17C-109 . The Commonwealth of Massachuser s
- -- -'=_- Dcpar tment of Industrial .4ccidents
_. ;� ---_- Office of Ir_ vesri, aeons
- 600 iT asltin on S : e
= ?� Boston, MA 02111
www.mass.g ov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
A.calicant Information PIease Print Leaibhv
Name ( Business /Oraanizatiortindividual): e `':` 4- t'y--a t :.% . i � _ , ` , "j‘ ; 'T • , ; s
Address —`T. L_ ` : } t' ,'
City /State /Z ti ' e . 't V - . t i. . ? I � - > Phone , L. 4 ; --' ' .- l' ' 7.-
Are you an employer? Check the appropriate box:
1. Type of project (required):
4 . 1 am a several contractor and I 6. ew consz action
� 1 am a employer with at
employees (full and/or part - time).* have hired the sub contractors Q "
2. ❑ I am a sole proprietor or partner- Iisted on the arached sheet 1. Q Remodeling
ship and have no employees These sub - contractors have S. ❑ Demolition
employees and have workers'
- working for me in any capacity. 9. ❑ Building addition
[No workers' comp. insurance come. insurance.?
required.]
5. W e are a corporation and its 10.0 Elec�icaI repairs or additions
:. ❑ I am a homeowner doins all work officers have exercised their 11.11 Plumbing repairs or additions
myself o workers' comp_ right of exemption per MGL
[� 1: ❑ Roof repairs
insurance required.] ' c. 152, § I(4), and we have no
employees. [� o workers' 13.0 Other
i comp. insurance required.]
*Any applicant that checks box #1 taus: also .11I out the section below showing their workers' conpensazion policy inforrnation.
Homeowners who submit this affidavit indicting they are doing ail work and then hire outside contractors must submit a new a'ndavit indicating such.
:Conn that check this box must attached an additional sheer showing the name of the sub - contactors and stare whether or not those entities have
employes. If the sub - contactors have enmiovees, 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 sire
information.
Insurance Company Name: LATei, EV%plo 11 3v24t1C- 1 D
Policy 1 or Self-ins. Lie. T: W C So 000 4-490 j 2_040 Ja Expiration Date: to 126/ 3/
Job Site Address: �, t -� �! �� M 1/-f • City /State,'Zip: 4 : �" 12 r-L��� '®., /�� °Ti
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 31.500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 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 under the pains and penalties of perjury that the information provided above is true and correct
/ _ '
S irnature : Date: - - ' -
Phone #: '
1 1 OJJ cia1 use only. Do not write in this area. to be completed by city or town officiaL
Cite or Town: Permit/License 1
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. Ciry To Sri Clerk 4. Electrical Inspector 5. P'umbing Inspector
6. Other i
i Contact Person: Phone -:
.
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑ p
Name of License Holder : V e.Q1/ e. Z At
License Number
3 l ?k fE STS. (...0g.,ert c-- tih4 . G 5 05 3 G
Address Expiration Date
58 a2S 1
b ` I
Signature 1 Telephone 1
9. Registered Home Improvement Contractor: Not Applicable ❑
(0 t2. 21
Company Name Registration Number
4��,s o -{ ` �O ►'l�V•'aG"� ►yl ( o �. Z'5 I r . 1 ✓ .
Address a v1 Expiration ate
J 'P t h� 5 t" - �"LS�tr -€."\C_ I1 Telephone 5 Qu 4 (.25
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 T No ❑
11. - Home caner Exemption /
The current exemption for " eowners" was extended to include Owrper occupied Dwellings of one (1) or two(2) families
and to allow such homeowner to age an individual for hire who does not possess a license, provided that the owner acts
as supervisor. CMR 780, Sixth E ' 'on Section 108.3.5.1.
Definition of Homeowner: Person (s) w 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 dw- ing, attached or detached structures accessory to such use and/ or farm
structures. A person who constructs more than o • home in a two - year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Officio , ■ n a form acceptable to the Building Official, that he /she shall be
responsible for all such work performed under the build' , permit.
As acting Construction Supervisor your presence on the job sit- ill 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' Compensa ' on) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General - ws 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 •th the State Building Code, City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts Ge • ral Laws Annotated.
Homeowner Signature
. .
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Section 4. ZONING All Information Must Be Compteted. Perm Can Be Denied Due To Incomptete Information
Existing Proposed Required by Zoning
This column to be fihled in by
Building Department
---- ------------ ---'----- ------
Lot Size .., , `__ - '__.---
' ----- -- A i
Frontage `�__'_-_____ __� _ _ _'-_-___-_-_--___--�
Setbacks Front -- 7 . �
---'' �' '
l �[ ---
- 1:, `,R: / r---IL�---� -] '
--- _ ---
L
Rear ___
/-
_l
Building Height [ [---' - �----
.---
Bldg. Square Footage --' '---' % r —� -- , , —
�� | �
Open Space Footage _ __ _� % -
�v"n�m�x maompuna _
' - _ 7 [--�� L |
parking)
[ — '
| [--—
#ofPud�ngSpaces ----- `-- ----
Fill: - i
(volume m Location) - - -� - -------- '--------/ ----------'------
A. Has a Specia / -en issued for/on the site?
�� 0 0
NO »�� DONT KNOW »�� YES «��
IF ¥ES, date issued:
` --
IF YES: W s the permit recorded aythe Registry of Deeds?
NO YB��
~^.' �� �_-
-- , --
IF YES: Page,
en�er Boo�� | ; and/or Document # {
v�� �~� � ~\
B. Does the dtecontain a brook, body nf water orwetbands �7� NO %�� DONT KNKNOW YES �_�
|F YES, has a permit been orneedtobe obtained �omthe Conserva�onCommis�omJ
Needs to be obtained »� Obtained
� x�� Date Issued: �- '--------|
�~� �-� , ' �_/
�
�
C. Dn any �gnxexist on the pnoper� �� property? YES x~� NO yC�/
^_
|FYE5
|
describe type , size, location: ,
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
-------------------- - ----------
IF YES, describe size, type and location: I |
---`--- ---- ------------'-----
. E. Will the conobuctio���'
construction activity ring.gradi ".exuavuU acre it on.or�||ing)nver1onoriopodcfaoommnnplon
that will disturb over 1acre? YES �� NO d��
�� ��
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) hS5 Roofing n
Or Doors I]
Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [0 Siding [01 Other [01
Brief Description of Proposed T> t ` • c --- r
Work: t<..Q_ CI C- t^ C7d (A) 1 -'\/ , ,'>`\UV.(Ii v±
Alteration of existing bedroom Yes i No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete 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 n 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 wetlan's- Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor -helm 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'' ''`` 0 I p ( i , as Owner of the subject
property (� � O � \
hereby authorize V - cc' Nre,
to act on my . . - , ' . , tters tive t. - ork authorized by this building permit application.
Signature .'owner Date
I, je-P-Pe.e. `_j g O , 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.
Print Name `
r 1 r
•
' r r,
Signatu 4 n:i ent Date'
--
\ \10.17„,
\
- "
` �
^
VE"" Department use
LJ of Northampton Staf o Permit ''
Building Department Curb CulDrtrewaye ttrt f {
III 3 2011 2 - 2 Main Street Se er /Septic Iitab ili t k ' 4-
Room 100 WatertWell Avails i ility a .
OF BUILDING INSPECT c lSI'OrthAmpton, MA 01060 T S ''
�.� •
noitTwwiPro Mn ° 1240 Fax 413- 587 -1272 P ottstt a Ar,
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
BA/8. Map Lot Unit
r -- Zone Overlay District
wl
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Pri Current Mailing Address:
Telephone
Signatu
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Sign: Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building C�?) (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) I r ere) Check Number ,3 ; 43 5
This Section For Official Use Only
Permit Number:
Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
16 STILSON ' AVE BP-2011-0967
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 109 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP- 2011 -0967
Project # JS- 2011- 001586
Est. Cost: $1500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BOTT 053157
Lot Size(sq. ft.): 11020.68 Owner: HOOVEN FREDERICK H & HEIDI B H
Zoning: URB(100)/ Applicant: JEFFREY BOTT
AT: 16 STILSON AVE
Applicant Address: Phone: Insurance:
32 Pine Street (413) 584 -6251 Workers Compensation
FLORENCEMA01062 ISSUED ON:5/24/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOW
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 5/24/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
16 STIL$ON AVE BP- 2011 -0967
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C -109 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP- 2011 -0967
Project # JS- 2011- 001586
Est. Cost: $1500.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JEFFREY BOTT 053157
Lot ize sq i1:p - 1 402E 68— -- - -- Owner : - - -- HOOVEN FREDERICK H & HEIDI B H
- - - - - -- - - --
Zoniny T T12w1ofry Applicant: JEFFREY BOTT
--- _
AT 16 STILSON AVE
Applicant Address: Phone: Insurance:
32 Pine Street (413) 584 -6251 Workers Compensation
FLORENCEMA01062 ISSUED ON :5/24/2011 0 :00 :00 d-7-- n/Eitvez
TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOW
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: 0 l - /( C ,,,,
THIS PERMIT MAY BE REVOKED BY THE CITY OF. ORTHAPTON UPON VIOLATION OF
WITS
ANY AND • . i ,,P M t � �
Certificate of Occu.a 1 ! _ nature: Attu YG�y� �4iTV
FeeType: Date Paid: Amount:
Building 5/24/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner