29-507 - ..- .. .• .
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. The Commonwealth of Massachusetts
=-.A.-f.........7-- Department of Industrial Accidents
Office of InvestigationS • .
600 Washington Street
Boston, MA 02111 • . -
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www.mass.gov/dia
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-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information . Please Print Legibly • '',:
‘ (---)
Name (73usinesS/Orgardzation/IndividiinD: R k C)LY1/4(\._cl ,v e....D p7
- „:,.... .
• - Address: '2..ti 13 JLLA 0-4 ie._ , . •• • .,
City/State/Zip: b 6 te.i.e., - O. t bk./ 6 Phone.#: qii 5J fa C
Are you an employer? Check the appropriatebox: • . -Type Of pi (required): J
1. 0 I am a employer with _ 4.. 0 I am a general contractor and I
6. 0 New CO ()fl
have hired the sub-contractors
employees (fall and/or part-time).*
2_ Viatit a sole proprietor orpartner- listed on the:attached sheet: 7. 0 Remodeling
These sub-contractors have. • ship and ha.ve no eloyees 8. 0 Derablition - —
- working for me m any capacity. ,i2m7loy workers' 9 .0. 1 , :hi ta i i t i , a - ,diti . -
[No workers' comp-. insurance
10.nElecttical repairs or additions
.• . 5. 0 We are a corporation and its
3.0 I am a homeowner doing all work officers haVex.ereised their . 11.n Plumbing repairs or additions
right of exemption per MGL •
myself [No workers' comp. • 12.0 Roof repairs . •
insurance required) t • . c. 152, § 1(4), and we have no
14:0 Othet
, . . en:iployees. [No workers'.
1 - . : . • . comp. insurance reqnited.j. - 1 . • • . . I .
*Any applicant-that cher-lcs box n must also fill out the section MO/showing theirivorkers'-compMstuion policy infornmiOn; . . ',.. .
t Homeowneri who submit this afficla;litincHcating they are doing an work and then hire outside contractors must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or notthoselartities have , . •
employees If the sab-contraCtorshtie employeed, they must providCttieir wOrkeis' comp policy number.
lam an employer that is P roviding workers'compenstrtion insurance for any enzplOyees. Below is tile policyand job site
information. . .
• .
Insurance Company Name: • , • . . • . •
• - . . . . • -
Policy # or Self-ina. Lic. #: . • Expiration Date: - • .
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Job Site Address :1 7 M A»&) ti L (1 La a CAA city/stafriZii:' M 'A, . _ 'D 1 0 GV...,
• Attach a copy of the workers' compensation policy declaration page(showing the policy number and date).
. . . . . ._. .
. • .. : .. • ; . , . ; ,, .
Failure to secure coverage as reqiiitidinider 152 ,Citi lead to the iiiiioiltiOri Ofnitil iienalties of a
fine tip to S1,500.00 and/or oixe-year imprisonment, as well as civil penalties in the form of; STOP WORIC-cRDER.a.uct a &_e
of up to 5250.00 a day against the viola* Be adyiSed, that a copy of this statement m a y be forwarded to the.Otgelof
- aVeitteatiarts OftliEDIXforiiiiii
ido kereb_y - ..cerilh it: the i ,..*., .• ; arid penakiei olperjury thaithe informationprovidedjiboi; . .:He_litrie - :rindr..nrr .....t ' , ._
• _ .
• ir LA. Iii
Si. -te: i 46. • • Aim ' H . 0 ath 7 - .
Phone
_
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it: .
z_i_I , ,s_1... _ .6 7._-9 t›, ' . _ • • .
. . .. ..... .......,___
• - 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. ElectricalInSpector 5. Plumbing Inspector
6. Other . . •
, I Contact Person: Phone #:
•
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : \ V L Sc b !- 3 I b V
License Number
- ZO IOLL rYe. J7 L01 Address J L 14- S � Expiration Date
0I6 (-l0
Signature Telephone
yi3 s -3 61
9." ReaisteredvH6me .Impro4emerit'Coritra"tor Not Applicable ❑
Company Name Registration Number
(..,(., 44P. - - � - rte
Address / `J l Expiration Date
/-7 e ✓ . pTs 6641 6 Telephone -S, 3 6 ./T l/
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 ❑
11.4Home V ner 6 M emption
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
i
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing E]
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (D Siding [0] Other [[.9f'
Brief Description of Proposed
Work: / A)S7ALC-.- wbO b '-t Vl. - Tj p - IA , ckLIM,Ne'l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6 i aiISe and ior" adclitionlo `existiri t ions nq .cc ipiite the:follawinp:
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
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
� n
I, /14417 / (. c , 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.
AittAttAi ,ref ..
Print Name /� // /
nature of Owner /A Dat
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning ,,
This column tobe filled in by
Building, Department
_.•
Lot Size 1 I _ ] L _._
1 .
Frobtage ... ....
Setbacks Front y ,
Side L: . R: L.,_ l L: _.N R �,
Rear L
Building Height t r
i I
Bldg. Square Footage I i ral % ( '"
Open Space Footage , ;_______,
(Lot area minus bldg & paved 1,�
parking)
r
# of Parking Spaces - -_ W.
Fill: I
(volume & Location)
A. Has a Sp cial Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued::
..r
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book i I Page and /or Document # ._._
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q , Date Issued
C. Do any signs exist on the property? YES Q NO Q
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 Q
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
}'s .!.<4$
City. f Northampton ta#k t fi r"
CEIV ED 6[.1 fling Department c as
2 2 Main Street =riblt
Room 100 ,r a , s
SEP 2 9 2011 N rthampton, MA 01060
phone 41 -58Z -1240 Fax 413 - 587 -1272
. OF BUILDING INSPECTIONS ¢ � •
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:
�� �(/� Map Lot Unit
1 rt..' ce /� Q (6 G Zone Overlay D
Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Reco '���] � ,4..
M�fF�ic.4i NVI J �� /1/(41/4"..4..) �. J 7orC -TC.Q "'W
Name (Print) Current Mailing Address:
i ..
Telephone � �
f ignature ,
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 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) LA.) b 0) S`r'to Il
5. Fire Protection t. (1 Db _ `�■_
6. Total= (1 +2 +3 +4 +5) 3 60 D Check Number 9 p
This Section For Official else Only
Date \)
Budding Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings ' Date
.
38 MATTHEW DR ' BP- 2012 -0352
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29 - 507 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2012 -0352
Project # JS- 2012- 000573
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 6011.28 Owner: MARCHAND MATTHEW R
Zoning: URA(100) //WSP Applicant: MARCHAND MATTHEW R
AT: 38 MATTHEW DR
Applicant Address: Phone: Insurance:
38 MATTHEW DR (413) 250 -2484 0
FLOREN CEMA01062 ISSUED ON:10/11/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE & TYPE A CHIMNEY
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 10/11/20110:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner