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17A-098 (2)
The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations � t 600 Washington Street Boston, MA 02111 _.47 www.mass.govfdia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print l,ceibh= Name ( Business /Orgalizztion/lndividuat): AL i Address: y /V0Y- 1 wt ee 1 .._ Cit /State/Zip: e 0 0j' Phone #: V/3 — nor zggo Are you an employer? Cheek the appropriate box: Type of project (required); 1.0 I am a employer with 4 . ❑ I am a general contractor and 1 employees (full and/or part-time).* have hired the sub-contractors 6. ❑ 1�°' construction 2_ ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ©'Remadeing ship and have no employees These sub - contractors have 8. ❑ Demolition working for rue lb any employees and have workers' Y city., 9. 0 Building additio [No workers corttp. insurance Amp• insurance.' requiroij • 5. W e are a corporation and its 10.0 .Electrical repairs or additiors 3.0 I am a homeowner doing all work officers have exacised their 11.❑ Plumbing repairs or additions myself jNo workers' comp. right Of exemption per MGL 12.0 Roof repairs insurance eta) t c.152, §1(4), and we have no employees. (No workers' 13.(] Other comp. insurance required) • *Any applies= dot ducks box ti twit also fill out the ter boa below thawing theawaiza' oangsou nion policy ieforsonioa. t Homeovnas ado submit thit affidavit iodinating they are doing all work and ibeo hoe outride onottu toss oast subunit a sew affidavit indicating such. zOnitstietoes that cheek this hoc ,ram auadrd as a4didanal abed showing the none of the sob<attraasas and state whether en rat those entities have . employees. tf the snb conttsettvat have anpbyees, they mast provide their workers' e.atp. potieyoa.aber. I am as employer that isproviding workers' compensation Wartime for my employees. Below is the policy and job site information. Insurance Company Nauc: e (ass l n sk./ r e Policy # of Self -ins. Lic. H: Cpl? g if i 58 7 Expiration Date: 0 8/06/20 / / Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy amber sod expiration date). Faiture.tai secure coverage as required under Section 25A of MGL c. 152 an lead to the-imposition of ai anal penalties of a Gnu up to $ 1,50000 and/or one-year imprisonment, as well as cavil penalties in the form of a STOP WORK ORDER and a fine of up to S2S0.00 a day against el* violator. Be advised that a copy of this statemearmay be forwarded to the Office of Investieatiens of the pjAfor in oy covverate verification. • 1do hereby eerie - ' the pelasasu p# of perjury that the htfotmmlar prdwrded above is Owe and correct. 4r1 1r . i • a , • rhone H: , • j • i - n use only. ' o not write In this area, 0 con . - .. day or tome official City or Town: Per mit /Lactase 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 d: Ir • • .. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / Not Applicable ❑ Name of License Holder : 54 L „01 (5 / 3V 50 U A r f / 1 n I License Number /) l 0"0� � ‘ J ar• J ,O �a'V, /!4 . ovaa yo12/e. / 2 Addr ess Q Expi D Signat Telephone :1 ,k E lip Not Applicable ❑ �f. ., x Pm` ,.,., , 4� , .,. Z gti:1J 1 wc / 3 Company Name Registration Number /et( AJ - a _4(ed 5 cPo/ Address j, A (1 Expiration Date N!9t fi q M , viep / a Telephone ri — 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 ❑ $ 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 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aor livable) New House ❑ Addition ❑ Replacementows Alteration(s) E] Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition El New Signs [D] Decks [I= Siding [D] Other [0] Brief Description of Proposed 17 i ,99 ,( , / Work: , 9 /.G° p / r-Af 1.J f \0'0 a Ovtj 5'4ri1° f' pt J7` yr 7 rf " r Alteration of existing bedroom Yes " Adding new bedroom Yes (...V Attached Narrative Renovating unfinished basement Yes ✓No Plans Attached Roll - Sheet 6a,f' ,_.' . ®1Fi ,i ;l ,'" x,adi, & cW' , i. ,„ ®, i.; 3 t ',:i; ,e :`k7' _ - r; I ,: :. 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? j f. Method of heating? Mr )( ----- ; s or Woodstoves Number of each mor g. Energy Conservation Compliance. M 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 I, g Hy t/ f ( f3,., , P // , as Owner of the subject property f l _ / hereby authorize )0 hv.. l.c. AC r to act on my behalf, in all matters relative to work auth rized by this building permit application. Signature of Owner Date I, T ©L4. (_.akv-A as Owner/Authorized Agent hereby declare that the statements ind 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. 75; L v.. L v44 Print Name 1{--gg — ( Signature of ner /Age Date t ,. 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 :L - l R : ,. L ._. R:._.,, _..' __. ' l Rear l..__ ' Building Height _ . _ ; " Bldg. Square Footage .. % ; t Open Space Footage % (Lot area minus bldg & paved ! ! .. parking) # of Parking Spaces - i L_. , Fill: (volume & Location) L it _. - _. .! .. :.... , ..,... A. Has a Special Perm' / : riance/ ' inding ever been 'ssued f. • • site? NO 0 DON KNOW 0 YES *I ! IF YES, date issued: , IF YES: Was the per it recorde• .t e Registry , ,f Deeds? I NO 0 DONT KNOW 0 YES 0 • IF YES: enter Book Page] 3 and /or Documen #_ 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 0 Obtained , Date Issued: _ ry C. Do any signs exist on the property? YES 0 NO 0 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: ' q 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . City of Northampton . � �, Building Department - � , 14 k * 212 Main Street � Room 100 ' -7 4 � . Northampton, MA 01060 � �x� °��. phone 413 -587 -1240 Fax 413- 587 -1272 � �� q �� .. . x n a �. A v g , APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1'- SITE INFORMATION 1.1 Property Address: 44nn t ,£ rfo. Z ee Y r lm St. ° 1; �. SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 1-4 Q C0 ��ci/ Current Mailing Address: 33 & i'� -4 si Name (Pri /� y /3 .....5g y ....07/ L� % " t Telephone Sign ure 2.2 Authorized Agent: Name (Print) / Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building "00 (a) Bu Permit Fee 2. Electrical (b) Estimated Cost of Construction fro {6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) 3 Check Number Q , r— This Sec For Official Use Only Building Permit Number: Date issued: Signature: Building Commiss of Buildings Date V . 33 GRANDVIEW ST BP- 2011 -0908 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 098 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2011 -0908 Project # JS- 2011- 001480 Est. Cost: $3000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN LANDRY 093450 Lot Size(sq. ft.): 9365.40 Owner: O'CONNELL PATRICIA A Zoning: URA(100) //RI/WSP Applicant: JOHN LANDRY AT: 33 GRANDVIEW ST Applicant Address: Phone: Insurance: 104 NORTH ELM ST (413) 204 -9880 WC NORTHAMPTONMA01060 ISSUED ON :5/5/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE PICTURE WINDOW & SIDE ENTRY TRIM 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 5/5/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner