,tS.. 4 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information -1 b Existing Proposed Required by'Loning This column to be filled in by • Building Department i Lot Size Frontage I H it Setbacks Front E x , Side L:' 1 R:: t L: i . ( t R:r : 6 = 1 I E Rear - Building Height I I j E 1 Bldg. Square Footage 1 i I% 1 j Open Space Footage (Lot area minus bldg & paved i ( I parking) # of Parking Spaces 1 - 1 Fill: I _ —_! _ ____ (volume & Location) A. Has a Special Permit /Variance /Findin ver been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:1 1 IF YES: Was the permit recorded at the Reg' try of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book 1 Pagel and /or Document #1 B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 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 0 NO Iii 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: I - - 1 E. Will the construction activity disturb (clearing, grading, a avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. �. 36 BUTLER PL BP- 2012 -0283 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 205 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP-2012-0283 Project # JS- 2012- 000451 Est. Cost: $11300.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WEATHERPROOF CONSTRUCTIONINC 062833 Lot Size(sq. ft.): 6011.28 Owner: GREGORY PATRICK BOLTON & JUSTINA W BOLTON Zoning: URC(100)/ Applicant: WEATHERPROOF CONSTRUCTIONINC AT: 36 BUTLER PL Applicant Address: Phone: Insurance: 24B NORTHAMPTON ST (508) 294 -4052 () WC EASTHAMPTONMAO1027 ISSUED ON :9/20/2011 0:00:00 TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE ROOF 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 9/20/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner