Loading...
17C-035 ■ . 4 ' ,2 . ■ . 4 . The Commonwealth of Massachusetts ....,, ,.. Department of Industrial Accidents Office of Investig,ation& 600 Washington Street J?' g Boston, MA 02111 %ar •7 - , , , www.mass , ■ -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers - - Applicant Information - Please Print Legiblv Name pusineseorpniiationfindividlinD: - • Address: . ; • City/State/Zip: - . Phone.#: - Are you an employer? Check the appropriatebox: • . •Type of project (required): 1" 1.0 I am a employer with 4•. 0 I am a general contractor and I 6. 0 New construCtion have hired the sub-contractors employees (fall ancVor part-time).* lis-ted on theattached sheet: 7• E1 Remodeling 1.0 I am a sole proprietor or partner- These sub-contractors have. -8. 0 Deinolition. ship andha.ve nci eimloyees worldzig for me in any capacity. emgo_yees-_andhave workers' - • _ 9: arrtiildiig (1,1 wor coriap i nsu i ance . _ Comp.inSncel.: _ . __,_—_,.._ r . requirecti - • • 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. W/ I am a homeowner dOing all worIc officers haVetcereised their . 11.0 Pluinbing repairs or additions .•.yself, [No workers' cOrop. right of exemption per MGL ■--, 12.Li Roof repairs . • i nsura ' nce r t . . . p 152, §1(4), and We have no • _ employees. [No workers' 13.0 Other r • 1 . coni p. insurance required.} . • . 'Any applicant -that checks box #1:must also fill out the section belowshowing theirworicers' cornpen.saiion policy infounation; -. . t Homeov.rnera who submit this affidivit.infr they are doing all work and then hire outside coniraCtora must submit a new affidavit indicating such. IContractors that r+.1.0 this box mustaaached an adifitional sheet showing the name of the sub and state whether-or notthose.eatities have employees If the sub-contractorsbiVe employee& they mustprovide their wciriccis comp poficy number. lam an employer that is pkovidin g workers' co mpensation insurance for my einplOyees. Below is the policY andjob: site information. . . . . Insurance Company Name: - • . , • - Policy # or Self-ins. Lic. #: . Expiration Date: . . Job Site Address: . - City/State/Zip:' • ' . .. . - Attach a copy of the workere'comperisation policy declaration page (showing the policy nwilOir and expiration date). Failure to secure Coverage as required brideit.SeCtibii'25A MGL"d. 152 can lead to the imposition Ofariiniti4liiinalties of a foie Up to 51,500.00 and/or one-year imprisonment, as well as cry' il penalties in the form of a STOP WORIC-QRDER ancla free °flip to S250.00 a day against the . yiedatif. Be adyiSeci that a copy Of this statement may be forwarded to tiliO , .„.•., , Hieltiiitions COViiii"'"ie"ifiiiii. - ' .. :- - -- '77. --. 7 . . iby. 6 71iiiikr tileiiici.anlipeilliii&i:olieVuly : that the infirMatiOnpividiii::Wad7ciorr7 ct.' .. ...- \ . r Signatue: Q\ ‘N\ , , T . • . - . : 715t e: ' 1 '(,t \ - - _ t. . . , . Phone #: - . .. _ . . - Official use only Do not write in this aria, to be completed by city or lowiiVicial City or Permit/License # Tovvn.: Issuing Authority (circle one): '• ' .1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electricalinspector 5. Plumbing Inspector 6. Other , 6- . • . . ■ 1 I Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 4, 'ReQiSteria=HaineiriiiioViriiiiiittoiifr'aalaeiaikSLUI - 4U 4 QkahaOLM:::;IR 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 ❑ m wn r motion 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 \ ° L ° �'J �r` SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition [] Replacement Windows Alteration(s) ❑ Roofing In Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [D] Other [0] Brief Description of Proposed y� ` 1 Work:. �Ox\1' tirki k1ti\ V�� �� \�1 to (�Vlt\ r\�,t�� �1 Alteration of existing bedroom Yes t /No Adding new bedroom Yes V No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet arl�c� .r�at� rll���t'el��Inp��Q�sfnq ccr��1`e,t�t�:follr�Wi�ap: a. Use of building : One Family 1.7 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 , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1, v`\ A16 C" 3? , as Owner /Authorized Agent hereby declare that t staterhents 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/ ti(kN,t o Ges &V\ Print Name f edu- �L °W�CZ . . ' "4-- S 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 a filled in by 4 , + 0 Building Depa ent, ,, ' Lot Size Frontage G.- -. - Setbacks Front 3 1 i . : Side L: i R:' ? L:___3 R :1 . Rear t - Building Height t 1 ` i L ... i__,......_ , a Bldg. Square Footage [Li 1 1 % 1 , r I i i Open Space Footage % — f (Lot area minus bldg & paved i parking) # of Parking Spaces --- Fill: ,,_,__ �_ �_ .,� ,, _, �_ ._. ,e _, _.. m, (volume & Location) -- -- A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO S DONT KNOW 0 YES 0 IF YES, date issued:I 1 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 0 YES 0 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 Q NO e. _, IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO ct IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, e cavation, 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. , C��tO City of Northampton s �� � # �� k ,' FtE Building Depar a m � . ., R �� ' 20 1 212 Main Street �x , ; 4; Room 100 � �ffi � � ": x �� i , , ;' N. hampton, MA 01060 tr -r •1 - ' - 87 -1240 Fax 413 -587 -1272 - fi A l , ids l: ,,ir :• .... " �' x, : : 4 3 ;lt, =• 9.. 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 IN 1 \ ) Q\4\ tA � t Map Lot Unit 1"�J\2 q °t�'� Zone _ Overlay 'District Elm St District CB District I SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: i 0A1 - 0Y1 C % ©1) t( h1r�, \h nary . yc o 01 Name (Print) Current Mailing Address: / "r /fl Telephone Signature �\) � " 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building i y� 4 t-k UAQ (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 35 i it 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Section For Offic Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 41101111 1111111Nimmift e . 109 NORTH MAPLE ST BP- 2011 -1028 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C - 035 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofmg BUILDING PERMIT Permit # BP- 2011 -1028 Project # JS- 2011- 001659 Est. Cost: $4000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 65340.00 Owner: GAGNON MARION E Zoning: URA(78)/URB(22)/ Applicant: GAGNON MARION E AT: 109 NORTH MAPLE ST Applicant Address: Phone: Insurance: 109 NORTH MAPLE ST FLORENCEMA01062 ISSUED ON: 6/8/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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 6/8/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner