17A-239 v
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The Commonwealth of Massachusetts
• ..v4.-----= Department of Industrial Accidents
Office ofinvestigations
600 Washington Street
Boston, MA 02111
- , www.mass.gov/dia . .
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 944/ 4- AA ik ft
Address: Liar 4,16 2E11/C , -
City/State/Zip: Fu e bA$ .e ilk Ici . Phone #: 91 - J./ C7 - & -.,-- 0 d
/
. -
Are you an employer? Check the appropriate box: • 6 Type of project (required): I
1.0 I am a employer with • 4• 0 I am a general contractor and I
have hired the sub-contractors
loyees (full and/or part-time).*
listed on the attached sheet. 7. WRemodeling
2. Olarri. a sole proprietor or partner-
ship and have n.o employees These sub-contractors have 8 1
'
working for me in any capacity. employees and have workers 9. D Buildin,g addition
[No workers' comp. insurance - cor insurance- .
required.] 5 Li We are a corporation and its 10.0 Electrical repairs or additions
3. [ I am-a-homeowner-doing-all-work _offic_e_m_havaxercised_teir__
; 11.0-Plumbing 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
employees. No workers' 13.0 Other
_ comp. insurance required.] • *Any applicant that checics box #1 must also fill out the section below showing their workers' compensation policy inforrnatiom
t Homeowners who submit this affidaVitindicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors 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 worIcers comp. policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
ircf_o_rmation.
_
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 covera.ge 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 a a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. rie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
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I do here i erti& the' e , , • , , d penalties of perjury that the information provided.aboveis_trueund-correct.____
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-4' ■ tare INPAIAVirdrAldi i a - —
, -
Phone #:
-
Official use only. Do not write in this area, tobe dbliipieted by cityor toivirarIciaL
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 #:
i
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Vitt V M A±I E -Sc N CS 8 G 1 0
License N ber
t t 0 1 7/ c la ti
Address Expiratio Date
0 >e Eeve_ m.
S' ature I t Telephone
-POr.-k. YuI� ` f t a r .��7
9' Reuister Kotnorhbiuoefm" ten Co c` a c . „ kg , ; ° 4 Not Applicable ❑
Companv Name Registration Number
Address Expiration Date
4 fD c E✓U C e /2E) 4' / 0 3 Telephone `fly -a i 9 - d
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 ❑
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
ttl
Ott amp Off •rianc =5, a e , -•_ • -_ •. 1. • - rat - Laws - Annotated. � „ .� • r - •.: ,
Homeowner Signature
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s
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Wir(dows Alteration(s) 0 Roofing ❑
Or Doors Fd'
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0]
Brief Descri lion of Propos A
Work: r a Fr. 0 o a I INS v LAI 7 9 Si E w W r tN A 4N S ( FQo n7` pat e /k
Alteration of existing bedroom Yes f No Adding new bedroom Yes (.7 No
Attached Narrative Renovating unfinished basement Yes `' No
Plans Attached Roll - Sheet
a. ti dSi;. IE k ,6Emdsbwfa [i1111 6agrf 1�, R1 et t fi:
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, Cg /Ill ah c itn d b , as Owner of the subject
property
hereby authorize
'PA-UL 444-ffps0'Iti
to act on m ehalf, in all matters relative to work authorized by this building permit application.
_ A.-.1
.— g
Signature of Owner Date
1, 964 LI 1 M as TES L
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.
PA ✓ c- AA il -}-( S a ei
P ' t Name ^/\ ■:TfA 43/. 1 _ 7 - I D
Signature of Owner /Agent Date
,
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 . i
1 1 . .......,..1
Frontage I —
Setbacks Front I 1 I 1 f 1
, ,-,,
1 --
Side L:i , R:i, _1 L::__! R:1_ , 1 ,
rn . ,
t i 1
Rear --
Building Height , --
,
i L.... .
Bldg. Square Footage
1 ,----- % f i
L L._ 1 __
Open Space Footage %
i 1 i---i f 1
(Lot aroa minus bldg & paved L--; — ,%
parking)
-%--,--%---
# of Parking Spaces 1___1 . .
Fill:
1 i i 1
(volume & Location)
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO 0 DONT KNOW � YES 0
t 1
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 i I Page! 1 and/or Document #.
. I
B. Does the site contain a brook, body of water or wetlands? NO 0( DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained
0 , Dat Issued:
C. Do any signs exist on the property? YES 0 NO
_
IF YES, describe size, type and location: :
-- D - .' - 11 AFe - 11 h - efe - t 1 - Eijii5 - iiiiia – clia - rigaTodriaatioinis o sigfirfrifelide ? YES 0 NO
! _ _
IF YES, describe size, type and location: ;
E. Will the construction activity disturb (clearing, grading, exc ation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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If
City of Northampton , ,�
Building Department • 4
212 Main Street
r 10j\ � , Room 100 I w
�� - lorthampton, MA 01060 6
0 . phone 4'13- Fax 413-587-1272 '�
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:
G ! E 5 -f - Map Lot Unit
( " n h I6 Zone Overlay District
-Pc °R -A/ c-c M 4 _ 0 I oC
„EimSt : District CB District
SECTION 2 , PROPERTY OWNERSHIP /AUTHORIZED; AGENT
2.1 Owner of Record:
Name (Prirllt Cu ent Maiing Address:
na it I CIA. Aho/it_toW S 1 , ice S ! ' d4-104 I� A 0 10(;1_. T ph on 21
`� p r _
Signature ' J ` j3 5 -- C1
2.2 Authorized Agent:
payc. rn44- i Eso AI 'i 6 8 F ,2 6
Na e (Print) Current Mailing Address:
� y r 3 .- d I 1 — Fs6 tS
Sig lure Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ISM 0 6 O (a) Building Permit Fee
2. Electrical 3 q d 0 , eS jf (b) Estimated Total Cost of
Construction from (f) 1 ,
3. Plumbing Building Permit Femme}
4. Mechanical (HVAC) clp 5 U
4 ) °
5. Fire Protection A (r
6 Total = (1 + 2 + 3 + 4 + 5) �j 1 Check Number L1i'�
This Section For Official Use On
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0882
APPLICANT /CONTACT PERSON PAUL D MATTESON
ADDRESS/PHONE 408 FLORENCE RD FLORENCE (413) 219 -8506
PROPERTY LOCATION 61 LAKE ST
MAP 17A PARCEL 239 001 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
Fee Paid / g- )*'6 j G ' 6v-iv di/3. 90
Tvpeof Construction: DRYWALL /INSULATE,REPLACEMENT WINDOWS/DOOR ENTIRE 2ND FLR
New Construction
Non Structural interior renovations
Addition to Existing 601/6 b
Accessory Structure q ( „ 0
Building Plans Included: 1 1
Owner/ Statement or License 86090
3 sets of Plans / Plot Plan 114(411- I N STALL- S r/! F a € ' E c d RS 2- ? Fl-ect2 --
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON Pt& Ct Fi f 6)0f5
INFQRMATION 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 Delay
1. Lt) 16
Signature of Building Official 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.
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6 4 "4 BP- 2010 -0882
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0882
Project # JS- 2010- 001304
Est. Cost: $18900.00
Fee: $113.40 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL D MATTESON 86090
Lot Size(sq. ft.): 24001.56 Owner: ANDREWS GILLIAN
Zoning: URB(100)/ Applicant: PAUL D MATTESON
AT: 61 LAKE ST
Applicant Address: Phone: Insurance:
408 FLORENCE RD (413) 219 -8506
FLORENCEMA01062 ISSUED ON:4/12/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: DRYWALL /INSULATE,REPLACEMENT
WINDOWS /DOOR ENTIRE 2ND FLR -must install smoke det on 2nd fir per current codes
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 $113.40
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
61 LAKE ST BP- 2010 -0882
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 239 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0882
Project # JS- 2010- 001304
Est. Cost: $18900.00
Fee: $113.40 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL D MATTESON 86090
Lot Size(sq. ft.): 24001.56 Owner: ANDREWS GILLIAN
Zoning: URB(100)/ Applicant: PAUL D MATTESON
AT: 61 LAKE ST
Applicant Address: Phone: Insurance:
408 FLORENCE RD (413) 219 -8506
FLORENCEMA01062 ISSUED ON :4/12/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: DRYWALL /INSULATE,REPLACEMENT
WINDOWS /DOOR ENTIRE 2ND FLR -must install smoke det on 2nd flr per current codes
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: S L `� House # Foundation:
/1 Driveway Final:
Final: Final: 57/3//e
Rough Frame: it .1 i (6 s C
Gas: Fire Department Fireplace /Chimney:
•
I
Rough: Oil: Insulation: 0 k ' ( 1E f o Lo
Final: Smoke: Final: F; ,+Ul AG CK S I 131 (0 Lo ( S
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
0 11'4446.0 A. 4
Certificate of Occupancy S t 3 10 A f Signature:
YU
Feel e: l ate Paid: Amount:
Building $113.40
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo