17A-253 The Commonwealth of Massachusetts
Aw, Department of Industrial Accidents
5 = — . Office of Investig,ations
r 600 Washington Street
r _ =1:=..,"' f Z Boston, MA 02111
' www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
•
Name ( Business /Organization /lndividuaI): 4 / 5/4 U 6 r ,--- �ti' ,
Address: 7 zii /130 y
City /State/Zip: Nni k,-,. ,, ro ) m4 / Phone. #: 6 � ?1 'y% �
Are ou an employer? Check t'he appropriate box: ,
Type of project (required): /
1. Ir_'J 1 am a employer with !/ 4._ El I am a general contractor and I 6. El New construction
employees (full and/or part-time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet 7. 0 Remodeling
ship and have no. �iloyees These sub - contractors have 8. ❑ Deraol ion
wor for me in an aci employees and have workers'
y ty 9. [J Budding addition
[No workers' comp. insurance comp. msTnan�e_
required:] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
9fficers_lav . a _. ■ --1-1: Plumbing 3. [� J affi a -lieme ork- -- - - -- — ❑ g- 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 checks box #1 must also MI out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ZContractors 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 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: i e21 l I U 7 0 ( /U ,5 6
Policy # or Self-ins. Lic. #:Ib Sid ' ' ' 3 d . / 7 9/ - 0) 7 E x p i r a t i o n Date: 6 6 ' / 6 ; 0 i 0
Job Site Address: J / U4 /C � C ity /Stafe /Zip: (J ;'(�( ID 6 Q I d
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 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 of a STOP WORK ORDER and a fine
of up to $250.00 a day aga1i st the violator. to advised that a copy of this statement may be forwarded to the Offi'r.P of
Investigations of the DIA for insurance coverage verification.
Ido hereby certify under the pains and penalties o,. rjury that the inforination provided _above is_true_andcorrect_
S i g n a t u r e : i "7----- ' / ' , G2 `/ Date; / 1 0 7'
-
Phone #: 0 ! 6
Official use only. Do not wiite in t L area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
- I: Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector___
6.Other J
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES •
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : LA) ,4\ 40
7g? £ �> �� License Number
Addres U )77A s Y E xpiration Date
/ 7i J''r� old o 0 ? - 7, - ( 9,016
Signature Telephone
9: Registered.Home lmprolierrient:Gairtr etan,4 ., `� ,., ;, . . . ,,,...,, Not Applicable ❑
Company Name / f" ' Registration Number
V Ui cb/ t ?� -� III
id 9‘
Address Expiration Date
7F / & ",l J �'/ 7 700 '•'¢' Telephone rCle 06 —/ 8' ‘9,0)6
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M:G.L. c. 152, § 25C(6»
Workers Compensation Insurance affida t must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the build' g permit.
Signed Affidavit Attached Yes No ❑
Omit
The_current_exemption for "homeowners': was extended to include Owner 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, in is iiiteiided 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 referenceto 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 r_ iU°� nanca, - Sta e . • • •-General laws- Annotated.
Homeowner Signature
9
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement • dows Alteration(s) ❑ Roofing n
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [El] Decks [[] Siding [D] Other [D]
Brief Work: Description of Proposed 55 7.41/ , , P i / 2:14.40 ), ) p 6 O �
Alteration of existing bedroom Yes No /' Adding n edroom Yes No
Attached Narrative . Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a if N ovrrMi Ouse arid* edtiitiort.i `exlstiiiq hoiasinq, Compi'ete , the.folly ring:
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 CONTACTOR APPLIES FOR BUILDING PERMIT
I, roperty C `/Z I St,/ ✓ lr.' U. �JU �! 1 6 , as Owner of the subject
p
her by authorize n'A c) 3 L "66A Q
to ct on half, in al atters relative to 2 authorized by this building permit application.
Signature of Owner Date / ) 3
1 , (, d2_,Lc1 >rl L '' , n? , as D /Authorized
Agent hereby declare that the statements and infor o n the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
( 1 /2 W1 I) � 75 dQ.o
Print Name
Signature of-51 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 .. _.._�
Frontage
Setbacks Front
Side L: R :' L: __.._ R:
Rear
Building Height
Bldg. Square Footage ° % r
Open Space Footage
(Lot area minus bldg & paved
parking) I I
# of Parking Spaces
Fill: �� _ ,,,
(volume & Location) — L
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES
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 ' Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES
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:
``AF tyre ariy proposed changes to additions o igns intended for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. WiII 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.
1
City of Northampton tf
'
ty p Sfatts � f� It
_ Building Department ey��
,` z - 212 Main Street $ 6 k ic z c ti
+� ` Room 100 � ' � � � � 4'} "
o- Northarripton, MA 01060 e ; ® ��a = s� - k` `�F ::r
phone 4 -587M 240 Fax 413- 587 -1272
' s ° - ' g e f ,
o { �or ., * X' , k C� � � '
- 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
Map Lot Unit
F /O g_, , C / 01 2-. Zone Overlay District
Y Elio St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
j ' t 4s _ kl, 1 / q 0A U r.' 1=lo e.. 6- t c e, rytA —'
Name (Pri . _ Current Mailing Address:
J C Telepho Cr
Signature y'` 6. /
2.2 Authorized Agent: �r
k.: i7/1/1---
y� L 'J aP(� J 791, /S21 ci - - I / 4 1:2 111 pi A! l
' i-4-
Nan a Print) / Current Mailing Ad ress:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Ofricia( Use Only
completed by permit applicant
1. Building ,* 3/,,5 6 1 (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 �
�� (5 °--''' 4 Cheek Number 1
This Section For flfficialUse Only
Date
Building Permit Number. Issued:
Signature:
Building Commissionedinspectorof Buildings -- Date
I
• y
BP- 2010 -0556
GIS ft: 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 -0556
Project # JS- 2010- 000782
Est. Cost: $3180.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot SIze(sq. ft.): 16291.44 Owner: BOYLE CATHERINE V & CHRISTOPHER J BO YLE
Zoning: URB(100)/ Applicant: B & R SIDING
AT: 149 OAK ST
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers
Compensation
NORTHAMPTONMAO1060. ISSUED ON:11/23/2009 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 11/23/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo