36-173 .: The Commonwealth of Massachusetts
` Department of Industrial Accidents
`- Office o Investigations
. s,- -- r fJ` f
, - ,:, 600 Washington Street
.,, Boston, MA 02111
=;x www. nuts s. gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly_
4 ., / %n ii
Name (Business /Orsanization Individual): ivy 6 v , !i l/6 - L. , j '�"� .: :. Y d t _
Address: M A': in t XA-.
City /State, /Zip: f— fiL. ° ,v L<rv�, t Phone 't �.' �%�;
Are you an employer? Check the appropriate box: Type of project (required):
1. K71 I am a employer with 9-‘ . ❑ I am a general contractor and I
employees (full and/or part - time).
have hired the sub contractors 6 ❑ New constriction
'. n 1 am a sole proprietor or partner- listed on the attached sheet. 7_ 11 Remodeling
These sub - contractors have
slop and have no employees 8. n Demolition
working for me in any capacity. employees and have workers
b P 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
q ]
3. Li 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 12.17 Roof repairs
insurance required.] c. 152. § 1(-I), and we have no
employees. [No workers' 1 �.[�} Other t �k , , W j
comp. insurance required.]
*.Atty applicant that checks box =1 must also fill out the section below showing their workers' compensation policy information.
Homeowners Nvho submit this affidavit indicating they are doing all work and than 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.
t
Insurance Company Name: C,. i ii {i f ti / v i✓ - t 1 ';`ire 3 k` U < 1
Policv # or Self -ins. Lic. #: IV C.. \ 3 7-cl Q O 1 9 Expiration Date: I I , .v
Job Site Address: 9 17 Flore1LP '5 City /State /Zip: : a, 4 0160
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 ■ erification.
1 do hereby certft under the pains and penalties of perjury that the information provided above is true and correct
Signature: PIP (.'vv / i 4 j Date: q- 2 b' 1 1
Phone #: i R : l,' J 5'Ji'[ "i �i�'
Official use only. Do not write in this area, to be completed by city or town official it
I ,
City or Town: Permit /License # i j
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector II
6. Other 1I
Contact Person: Phone #: '
1
SECTION 8 - CONSTRUCTION SERVICES
X8.1 Licensed Construction Supervisor. ` Not Applicable ❑
Name of License Holder : / / 6 (3u 7 k / y fie 13
License Number /
ROC'eU'e AU �d,�l { � �� ,/'IA- 0 030 S6 k )
Address Expiration Date
l ef 4GD
ignature Telephone
/9s 1Oo //
A. Registered Home Improvement Contractor: Not Applicable ❑
R Ob , e(+ VctA tv;140,. witit Company Name 1 Registration Number
;S[ wa6- s� , en 3 I,S/1f
Addr s/, c� Expiration Dat
f /�7 Telephone 6� (`l
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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 fs7' 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 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 applicable)
New House El Addition 1 1 Replacement Windows Alteration(s) n Roofing
Or Doors D
Accessory 8idg. 0 Demolition , 1 New Signs [El] Decks [Q Siding [D] Other [DI
/Brief Description of Proposed 3
/ Work: V I '1\/ L f - pl4c- effri,„ L' I t aC
Alteration of existing bedroom Yes 1 No Adding new bedroom Yes No
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 .
L 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
k p S V` , 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.
e ,e41. r Btt s t-1-1 3)1—
pint Name
/ a% .A
Signature of Owner /Agent Date
•
,•
-7
RECEIVED
Department use only
SEP 3 20)1 - City of Northampton status pf Permit:
Building Depa rtment Curb Cutlbriveway Permit
o �r oF eu,tn, NGINSrlcnoN� 212 Main Street Sewer /SepticAva,lability
4•10 No art,n PTO MA01 60 Room 100
water/ sltAvala t !;
Northampton, MA 01060 Tyro Sets of Structuralf'lan
phone 413-587- 1240 Fax 413- 587 -1272 Ptot/Site Mans
Other Sp
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TW FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section be completed by office
e irICk Map Lot to U
'� Zone Overlay District
/ /li !a
/'+ {r / U Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: f3u 511.e7 / VVet / il Li4 / 'R 1( if 11541414147
Name (Print) Current Mailing Address: Cl (i
,Apioc/ 3.- ,A,,,-.A
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Perm 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) '� Check Number V 0 v y5 � 3 5
This Section For Officiate al Use Only
Building Permit Number: Issued
Signature:
Building Commissioner /Inspector of Buildings Date
. .
•
717 FLORENCE RD BP- 2012 -0323
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 173 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: window replaced BUILDING PERMIT
Permit # BP- 2012 -0323
Project # JS- 2012- 000525
Est. Cost: $735.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT E BUSHEY JR 57011
Lot Size(sq. ft.): 14592.60 Owner: GARTIN TERESA J
Zoning: SR(100)/ Applicant: ROBERT E BUSHEY JR
AT: 717 FLORENCE RD
Applicant Address: Phone: Insurance:
351 WALNUT ST EXT (413) 786 - 9906 WC
AGAWAMMA01001 ISSUED ON:10/3/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 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 10/3/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner