10-007 (3) • 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
Name (Business /Organization/Individual): -- /� '� �- • i' C5
Address:
City/State/Zip :3 ;! / // / .es Phone #: YAA'
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
Employees (full and/or part-time).*
Remodeling
listed on the attached sheet. 7. have hired the sub - contractors 6. E] New construction
2. I am a sole proprietor or partner- ❑
ship and have no employees These sub - contractors have 8. E] Demolition
for me in any capacity. employees and have workers'
working Y P h'• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. n We are a corporation and its 10. ❑ Electrical repairs or additions
3. El 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. [ 1ther
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
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: / , Ili % >
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 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 u er t , pains a enal es of perjury hat the information provided abo e is tru and correct.
./ 0
Signature: � , �, / i J � �� Date:
Phone #: / �✓ PJ 4 " 1 /4""
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 #:
SECTION 8 - CONSTRUCTION SERVICES
b
8.1 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder : L� - 6[7 29,4 -. c�.�'/
License Num4er
O r�� 1 ,1 e L✓ 116"(21 / � Expiration ate a
Signat Tele hone
/ /d
—
9:" - edlTome, m a rovernent on" . cto - ° . A 'V Not Applicable ❑
C m te N me
egist ation Nu fib er
Address Exp Date
0 1 . Telephone 00
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 l" ,
i
11; oome Gwner. ; , emptiion
The current exemption for "homeowners" was extended to include Owner - occupied Dwellings of one (1) or two(2) families
2 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
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i
.441 21-
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) `� (,( w " L (�
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors El
Accessory Bldg. 0 Demolition ❑ New Signs [D] Decks [Q Siding [D] Other [WK
Brief Descriptio of Prop .sed��`'Sto - / ,
Work: / AA I / _ LI / r A ,r i
I Y • -
V
Alteration of existing bedroom Yes L. No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement es y No
Plans Attached Roll - Sheet
s .1f ; civ 76147 na d,oriacJdition to existi' hotis[hq comp :ete: the .follOivinq: N
a. Use of building . • ne Family Two Family Other
b. Number of rooms in ea -mily unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construe- . Dimensions _..../ V'''''''''''''.....-1
e. Number of stories?
f. Method of heating? ir- = -ces or Woodstoves Number of each '
g. Energy Conservation Compliance. Mass - -ck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. o - lands? Yes No. Is construction wi 100 yr. floodplain Yes No
j. Depth of basemen : cellar floor below finished grade
k. Will building c' form to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
t`
1 .
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 ct on my behalf, in all matters relative to w rk author ed by this buil ing permit application.
Signature of Owner Date
1, , as Owner /Authorized
Agent hereby declare that the 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.
Print Name
Signature of Owner /Agent Date
t
r- .
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required byi!'Loning
This column to'pe filled in , :
Building Deparent J p } k i
Lot Size i
H a r.
Frontage 4' i
Setbacks Fron !__ 1-7, i
,
!
Side L: R: L:; 1 R:':
Rear
1
Building Height 1 1
Bldg. Square Footage # % = ! i
Open Space Footage
(Lot area minus bldg & paved l I
parking)
# of Parking Spaces
' I 1 i
Fill:
(volume & Location) I
A. Has a Special Permit /Variance /Finding e e `been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at Registry of I -eds?
NO 0 DONT A ,1 0 YES 0
IF YES: enter Book I 0 1 Pagei 1 and /or Document #1
B. Does the site contain a br , body of water or wetlands? • 0 DONT KNOW 0 YES -
IF YES, has a permit • -en or need to be obtained from the C. servation Commission?
Needs to be obtai e-- 0 Obtained Date Issued:
C. Do any signs - . - on the property? YES I NO
:
IF YES, describe size, type and location: I
D. Are there/any proposed changes to or additions of signs intended for the propert 7 YES 0 NO 0
IF ,ES, describe size, type and location: I
E..% the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part • a common plan
AV
t will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton Stafus at'ermita � C�
RECEIVED Building Department r: G F� ' �' ti
212 Main Street S EMOLIS eerJS e i s O�tatlE ab O AMILY v
+€i' Northampton 100 11a „ - 4' al4t � for
, r nra a ® � S r I ra Pan • w r
i � „, r • �
• • ne 1 TRUC 1240 Fax 01060 4 AIR, RENOVA TE OR Pla 51 a s
��u. APPLI ; ;.. ; . �7t�e, •
fy • ' �
CATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE D A N OR T W F DWELLING
SECTION 1- SITE INFORMATION
1.1 Property Address: _ This sectio to be completed by office �, "_ *y
® �/J� /A //� 0. '.,T u ' ' ,� t t completed k ' ..0 5 'S' •- ,,, a y ` `.3 '.+.':41 ^k
7 /�' �� [/ � - a= 'x wad w, .;rn a a Tt t ,- i �,; x . l ,,, i .
4 �� , F ��tu -] 3.43. h .0 "Y'}`y�? tT s1�
01651 Zone � � � Overlay Distri ��� �� � x � ,
c 3 n
El 3t District ,s CB District
SECTION 2 PROPERTY OWNERSHIPIAUTH AGENT,
2.1 Owner of Record: ti'
Nam Print) ::::
`e�i
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION N COSTS
Item Estimated ted Cost (Dollarspermit ) to be Official Use Only
mple byo applicant
1. Building A/ � ��� 40' (a) Building` Permit 1=ee
2. Electrical (b) Estimated Total Cast of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) �, / �� CheckNumbef . ;•
�, This :Section For Official Use Only
Building Permit Number, - Issued:
Building Commissionerlinspector o f, Buildings Date
•
"11.4
.
200 AUDUBON RD BP- 2012 -0316
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 10 - 007 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: shed BUILDING PERMIT
Permit # BP- 2012 -0316
Project # JS- 2012- 000088
Est. Cost: $3000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THEODORE G SARANT 005640
Lot Size(sq. ft.): 34368.84 Owner: BRANDT ROBERT & JOAN SWERDLOW - BRANDT
Zoning: RR(100) //WSP Applicant: THEODORE G SARANT
AT: 200 AUDUBON RD
Applicant Address: Phone: Insurance:
67 VENTURA ST (413) 734 -5558
SPRINGFIELDMA01108 -2162 ISSUED ON:9/29/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR 72 SQ EXTERIOR WALL
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 9/29/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner