38B-044 , • .
The Commonwealth of Massachusetts
. -
I ry
!.:
u Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information __ Please Print Legibly
(
Name i Businessiorganr7ation/Individua I i
Address: , ) ..:',-- .), — -,. T : ' -,,
, . ,
City/State/Zip: '..1 : V. \ 'i ) i4 ( ,,,' Pho te#.
!
Are you an employer? Check the appropriate box: ' Type of project (required):
1 X I am an employer with [ 0 4 I am a general contractor and I 6. Ncw construction
, employees (full and/or part time).* have hired the sub-contractors
I , 7. I R-,.imodeling
2. 1 am a sole proprietor or partner- listed on the attached Theo.
ship and have no employees These sub-contractors have 8. Demolition
I working for me in any capacity. employees and ha e workers'
9. Building addition
[No workers* comp. insurance comp. insurance.
required] 5. We are a corporation and us 10. Electrical repairs or additions
3. 1 am a homeowner doing all work officers have exercised their
I I. Plumbing repairs or additions
, myself [No workers* comp. right of exemption perm :VIOL
insurance required] t c. 152, § 1(4). and we have no 12. Roof repairs
employees. I no workers
1 Other II 1 -)--- ICA. -- IC) t"t
eomp. insurance required 1
*Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information.
illomeowners who submit thi ffidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contactors that check this box must attach an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If
the sub-contractors have em.lo ees they must .rovide their workers' com . • olic■ number.
I am an employer that is providing workers' compensation insurance Pr my employees. Below is the policy and job site
information.
Insurance Company Name: , ,, ',.. ,- ; k i i , , i i • -, e ' L '' ‘.. , , i
i ;Th -, i t
Policy / or Self -ins. Lie. /;: '.._,1 l . ,:) I - f . I-'2'-''' Expiration Date: '-' ' 1l,_, /
,z /
Job Site Address: City
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 152 can lead to the imposition of criminal penalties of a fine
up to S1.500.00 and/or one year imprisonment as well as civil penalties in the fonn of a STOP WORK ORDER and a fine of
S250.00 a day against violator, Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for covera verification.
1 do herby certify un r the pai s and penalties of perjury that the information provided above is true and correct.
i
Signature: Mite j- / H i H
....._, - _
Pt-int Name: 1 , _Q'e r ,,-:,, 4 I (;_ -* - Phone 4 (1 - Li :< - )),)
Official use only Do not write in this area to be completed by city or town official 1
!
City or Town: Permit/license #:
Issuing Authority (circle one):
1.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact person: Phone #:
1
4
--- -"RN
14ACC)RD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/00/YYYY)
•
flbasere■-- ';/2 4
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
s : PHONE — PAX
4 (Art, No Ext) — ; (A/C, No). - -
E-MAIL
ADDRESS
PRODUCER
CUSTOMER ID a
INSURERS) Al-FORDING COVERAGE HNC e
INSURED
INSURER '„ „: :•• .!
INSURER C
INSURER
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER. ' • REVISION NUMBER:
TS IS TO CERTIFY THAT THE POLICIES OF INSURANCE ISTED BELOW HAVF''BEEN 'SSW D TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED NOTWITHSTANDING ANY REOJIREMENT I OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAY BE ISSUED OP MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR ADDL. SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/OD(YYYY MlarDCWYYYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE
DAMAGE TO RENTED
COMMERCIAL GENERA, PREMISES tEa octurrer ce, $ '
CLAIMS-MADE ocC LIED EP An ono person) S
PERSONA,_ 6 AD \r INJURY S- . •
:;ENFRAL AGGREGATE
OEN', AGGREGATE ,IMI APPLIES PE PRODuCTS - COMP OP AGG S-; ;
PRC-
POLICY JF .1 LOC
r- AUTOMOBILE LIABILITY COMBINED SINGE LIMIT
Ea accdent■
AN Au
3-0 INJJR ;Per person, $
AL, DIAINL) UTC ric,Dit ,Per accLoent,
EO Au
PRONY DAMAGE
HIRED AUTOS ,Per occ.raer
NON OWN ALL FOS $
UMBRELLA LAB EACH DC,OJRRENCE
EXCESS LIAB 'MS-MACIE AGGREGATE
LEDJ(I
RE TFN HON $ $
WORKERS COMPENSATION WC S7. AT,/
AND EMPLOYERS LIABILITY TORY LIMITS
Y N
A'Sy PROPRIE TOR NER,Er(ECu IVE E c EACH ACCIDENT
Of-FICER,MEMSER ExCc,JUL.F N ' A
(Mandatory gn NH) DISEASE - EA EMPLOYEE
11 ye!, descntre
UESCRIPTION OF OPERATIONS below L DISEASE - POLICY LIMIT S —
DESCRIPTION OF OPERATIONS / LOCATIONS r VEHICLES (Attach ACORD 101 Additional Remarks Schedule. rt more space (t. required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
IN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR/ZED REPRESENTATIVE
4/Ifik
1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
...
*
‘1,4%.»..ichukcii. - Ihparinieni al Public 'salvo
Board 44 Hui !dint; Reuulai urns anti shaitLiril.
Construction Supervisor License
Lit ense CS 92540
•
THOMAS B ROSSMASSLER '-
100 MAIN STREET
HATFIELD, MA 01038 , ..
c>2.... ..e ........- -e
E *par ail; 4-1 9/2/2013
( ..ifiiiii.......n. r T 794
.0.
•e 6osoptimonameat04 el . it.e./.4(444‘.14
License or registration vittni for individul use only
Office of Consumer Affairs & Business &mutation
before the expiration date. If found return to:
..- St - HOME 00PROVEMENT CONTRACTOR
Office of Consumer Affairs and Business Regulation
ReMstratien: 166169
10 Park Plaza - Suitt 5170
Expindicat 1/11/2012 Tr# 292481
Boston, MA 02116
Type: LLC
ENERGIA LLC
THOMAS ROSSMAWER
242 SUFFOLK STREET
HOLYOKE, MA 01040 i'adersecretary Not valid without signature
.,,
•
Property Address: I S c S VI u At■ JT
Contractor
Name: Ca 5 oSS or,ct. s,/t,-
Address: 5 c S 4.,4 4. 5
City, State: »V/ t/42 Iniq e l o do
Phone: 03 -32z - 3iii
Name: Owner , v . b, 2 b0✓'GL C lrt, vrer)
Address: ( TS - $ t1 5 -f -
City, State: ,A':: - 11. h �, le ,^ , G � w o tots a
i - 11f-- , 0- s Asim 0 Ss I K (contractor) attest and affirm that the building t intend
to insulate cues not have any open air (knob and tube) wiring in the spaces to be insulated and
that I have provided the property owner with a copy of this affidavi
Contractor signature b t f ...
4 Date 1/8'I1 0
ZOO it ZLZTLBSCTt• XVd LZ :TT OTOZ /CTi80
,
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' SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor Not Applicable 0
Hanle of License Holder : 1 1/x.0 v s S h^3' SS I G✓ q s `r b
License Number
2q sUF ;1k 5 f431 1014R #ii (woo Z 13
Address Expiration D e
` I 1 3 - 3Z1 - 31(1
Signature Telephone
9. Rt ete
istered Home Improvement Contractor: Not Applicable ❑
,v a i 1.-L, I �5i�9
Company Name Registration Number
2qz 5,//'41K 51- #010 /) 0104( so 1y4 (42
Address di Expirat on D to
Telephone 4 '/3 -3 2 2 -3/ 1
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 ij 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors EJ
Accessory Bldg. ❑ Demolition ❑ New Signs ID] Decks [IZI Siding [0] Other
111sv 1400 •
Brief Description of posed � ?
Work: 'it $T CC / /L/ /ifl i h f✓ /ICJ / ON 'h L. / , f ,
Alteration of existing bedroom Yes 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 .
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, bt a-L.61 `r , as Owner of the subject
property
hereby authorize 74,4 t . ntzkf ,,,j i ' s /��✓
to act on my behalf, in all matters relative to work authorized by this building permit application.
c 4114 A - 60 i 131 ti
ignature of Owner Date
d�a j /�Sfivteiff /c✓ as Owner/Authorized
Agent her y 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.
h'�AI Sfh-7.11f
Print Name
j-z411
Signature of Owne Agent Dat
e
•
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: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO O DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES O
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained ,Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O
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 O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
ing
S ski
�L? Department use only
. -7- I 1 , I ' ,,, e , ..,ek/
��e City of Northampton Status of Permit:
Q� Bu ilding Department Curb Cut/Driveway Permit
0 .I. o 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability
�;' � Northampton, MA 01060 Two Sets of Structural Plans
10 4: 0 :00 phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be completed by office
155 sc - t4 <,
Map Lot Unit "`
V or4k, ,(› 'co \N
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
-4 2.1 Owner of Record:
D e/ bnr - /A1 4. (rev rrer. (55 „-)-C, s Nv -4 ..e m , /KA-. Q /OGo
Name (_P rint) 4 Q ! Current Mailing Address:
Telephone
ignature
2.2 Authorized Agent:
- 11A I 2 0f5 Mg mlcA - 2(47. Sci-P' //h 11 #13/ .1ee in omy0
Name (Print) Current Mailing Address:
W3 3// /
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 1 LI 6 I s . b (a) Building Permit Fee
2. Electrical In (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection f if*4■J°
6. Total =(1 +2 +3 +4 +5) — l t 0 LLfl , r�lo Check Number //a9 _
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: _
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0445 '
APPLICANT /CONTACT PERSON ENERGIA LLC
ADDRESS/PHONE 242 SUFFOLK ST HOLYOKE (413) 322 -3111
PROPERTY LOCATION 155 SOUTH ST
MAP 38B PARCEL 044 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /7 /Jd9 o
Fee Paid
Tvpeof Construction: INSULATE WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 92540
3 sets of Plans / Plot Plan
THE FOL NG ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission Permit DPW Storm Water Management
Demolition D - . y
/� <el' ,,.
G //
nature of B ild b fficia Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
155 SOUTH ST BP- 2012 -0445
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 044 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2012 -0445
Project # JS- 2012- 000716
Est. Cost: $4067.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ENERGIA LLC 92540
Lot Size(sq. ft.): 23217.48 Owner: CHARREN DEBORAH A
Zoning: URB(100)/ Applicant: ENERGIA LLC
AT: 155 SOUTH ST
Applicant Address: Phone: Insurance:
242 SUFFOLK ST (413) 322 -3111 WC
HOLYOKEMA01040 ISSUED ON:11/2/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:1NSULATE WALLS
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:
FeeTvpe: Date Paid: Amount:
Building 11/2/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner