24C-082 The Commonwealth of Massachusetts
Department of Industrial Accidents
—.,;; E Office of Investigations
a 600 Washington Street
_' S°::' a ?.r:; Boston, MA 02111
4 „s.n www.mass.gov /dia
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Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information r Please Print Legibly
Name (Business/ Organization /Individual): f " /� dei E_ y ti Z.
Address: i M ' t' ../ fr''ee
City /State /Zip:6 7'1C frI /Vl,0 f/ 3o/ Phone #: • 7. - 7155
Are you an employer? Ch the ap box:
Type of project (required):
L [ I am a employer with 4 / 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in act employees and have workers'
g any capacity. 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10. ❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
[No p
myself. o workers' comp. right of exemption per MGL 1212.E] Roof rep .
Y
insurance required.] t c. 152, §1(4), and we have no ��� �
employees. [No workers' 13. ,] Other , /1tc1 tali. -/t 23
comp. insurance required.] , rid or 'a
*Any applicant that checks box 41 must also fill 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.
Contractors 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 mast pmvide 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: • - e7/ V a v7? <-1"n y'
Policy # or Self -ins. Lic. #: ( C /9 ()€ 0A/ V Expiration Date: t',j 0 /' <9 /
Job Site Address: 13 1 as D , 4S 1- • City/State /Z " D r +� G�P n Ma M itt D
i
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 m the form of a STOP WORK ORDER 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 Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi der the pains ►,d penalties of perjury that the information provided abov is tru and correct.
Signature: { r Date:
T30 l
Phone #: t (43 - 7,2 - O`
Official use only. Do not write in this area, lo 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. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
0
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Oa, > cL C - �e- , cD ci 1 ( 4 l
License Number
1 SS 1 4 C k - 'in A-. ��� If . � � � tAc(. Di e5 t ' 31 i 1r j
Address Expiration Date
aItc C(O . -015
Sign °. Telephone
Reaistet'ed Hothe iniothiiiiiiiititeatitrackitikairaWkaaitteNeimA Not Applicable ❑
( Pel1 orb 1uC � 1 t�C • [ L2,7`i
Company Name R egistration Number
1.65 FAQ. n `S� Gifekn' t Act t . Cl3 \ 3 2y ( 12—'
Addre Expiration Date
a C . 4 J W Q . Telephone i 1 1 /2.0151
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 Ig No ❑
. =. ame wna
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 Alteration(s) Roofing J
Or Doors [�
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C7 Siding [0] Other [0]
Brief D sc if4�io 9f Pro heti �
Work: T�GIlin {(J / bOtnJ1»5• uSl�34 &Sf"/✓1QOpen1ft3 J1rc. iL/� 1
Alteration of existing edroom Yes ✓ No Adding new bedroom Yes J ✓ No / c h4n-qQS
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet (4- U 4 ( e
64 , ;it house andtaadc�lti / n to e�r�stlnq, hnusirdcntf>tbiete e `i�[trtwiitiq:
a. Use of building : One Family V 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 Red tale merit
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, t: A �.� 4 I ' d L. -4-- 1 14 .4(....I ` , as Owner of the subject
prope i 1 t
her sy authorize �� ` `G Ti O L1 G ` n-( -
to _ct on my behalf, in all matters relative to work authorized by this building permit application.
• t\
• Signature of Owner Date
f d_.A `a R ((7 c LkC'K f ` , 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.
T cU'\ C. (13 h��`�
Print Name ca C It) Kb., \:/A. kl
Signature of Owner /Agent Date
.
I
1
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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 L. ._.... _.__. _ -_ 1 i `
Setbacks Front `- r_____,
Side L::. -. i R. .. L: _1 R :E 1 ? ______, :
Rear 3 L ~—{ „_._. _
Building Height € . _.�_ .�.
Bldg. Square Footage ! % 1
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces r----1
Fill: ___.m.__ i _ ,
(volume & Location) ___. . ..__. -. _ .
A. Has a Sp cial Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued: 1
IF YES: Was a permit recorded at the Registry of Deeds?
NO DON'T KNOW ® YES 0
IF YES: enter Book I v _� J Pa ged and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 6 DON'T 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 Q , Date Issued:
C. Do any signs exist on the property? YES 0 NO d
r
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
IF YES, describe size, type and location:
I
E. Will the construction activity disturb (clearing, grading, e vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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�� ity of Nort • � irni " � 8 : � :
'�(` ` : ilding Department . �$ ® # a P_
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rr ampton, MA 01060 . • . �
is ,, ,, - •
e 4 13 - 587 -1240 Fax 413- 587 -1272
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: Th section o.be by office
1 j �4 SSQ S b 4 S Map Lot Unit
N or m e it i , 10 D O Zane Overlay District
Eim St. D istrict CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2 Owner of Record:
C' �� ,J. /v k�� y/c �3 I ' 1 4SS a so S �r •
Name Print) . Current Mailing Address: �1 5 ��
g = /C Telephone
Signatur
2.2 Authorized Agen
Te CIL ��u��e - �n l 5 � N�o� C-tteen �, t`‘Q
Name mt)
Current Mailing Address: 1 con)
O ` 2,� \
t-t Y C c to • r yz . CJ Jv
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
ii/49
Item Estimated Cost (Dollars) to Offic Use OnMy
completed by permit applicant
1. Building
O (a) Building Permit Fee
2. Electrical (b) Estimated Tota Cost of
_ Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection 11
(1 ) l � O • 00 Check Number
6. Total = 1 +2 + 3 +4 +5Q � _�s_
This Sec For Official Use Only
Building r: Date
Issued`
Permit Number:
Signature:
Building Commissioner /Inspector o Buildings Date
13 MASSASOIT ST BP- 2012 -0222
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C - 082 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Peucit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP- 2012 -0222
Project # JS- 2012- 000329
Est. Cost: $1800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PELLA PRODUCTS, INC 091496
Lot Size(sq. ft): 6011.28 Owner: NIKONCZYK PETER A & CYNTHIA J
Zoning: URB(100)/ Applicant: PELLA PRODUCTS, INC_
AT: 13 MASSASOIT ST
Applicant Address: Phone: Insurance:
155 MAIN ST (413) 772 -0153 WC_
GREENFIELDMA01301 ISSUED ON: 9/1/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 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 9/1/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner