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17A-231
The Commonwealth of Massachusetts Department ofl tdustrial Accidents Office of Investigations m 600 Washington Street =� Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbe A • 'leant Information Please Print Le ibl� • Name ( Business /Organiationitndividuat): w i rA_ r - Address: /p ' AL N-14. S -ee f City /State/Zip:_ ,AO 0/DO Phone. #: V /3 0.10Y—,$8O Are uoy uoy an employer? Check the appropriate box: Type of project (required): �{ 1, El 1 am a employer 4. 0 I am a general contractor and 1 with employees (full and/orpart - lime }.• e at linen! on have hired the tub- eoattaesocs 6' ,E N v eorsttguctioa 2_ ❑ " I am a sole proprietor or partner unwind shat. tJ Remodeling ship and have no employees These sub contractors have 8. 0 Demolition employees and have workers' wonting forme ill any capacity. 9. 9. 0 Building addition [No workers comp. insurance Amp. " �1 5. . We are a corporation and its 10.0 F iortrical repairs or additions 3.0 I am a homeowner doing all work officers have eaatcisod then 11.0 Plumbing repairs or additions y � tight description ription per MOL 12.0 m o worirrs comp. c.152, §1(4), and we have n 1Z. Roof repairs insurance tequirz j to ( mss' 13.0 Other comp. insttraaoe regoiret *Amy ssis itme ks box II most also if oat dse session below showing their bahos•complasaoionpolicy isfebratics. t tienaom s woo submit thin affidavit indi.- .tg flay sae doing as wept and rhea biro se r• &cooeocloa oast s oar affidavit aid wig such. =Cootraetoes that chock this boa atuststbehed m additional shed its the AMC d die solvcarman tmd sbke whether or not those entities have employee& if the snbeaateaetots have an4k , they must provide their waken' abb. Peliev . I oar es employer that irprovlding workers' compensation lesurance for ray employees. Below is the policy and job site information. 1 Insurance Company Nauac: ' Ver . f �ci5 /A. Sv c & C e Policy # of Self -ins. Lie. tl: eg? ? 557 Expiration Date: d B#/e24 // Job Site Address: City/State/Zip: Attach: copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Ramie secant coverage as required under Section 25A ofM e. 02 an lead to the - ,imposition of criminal penalties of a fine up to St ,500 00 an+dler one yeer impsis , as well as civil penalties in the form ofa STOP WORRORDEit and a fine of up to $2SVA0 a day agninst the violator: Be advised theta eopyof this sat enenimay be forwarded to the Office of Emend a x' oft}ieDIA forinsurance aloe vaifcation. /do hereby wet - :th e painsiaaipunallies ofpe dw y that the Worm** provided above, ls:maid correct DtL An . i • ate: s .,._15 • Off use only. ' . not was in Usk area, 0 , -. • chi of town officiol City or Town: Peradt/Ltcsase r Issuing Authority (circle one): -1. Board of Health 2. Banding Department 3. Citytfown Clerk 4, Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: - Phone I: • • SECTION 8:- CONSTRUOMON serivOES 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder : Jet," 1,,„ ©y3 y60 License Number / te-t-•-r /9/,2e Acldrets Expiration Ddte AJ .. .. i /3'- 41 Signature Telephone ' ;mss ., Not Applicable ❑ ‘ get4 -1 ' 7e -):4,, FL,;( I L (S / Company Name Registration Number /Z `/ tic $4 - Address '�nl Expirab Telephone t/ /3 ° �'1Vg R zg SECTi N 10 -;WOR ' . ONS$ T t44SUi NCEAIFIDAVfT(M O L c. 15 ; § 006 ) 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 buildingpermit Signed Affidavit Attached Yes l 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 Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK {check all aoolicable) New House ❑ Addition ❑ Replacement W' Bows Alteration(s) ✓� Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [CI] Other [Dl Brief Description of Proposed / / T / J c00 4 4/117,-/./54,,,,,,, Work : v+nGG f / �/ 1'�X r 5 .( -1 �l Alteration of existing bedroom Yes /\ No / Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet •.4 . , °-ar 440,0r,---,,,,or .t :..2. . � �. 1.�.. b= ....L.....11., - d ' .,, • . « gre. 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? I f. Method of heating? Mr Fireplaces or Woodstoves Number of each r 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 la -OWNER AUTHORIZATION - TO BE COMPLETED. WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I , P / C U'- " "S , as Owner of the subject property hereby authorize )C) L v. 44 iAd r to act on my behalf, in all matters relative to work aut by this building permit application. Signature of Owner Date I, c: - - 1.,.. , as Owner /Authorized Agent hereby declare that the statementnd 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. .saw, I 1 i/ Print Name I ..4 4 1 1 1 1 . p Signature of Owner /Agent Date Y . . * 4 ■ richt !N. PV EEP �1t • #,„ • City of Northampton i f Y , ruip Building depart m ent f s �' ;- 212 Main Street ' oer of Room 100 �`� Northampton, MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 `��t ' 9 APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION 1.1 Property Address �I ,...7,7:77.4,50-...- ' 7 , $ l aw 5 k � y� M R f �e a .,, as Ai ' ,Y" 3 , 7,""J '$`e '1 -s ` ''�".,� SECTION 2 - PROPERTY OWNERSWIP /AUTHORIZED AGENT 2.1 Owner of Record: g � - r N C� v.45, �� L 5 f Name �6cint) Current Mailing Address: d % ( — e; < 9 j /; l.,.,.(( f/ . t:, ,.� Telephone Sig n ature 2.2 Authorized Agent: kw, L -s i' s r f L _/ 5J Name (Print) Current Mailing Address Signature Telephone SECTION a- ' ESTIMATED CONSTRUCTION COSTS Item ) to be UffiCial Use Only completed Estimated Cost by permit (Dollars acant 1. Building (a) Building Permit Fee 2. Electrical -76) (b) Estimated Total Cost of construction from (6) 3. Plumbing / ece) Building Permit Fee .01,,i..i IiiZ6-''' 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5 57 � Check Number This Section For Official Use Only Building Permit Number. Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File # BP- 2011 -0683 APPLICANT /CONTACT PERSON JOHN LANDRY ADDRESS /PHONE 104 NORTH ELM ST NORTHAMPTON (413) 204 -9880 PROPERTY LOCATION 97 LAKE ST MAP 17A PARCEL 231 001 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 0 1 5 Fee Paid Typeof Construction: REMODEL BATHROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 093450 3 sets of Plans / Plot Plan THE FOLLO G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION 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 - ,► • 'tion Delay r„... /7-1 .1. ...re of Build g 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. • 97 LAKE ST BP- 2011 -0683 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A - 231 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -0683 Project # JS- 2011- 001121 Est. Cost: $5700.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN LANDRY 093450 Lot Size(sq. ft.): 12937.32 Owner: MCGUINNESS PATRICIA Zoning: URB(100)/ Applicant: JOHN LANDRY AT: 97 LAKE ST Applicant Address: Phone: Insurance: 104 NORTH ELM ST (413) 204 -9880 WC NORTHAMPTONMA01060 ISSUED ON:2/17/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL BATHROOM 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 2/17/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner