25C-190 11/10/2011 15:6 413-247-0276 JW COTTON LLC PAGE 01/02
t - L2.2„..t.
f2II,1/4. ' The Commonwealth Of Massachusetts it i ri7
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Department of Indaairial Aeadents
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Office was of h i - 41 nv gio estigations
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B eass. v 1
Workers' Compeusation insurance Affidavi t: Brulders/Contractors/Electricians/Plumbers '
AppIicant yfformalion . zo _ . ... NLLC. . '1 easc Lev lA
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Name (Busincss/Organization/Individual): i ib . dik gm. •..., .
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Addreas: . ' H A TFIELD -MA - •
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City/State/Zii: • . •• .‘ ... : . : .,.- •. .hone . . • .
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Are you an employer? Check the aPproprlate ham . • ,. .:::::.:::. ': : .::: .. .: ' . .. ;4L..... 0 /4 4 .. 0 - - J t ( d): . .
1. ii:ci an a employer' With ' It'!"! . . 4 . .0 I On A 0.i0i.i_ OfilSeitkiind I • ' :
. , . .., . ,.. .6 D New oprestruction
employees (full audiorpart4ime).* h i
aire linDdlte anbzoentnictors ' • •
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t.:•••:
2.0 Lam-a- soleproprieterer-partne$-... ... :, ..A.7. d'PliO'nt„- ... ._ .).:1..Ii=mtideling
. ship and have no employees These soPeontrattors Iwo ' • ' 8, 7Ef1S
cmpleYeas. and belie-Workers'
working for me in any caPiteity 9. 0 Bitilding addition
[N6 Workers'. comp. insurenee • cott -. 4k , ..i ii i- u — i i iiit .-6 1 :=‘,...-.,.,... .: .. ..
... . .
' required.] . ' . S. 0 • we areTurertnetion and its. , ,. , 10.0 Electrical repairs or additions
..... , .
• 3. 0 X tun a .120111p0;,' (iii;i all • • o ' 7 .. ,' e*P „.8 - . 1 . -1:1 Plumbing repairs or additions
------ , - . • myself DieworIcereeorap, . : . — ' 7 — 12:0 Roof rePair9 .
insurance required.] t o.• 15.2,.0(4), and *have no •
• , 12
employees... We worlets' 13- Other . •
,
comp initiiiide reeiii*Li . • .
_ •
*My applicant that checks box #i mast artat filfout the aecticia belidiiiiiiiillieittEtittion policy information.
t Homeowners Who sabnift thin Wait* Wit:Ming they arc doing all work =dim Ifitentitaide acidulates, ;riot submit knew affidavit iodinating finch.
:Contractors that cheek drill box mint attached an additional abed showing the JIM* of the sidkontract ort and edge whether ornat those entitles have '
employee% If the sth-contractors have mnployem, they smite & emir Worbers' coMpipolicynnniben
l am sa employer that is proriding contpenseitiOn insurance for no angiloyeexi fe tile Palley ain f jO0 site
.information.
Insurance Company Name: L /$6t.-- — pt...i......:77.-.4 L . . .
Racy Nor Selfitti. Lie. #:. (4.PC( 315 - 4 ' 7e) 4.. 70 -- 0 I 0 • . ExpiratiOn Date: i ( C
Job Site Address: 3.9 '#) ?I, tr. 44- A-'4- trea--af l'Abs-6- 3 , . ' ..city/stiiteri4 Vt7/4.-144A.." l it-tif oiro‘..4P
• ..,
_ . .. .
Attach 2 copy of the wOillkeriiqiataiiiaaieTbIToiiiakideriiiiitltii Pileislin4ing" the policy number and expiration date).
• . Failure to secure coverage ai required...under Section 25AnfMGL;C;1$2.cattiead to die imPosittcm of minimal penalties of a . •
fine up to $1,500.0D and/or moll:tar imprisonment, as wellies civil penalties in the RAM ofii. STOP WORK ORDER. and &fine
of up to $250.00 a day against theadolatnr.;..Be_advised that a. coPy of, this. statement may be forwarded to the Office of .
Investigations of the DIA for inaurenee verifieation: .: , • . . .
I do hereb; i i. under the ' - iiiiiiiiiiiiiiiei qtperjr4itinitkeliiinnintiolipyividefiaboi is trite 04
-.. correct
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k/ . - •-• , Daft: • •-,-/
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1 Official use only. Do not writ.? in this area, to be completed by eft yoi, tome:Oda
, Cify Or TOVItn!
• • ' .• - . --Issuing Authority (circle one): . . . .
. 1. Board of Health 2. Building Department 3. City/Town Clerk 4..Electrical Inspector 5. Plumbing Inspector
. . . 6. Other ' . . ...___ ... .....:........ ..
....
! Contact Perm: Phone*
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. ,
____.____. .. •
...
11/10/2011 15:06 413 -247 -0276 JW COTTON LLC PAGE 02/02
.rr��w�,i �+e..r+rruw
NOTICE NOTICE
TO =. z� TO
EMPLOYEES
•=1. EMPLOYEES
w �wwwr
.. •
+� +a
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL L ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617- 727 -4900 - http:llwww.masS, og �'d�a
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notitt
that l (we) have provided for payment to our injured employees under the above-mentioned chapter by
insuring with:
LIBERTY MUTUAL INSURANCE CO _
NAME OF INSURANCE COMPANY
PO Box 9102 Weston, MA 02493 - 9102 1 800 - 762 - 5026
ADDRESS OF INSURANCE COMPANY
WC1 - 31S- -370670 - 010 _ 11 11
POLICY NUMBER EFFECTIVE DATES
R C NEYLON INSURANCE AGENCY (413)467 - 9133
NAME OF INS RA CE AGENT PHONE #
2 AMRERST ST GRANBY MA 01033
ADDRESS OF INSURANCE AGENT
J W COTTON LLC PO BOX 713
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' C 0 MPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with
the provisions of the Workers' Compensation Act, A copy of the First Report of Injury must be given
to the injured employee. The employee may select his or her own physician. The reasonable cost of
the services provided by the treating physician will be paid by the insurer, if the treatment is
necessary and reasonably connected to the work related injury. In cases requiring hospital attention,
employees are hereby notified that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Ih9uted Copy
vt.tssac�husctts • - Departn1 nt of • Public' Saf
Board t Building Regulations and Standards '<
Construction Supervisor License
License: ICS 85046
JOHN W CO _.
PO BOX 095
WILLIAMSBIJ G, MA 01096
• Expiration: 4/7 /2013
('u�nm issioner Tr#; 14026
•
CITY OF NORTHAMPTON
Construction Debris Affidavit
In accordance with the provisions of MG.L. c. 40 § 54, all debris resulting from any work
-- -- -- covered by a Building Permit shall be disposed of in a properly licensed disposal facility,
as defined by M.G.L. c. 111 § 150A.
Address of Work: PAA-.s 4 s S / n"" //:7X 14J
The debris will be transported by: w 5e,q u -73( L F-
The debris will be received at: J v U3 S 7`c
�,,.,�
Signature of Permit Applicant /_ "2 '�L��. '9i� At &X.-it—,
Date / ! / D /?.c' // /
Building Permit Number:
9
•
•
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occuvancv
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
iermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
1, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
,‘ •
The Commonwealth of Massachusetts
Department of Industrial Accidents •
Alk =r 1
Office of Investigations .
• L...........i= t...
600 Washington Street
i sillif- I Boston, MA 02111
.. ---
, • ' www.mass.gov/dia . .,
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name pusinessiorganizzionandivirimD:
• Address: ;
City/State/Zip: - Phone.#:
Are you an employer? Check the appropriate box: Type of project (required): I
1.0 I am a employer with 4• 0 I am a general contractor and I
6. D New construction
have hired the sub-contractors
, - employees (full and/or part-time).*
listed on the attached sheet 7. 0 R.emodelin.g
2. E] I am a sole proprietor or partner-
\ ,./ship arid have no e,..loyees These sub-contractors have. . 8. czi Demolidon
.,,—......, employees and have workers'
working for me m any capacity 9. - Ef Building additiOn
[No workers' comp. insurance cm
required.] .‘. \We are a corporation and its 10.0 Electdcal repairs or additions
3.0 I am a homeowner doing all work officers have4xercised their 11.0 Pi repairs or additions
.
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs .
insurance required.] t c. 152, § 1(4), and we have no
errgAoyees. [No workers' 13.0 Other
comp insurance required.j
*Any applicant that checks box #1 must also fill out the section below sboaing theirworkers compensation policy information.
1- Homeowners who submit this affida indicating they am doing an 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-contractars and state whether or 110t those entities have
employees. If the sub-contractors have employees, they must provide their workers' comp. policy mmtber.
2" 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/Slate/Zip:*
Attach a copy of the workers' compensation policy declaration page (showing the pulley number and expiration date).
•
Failure to secure coverage . as required inkier Sectidif 25A OfNIGL c. 152 can lead the iiopositiOn 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 WORICORDER. 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 Offfie of
InVestiiationi Of the DIA for insurance coverage verification. ,, , .._
_ I do herebycertifr under m ,,,, , . ' and penalties ofp erjurythat the infartrtation_providediabovaitinzaand_eopret _
Signate: < r - Ii 11 -
- / i
Phone
, . a : ?- ,
13) / -
. G - c Li c-, . •
Official use only. Do not write in thiv 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 ,
Contact Person:
Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
t , , ,`
Name of License Holder : \-7
-7 566 i
License Number
4 5
1 i1
� t t1( :*, - $ t 1
Address ' 01 -110 Expiration Data
Signature 's— Telephone
! '
B; Rpcltstera +�i elrxiti rreii�erttCtsiilra for~., �� r -$ :: letia. 4 2. i Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
•
•
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 C�
•
11• ; : i filninter - ern On
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 1083.5.1.
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
s
SECTION 5– DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
�—
� Or Doors CI
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [C1 Siding [0] Other [0]
Brief Description of Proposed �ry v�U�l� ` +� J� CL Q n Q �G� Le �`Cj
Work: �,. j� a'1C
Alteration of existing bedroom Yes No Adding new bedroom Yes No "`
Attached Narrative Renovating unfinished basement Yes No CO
Plans Attached Roll - Sheet
6a k1 ew hottses�'a lid oc addm'ori, € ,sti . o nc ` npfi fii' . Wi : -6 O ct MY' •
a. Use of building : One Family Two Family Other i 'A"`ep 6.e.. • i. • 1 • , 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, 1 V\. 01 M t c') CC t/LA 1 f f , as Owner of the subject
property
hereby authorize '' "L so H N W ��O
to act on my behalf, • all matters relative to work authokized this building permit application.
l0(a5 i (
Signature of Own Date
1, <jr_ " ( ° , as Owner /Authorized
Agent hereby declare that the statements and info ^ - ion on the foregoing application are true and accurate, to the best of my knowledge
and belief. / -' ,( ,
Signed under the pains and penalties of perju
4 ■ AZT '
Print Name 1 D w i` ''"" MI
vv �,`, : -{v\ t
Signature of Owner /A Date // /p --?_o //
r / ��2 p, Tom- y / . 1 s
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
: is column to be filled in f T t
i
ilding Departmen `1 9
Lot Size s . . �m m
�.
Frontage i i i --..
Setbacks Front P ( 1 I j
Side L: R: L.= 1 R:[ _____
Re ar __
Building Height ? 1 `
Bldg. Square Footage f 1 %"""'1 = ...e
i
Open Space Footage ? , % i
(Lot area minus bldg & paved „.„ ____.€ € i
parking)
# of Parking Spaces I i # „.a
Fill: I I�.��
(volume & Location) - €i
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 - ~ 1 Page? i 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 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 0
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
i~
ECEIVE° City of Northampton ° e , , ;
Building Department -.� g E ;
` 0 to t` 212 Main Street
siti Room 100
N. hampton, MA 01060 �k»
� eu I � G p !Iae' 587-1240 Fax 413 -587 -1272 !::;
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
3 9 l' ti---61.044) Caw Map Lot Unit
Zone Overlay District
EMI. St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:.— .
---) -e tn> - it � � �' ((0' -t C,( GIL 1 t lf\ 6 0 J 3 ,A,1 b t4%
Name (Print) Current Mailing Address: t" .Z. .-2.--
L Telephone
Sign re
2.2 Authorized ent: 7- 4� w — ' %Tr' L 6 e y r ST ���74� e`‘ "-mg a'
Name (Print) 1 / / -- ..., Current M. Iir Address: Pc' I '7c 7 <5 114- i ete ,44-,4 r� f .. Q 4. y,�f
C y l .. .. I ; . ` , l,' . , - ... ‘-11 3 -.25(7 `0
Signature , el phone '
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) %] IP
5. Fire Protection;
6. Total= (1 +2 +3 +4 +5) % 0-7-7 ' Check' Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0474 '
APPLICANT /CONTACT PERSON JOHN W COTTON
ADDRESS/PHONE (413) 247 -9608
PROPERTY LOCATION 37 HIGHLAND AVE
MAP 25C PARCEL 190 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out (,t� "
Fee Paid T�
Tvpeof Construction: DEMO BARN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 085406
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ION PRESENTED:
pproved 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 Delay
// / u
Signature of B mg fficial 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.
37 HIGHLAND AVE BP- 2012 -0474
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 190 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: demolition BUILDING PERMIT
Permit # BP- 2012 -0474
Project # JS- 2012- 000786
Est. Cost: $1000.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN W COTTON 085406
Lot Size(sq. ft.): 6490.44 Owner: HEIN JENNY M
Zoning: URC(100)/ Applicant: JOHN W COTTON
AT: 37 HIGHLAND AVE
Applicant Address: Phone: Insurance:
5 WEST ST (413) 247 -9608 WC
HATFIELDMA01038 ISSUED ON ::11/10/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: DEMO BARN
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 11/10/2011 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner