32C-235 (2) . ,
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The Commonwealth of Massachusetts
Department of Industrial Accidents ,
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Office of Inves
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• 600 Washington Street
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Boston, MA 02111
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-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeiblv
Name (Busitiess/Organiza tifs›: 1
j
• Address: ' i /
r AL .. - • •
City/State/Zip: (466 414 di)53 Phone.#: 3 I' /let-)
Are you an employer? Check the appropriate box: Type of project (required): 1
1. El I am a employer with 4 • 0 I am a general contractor and I
6. Ej New construction
have hired the sub-contractors
_.... eleffees (full and/or part-tiro.e).*
a sole proprietor or partner-
listed on the attached sheet 7. 0 Remodeling
2.1.1-am tr
ship and have no e,.w These su
loyees b-conactors have. 8. 0 Deinolidon
envloyees 3.nd have wOrkers'
working for me in any c.apacity. 9 0 Buildin i addition
# • •
[No workers' comp. insurance
10.0 Electrical repairs or additions
required] • • 5. Ej We are a corporation and its
3. 0 I am a homeowner doing all work officers havexercised the•ir .
t 11.0 P ing repairs or additions
rieu Of exemption per MGL .
myself [No workers' comp. 12. Roof repairs . -
insurance required.] t • c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
• •
_ con p. insurance required} -
*Any applicant that checks box #1 must also fin out the section below showing their woricers compensation policy information.
t Homeowners who submit this affidavit fru:Heating they are doing all work and then hire outside contactors must submit a new affidavit indicating such
:Contractors that check this box roust attached an additional sbeet showing the name of the sub-contractors and state whetheror 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: . • , • -
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 coverake . as required under Section 25A ofMGL c. 152 can lead to the imposition of Criminal; penalties of a
fine up to $1,500.00 andior one-year imprisonment, as well as civil penalties in the form of a STOP WORK-ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
...... ,_ _ - ._ .. . ..._ ..... _
afiiiiiitions of the DIA for insurance coveileOVerffication. _
/ do hereby_certibl un . , , , . ..; 4 ■ , ' i enalties ofperjury that the informationprovidedirbove_iitrue_tindeotrerr
_
.PC/ 24 2°14 •
Sienature: , - Date-
Phone ii 5 -
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
• Permit/License -
Issuing Authority (circle one): "- # '
........ ...
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:
Phone #: .
•
v
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ) / , Not Applicable ❑
Name of License Holder : ✓• "' "' e''`""
License Number
po Dom-- fH Le..04 i dA$) /z —/� 11
Address Expiration Date
Telephone
i "eais i.34 e lmttroviiiiii diliit"ractior t `Y tg. 4 ; :. Not Applicable Er
Company Name Regis ation Number
2z- 4va1,40.. 126/ ? J - -7L-
Address E xpiration Date
/094 41,4 e` d c Telephone 331 P
—
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin ermit.
Signed Affidavit Attached Yes No ❑
t1 :� m Tim
The current exemption for "homeowners" was extended to include Owner occupied Dwellines 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 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 buildine 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
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0/
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [D Siding [0] Other [0]
Brief Description of Proposed mei
Work: S+s O S 11 ‘ 1 4 ,ear
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sk itt te* 6iiii. rrdl- a dt i' �i . t fti ' `o iT ffiB t e li na:
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
1, � /ll(p,n J (2J•1 .n» 5144 , as Owner of the subject
property
hereby authorize Tj h+t Ltce.8
to act on m bb half, in all matters relative to work authorized by this building permit application.
p-ru,.G..... Z(. Oc t n,Ser2 2
Signature of Owner Date
' J , -
I, �� yy,� ( //� ---' , as Owner /Authorized
Agent hereby Clare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pans and p� of perjury.
P tName
all,6, Un
` Date
�:Il� f 0w • , gent
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 1 L i
ii
1 i
r
Frontage 1 1 1 I, ,,.
Setbacks Front = _.
Side L :1 i R :. L:i__._... 1 R:i I I _. _._
Rear = 1 , 1
€ 1
Building Height 1 r 1 3
Bldg. Square Footage E 1 % 1 1 1
•
Open Space Footage % 1 ,,.._ 1
(Lot area minus bldg & paved 1 ? L__„ j ? z
parking)
# of Parking Spaces '- .
Fill: i
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book F I Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: i
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: 1
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
�r EIsEO Building Department
212 Main Street r
9 620 Room 100
^ k
ger
N orthampton, MA 01060 § *
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=,,� on-- 413 5 87 - 1240 Fax 413- 587 -1272
-1111 ►- . -,�,��— � !M� .: f ,.
- APPL ICATION 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:
l 1 tkil I 1 ht,.-.s T Map Lot Unit
Zane Overlay District
Elm St District' !'. CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Willf Ar �T, I urtnnns . PO. 1'30.1' / LPG /Yh9 OJOS $
Name ( Pri ) Current Mailing Address:
h . Telephone 1 /13 5' 8 6 1 t/oo S
Signature
2.2 Authorized Agent:
:71014/ eD / AA 3
Name (Print) Current Mailing Address:
/ V/3 3 ? fF)
Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building / 41U2 (a) Building Permit 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) f7 pia '" Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings, Date
11 WILLIAMS ST BP- 2012 -0429
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 235 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0429
Project # JS- 2012- 000647
Est. Cost: $1800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 100515
Lot Size(sq. ft.): 5532.12 Owner: TUROMSHA WILLIAM J
Zoning: URC(100)/ Applicant: TIMOTHY J LUCE
AT: 11 WILLIAMS ST
Applicant Address: Phone: Insurance:
P 0 BOX 14 (413) 387 -9800
LEEDSMA01053 ISSUED ON:10/26/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE GARAGE 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 10/26/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner