17C-068 •
James Harahan (413) 498 -2649
437 Millersfalls Rd.
Northfield, MA. 01360
WC Phoenix Ins. # WC687 -47 -39
GL General Casualty Ins. # CCI0439257
Masonry: Staelens Masonry (413) 863 -2175
246 Mountain Rd.
Gill, MA. 01354
Crane: Deerfield Valley (413) 665 -7059
8 North St.
South Deerfield, MA. 01373
Painter Jim Sayer (413) 512 -0632
39 West St.
Greenfield, Ma. 01301
WC Granite State # 4396704
GL General Casualty # CCX0396577
Drywall: Rich Fay (413) 537 -5103
60 Chapel Rd.
Amherst, MA. 01002
WC Liberty Mutual # WC2 -318- 352781 -026
GL Peerless Ins. # CCP8302223
Flooring Booska Flooring (413) 863 -3690
Ave.A
Turnersfalls, MA. 01376
WC Liberty Mutual # WC2318355194017
GL National Grange Mutual # MPO89023
All Around Tile (413) 625 -8460
Mohawk Trail
Shelburne, MA. 01370
WC (Use sole proprietors installers)
GL Phoenix Ins. # 6804757W692
M. R. Damon Construction
189 Eden Trail
Leyden, MA. 01337
(413) 774 -4187
9/1707
Sub - contractor List
Excavation: Robert Deane (413) 648 -9089
58 Deane St..
Bernardston, MA. 01337
WC General Casualty # CWCO393732
GL General Casualty # CCX0393732
Renaissance Excavating (413) 863 -4462
Main Rd.
Gill, MA. 01354
WC AIM Mutual Ins. #WMZ8003941012006
GL Peerless #CBP9606177
Concrete: Dave Bernard (413) 863 -2144
10 Randell Wood Dr.
Montague, MA. 01351
WC AIM Mutual # 7010891012007
Carpentry: Brandon Grover
300 Brattleboro Rd.
Bernardston, MA. 01337
WC — AIM Mutual #6002984012005
Electrical Harley Wiemers
Plumbing: Frank Marchand (413) 665 -7177
54A Whately Rd.
S.Deerfield, MA. 01373
WC Preferred Ins. #XACRUB8726W75007
GL Travelers Indemnity #680199C7627
Insulation: Builders Insulation Co. (802) 251 -0250
62 King St.
Auburn, NH. 03032
WC Liberty Ins. #WA7 64 D 005193 015
GL Zurich American #GL)913952700
•
EMPLOYERS LIABILITY POLit..
v`-t�S v•st QUOTE PROFILE
POLICY NUMBER: (7PJUB- 0149M45 -2 -08 )
INSURER: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA
13579-MA
INSURED'S NAME: DAMON, MITCH R. DBA
M.R. DAMON CONSTRUCTION
RATE BUREAU ID: 000325183
PREMIUM BASIS
ESTIMATED RATES ESTIMATED
TOTAL ANNUAL PER $100 OF ANNUAL
CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM
LOCATION 001 01
FEIN 020481862 ENTITY CD 001
DAMON, MITCH R. DBA
M.R. DAMON CONSTRUCTION
189 EDEN TRAIL
LEYDEN, MA 01337
CARPENTRY NOC 5403 IF ANY 11.46
ROOFING NOC & YARD EMPLOYEES,
DRIVERS 5545 IF ANY 32.80
CARPENTRY - DETACHED ONE - OR TWO
FAMILY DWELLINGS 5645 IF ANY 6.80
CARPENTRY - DWELLINGS -THREE
STORIES DR LESS 5651 IF ANY 6.80
DATE OF ISSUE: 06 -09 -08 MR ST ASSIGN: MA SCHEDULE NO: 1 OF MORE
Information and Instructions
•
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required." s•
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall"'
enter into any contract for . the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub - contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
• Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self - insured companies should enter their
self- insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city'or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. .. _ _
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE
Fax # 617 -727 -7749
Revised 11 -22 -06
www.mass.gov /dia
! } , 1.
The Commonwealth of Massachusetts
Department of Industrial Accidents
i 0► = . Office of Investigations
=°alt 600 Washington Street
= = � Boston, MA 02111
.., w www.mass.gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information ‘t
Please Print Legibly
Name ( Business /Organization/Individual): e e R C 0 ,�vvtoie. C t1 S 'cue_ ev.
Address: ( c'1 Ed et' roj t Le.A j a 1 V�1 k . O 1'33 7
City /State /Zip: .1 Phone. #: ti l 1 /7 L Li 1 Z 7
Are you an employer? Check the appropriate box: Type of project (required): i
1. ❑ I am a employer with 4. ['I am a general contractor and I
�mployees (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 eloyees These sub - contractors have 8. ❑ Demolition
for me in an capacity. employees and have workers'
working Y P ty 9. ❑ Building addition
$ .
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ officers I am a homeowner doing all work have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. [w]'f2oof 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 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 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:
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 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 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 certify un er ins and penalties of perjury that the information provided above i true and correct
/
Signature: / I �...vi '�-- Date: / / er 01 _
Phone #: y/ 2 7 7 `i `il ec 7 (c) 6113 SS 1 / o 1 3
Official use only. Do not write in this area, to 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. EIectrical Inspector 5. Plumbing Inspector
6. Other
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
9..Registered Home= Improvement Contractor , . N ,:'i... „,. ...i ,i, 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 ❑
0 0:e 3 :ggi
1,I. H rnie1Q ET4, tx E! i„ On
T_he_current_exemption for "horneoners" 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
_ - — T. , . -- Gener-ai- L aws - annotated.
Northampton r tnan� s a / - • . -- . • • ... .� � � - � • . e - . s
Homeowner Signature -elaj 44,-
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House 0 Addition Replacement Windows Alteration(s) El Roofing n
Or Doors D
Accessory Bldg. ❑ Demolition New Signs [❑] Decks [[] Siding [❑] Other [❑]
G
rief Description of Proposed � ' , 4 2 J/ 1 C.
Work: P. /N6-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative . Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a If New house and or addition efist ng houslnci comnlete =the following:
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
I 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, [ 1Ge-r' \)Q,r't}rm2.,- , 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.
K a - tn (.. . -<--
Pr' • Name
6 -6
6 Q
. �Q
Signature of Owner /Ag-nt ,_ 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
Open Space Footage
area minus bldg & paved
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Pag 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 0 NO
IF YES, describe size, type and location:
D: Are there'any proposed c to or a pions signs irifended "for the property ? YES 0 NO 0
IF YES, describe size, type and location:
E. Will 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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r*
City of Northampton Status9f Peit
Building Department Cu cut/ way itt p
212 Main Street Sev✓erGSx#iAvailailIy ��
s Room 100 iii p 4:i £
-, t45.rthampton, MA 01060 Titcx ofS �P,Iaris �x�
phone 413- 587 -1240 Fax 413 - 587- 1272CSe
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
CTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
I / S C µ E ST N U T S f t E T Map Lot Unit
rF L0 r Vl N C F ttn a 1 b & "L— Zone Overlay District
Elm St District CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
- TPt .. -� f qME ---- - - - - -- __. - I FLo, A
-- 1ys -_c_ - , � N' a,o6
Name (Print) Current Mailing Address:
/ �{ 3- S' 2 -o
,,' ,._�- Telephone
Signatur- —
�f
2.2 Authorized Age
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Ite Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building 00 (a)''Bullding' 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) 0 U O Check Number • '1I
This Secfan Fr Affir_ia1 Use Only .. T... _
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
BP- 2010 -0277
Gl`s tf: COMMONWEALTH OF MASSACHUSETTS
ap.B1opk: 17C 068 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 -0277
Project # JS- 2010- 000356
Est. Cost: $4000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MITCHELL R DAMON 056721
Lot Size(sq. ft.): 27834.84 Owner: JEROME KATHLEEN F & MARGARET K KANOUSE
Zoning: URB(100)/ Applicant: JEROME KATHLEEN F & MARGARET K KANOUSE
AT: 145 CHESTNUT ST
Applicant Address: Phone: Insurance:
145 CHESTNUT ST WC
FLORENCEMA01062 ISSUED ON:9/10/2009 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 9/10/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
145 CHESTNUT ST BP-2010-0277
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 068 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 -0277
Project # JS- 2010- 000356
Est. Cost: $4000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MITCHELL R DAMON 056721
Lot Size(sq. ft.): 27834.84 Owner: JEROME KATHLEEN F & MARGARET K KANOUSE
Zoning: URB( 1001/ Applicant :_ JEROME KATHLEEN F & MARGARET K KANOUSE
AT: 145 CHESTNUT ST
• —____- ______ _ Phone: Insurance:
145 CHESTNUT ST WC
FLORENCEMA01062 ISSUED ON :9/10/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of 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: m Y 5-P-O`j-- A.,
THIS PERMIT MAY BE REVOKED BY THE CIT . OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy ,/ Pi" Signature:
FeeType: Date Paid: Amount
Building 9/10/2009 0 :00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo