17C-167 (2) c No • .... •—• * 7
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The Commonwealth opfassachusetts
Department of Indus Accidents . ,. .
Office of InvestigationS . •
600 Wcishington Street
: Boston, MA 02111
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, www.mass.gov/dia
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-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly
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Name pusineseorpniiat1onadividn2D: \ a i , Z ,
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• • Address: \ -erZ4 Ov 64-.,, \ ,. - •
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City/State/Zip Phone.#: Li \ , — 5 , — 8 7.-. ,
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 coistruCtion
have hired the sub-contractors
employees (full and/or part-time).
2.. I mit a sole proprietor or partner- lis-ted on theattadted sheet. 7.14Remodeling
These sub-conixactors have.
' - and have to :i•loyees .8. 0 Demolition
working forme is any capacity enffiloyees-_andbave workers' : . - ._ . -; •
9: lalliildinkraditiOn
No workers -' comp:Mai-awe • - enn * - .
0 We are a corporation and 10.0 Electrical repairs or adcrtions
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• 3. 0 I am a homeowner doing ill work officers havexercised their . 11.0 P1miabixt repairs or additions
myself [No workers comp. • flea of exemption per MGL
12.0 RoofrepaiX s . i •
insurance requiredj t . . ,c 152, §1(4), and we have no •
eroployees: [No workers' 13D Other F 9c f,tAtts,34+
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con all insurance recli* -6(1 • •
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• *Any applicant -that checks box innaist also fill out the section belowshowing theiriVorlocre compeOsation policy infant:glen;
I Homeownert who submit gni affidaidt incricating they are doing aD work and then hire outside contraetora must submit anew affidavit indicating such.
:contractors that check this box mtutattached an atliEtional sheet showing the name of the subcontractors and state whether ornotthose =ides have -
employees. If the sids-contraCtorsbmie employeeS, they mustprovide their wariceis' con* policy number.
• .1 am an employer that is providing workers' compensation insurance for my einplayees. Below is the policyandjob site
infornzation. . . •
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Insurance Company Name: • - . . •
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Policy # or Self-ins. Lic. #: . • Expiration Date - • - • • •
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Job Site Address: : • - City/State/Zip:' - • . - . . - - :
• Attach a copy of the workers': compensation poliey declaration page•(showing the policy iminber antklexpiritiott date).
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Failure to sect= coverage as reciiitedinicter Sectiiiil25A 152 can lead to the irov P Of erithing Pei:Lai of a
fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties m the form of a STOP WOPX-ORDER and a foie
to S250.00 a _day against the violet:it. Be advised that a copy O,f ithis statement may be forwarded iOiti 0i6Ce of
"fft • , e/)1Kfot ',., -. . i - ". . - .. e viiification - . • - ' __ _.; •-,..--..,. :.L.:. -,..„...:•.....„.. ._ _._ . __
_ fa;437 -, ;= , , ,.' -, , , penalties , pedal.) that - the inforn urtionprovided_ribov:tittinz_and.correci
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Sinnature: i / I / f d i ' / • _ ate, 4, • . • ,
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Phone #: ' _ . . _ -
: - Officia I use only. Do not write in this area to be completed by eh), Or toWn'official
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• City or Town: .
.- Peradt/License #
Issuing Authority (circle one):
:1. Beard of Health 2. Building Department 3. City/Town Clerk 4. ElectricalIrispector 5. Plumbing Inspector
6. Other
Contact Person: . . .
Phone #: .
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Constructs Su isork Not Applicable ❑
Name of License Holder : / A1/6
License Number
1 , l _ _ qe€ GS 4x493
Address Expiration Date
4//4/4k3
Signature Te *Ione
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to ;Flo-Im ", a r a r "1 Not Applicable ❑
Company Name 1. Re istration Number
Address _ IMP*/ Expiration Date
�I�,�,�j 111.44 1 t .hone� 1��1 - 7 11!4 26 iZ.,
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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 ❑
1 -A om%eeOwner ixem tion
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 1083.5.1.
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
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Vyjndows Alteration(s) 0 Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[= Siding [D] Other [0]
Brief Description of Propose / L _ R T
Work: eee is [ e _ 1114 ■i�0.441. QA s \N %11� M41YI \ - . 6 4 _. U 1f ►W1
Alteration of existing bedroom Yes ` X No Adding new bedroom Yes
Attached Narrative , Renovating unfinished basement YesNo
Plans Attached Roll - Sheet
t o 1 oxiil 16USe at d,or adaittaf O'ezisti»c ..horlSTfl Omli(e l e'fottow lria:
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
.■ eei GCS , as Owner of the subject
property
hereby authorize
to act on m behalf, in all tt relative to work authorized by this building ermit ica .
a pltion
664 ' yet L) -26r 1
Signatu of Owner t
I , 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
Signature of Owner /Agent Date
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• Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To I omplgt infcu,, lea M
Existing Proposed Requi ed by Zoning
This co umn to be RIFEL,In by r
Buildi Departmeii * "? `
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Lot Size I _� . I
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Frontage ! , .. . - .
Setbacks Front i 1 1
Side L: I R: Y L: � R:= _I i
Rear
Building Height - °'°
Bldg. Square Footage 1 + % i i
Open Space Footage %
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(Lot area minus bldg &paved i , ? !
parking)
# of Parking Spaces
Fill: I i
(volume & Location)
A. Has,&Special Permit /Variance /Finding ever been issued for /on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:; 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i 1 i Pagel ! and /or Document #, Ym_µT ry
B. Does the site contain a brook, body of water or wetlands? NO
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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 Q ,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 changes to or additions of signs intended for the property ? YES Q NO el
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.
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RECEIVED c ity Df Northampton te1 T e nn i' 4 1 ` } �Y � "
Wang Depa rt m ent 'a ® _ -, "., ��- . �� � .
' 212 Main Street S e = p 4 _..,
Room 100x.«
N ha Tipton, MA 01060 4 �
ben oF �58 i�1240 Fax 413- 587 -1272 ro = � �� #- 11
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
-jo t42._ 1 tA Map Lot _. Unit
Zone Overlay District
Eim St District CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: . i
--es O S 1 -10 r. f ; die-tee-
Name (Print Current Mailing Address:
Nom'_ ` vj i
Telephone L(Ti 1 3 11 Q
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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 2 % li90� (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
(1� Construction from; (6)
Building Permit Fee
3. Plumbing wok,.
4. Mechanical (HVAC) k&(.1 �� J
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
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This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
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File # BP- 2011 -0803
APPLICANT /CONTACT PERSON NATHANIEL DAVIS
ADDRESS /PHONE 18 PLEASANT GREEN (WEST) EASTHAMPTON (413) 529 -0608
PROPERTY LOCATION 42 HIGH ST
MAP 17C PARCEL 167 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out , ) -t
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Fee Paid I� .p (0 l `�
Typeof Construction: REPLACE PORCH WINDOWS /DOORS & SOME FRAMING
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/ Statement or License 084975
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN_ F¢RMATION PRESENTED:
Approved Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND /OR Special Permit With Site Plan
Major Project: Site Plan AND /OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received & Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission _ Permit DPW Storm Water Management
Demolition Delay
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Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health, Conservation Commission, Department
of public works and other applicable permit granting authorities.
* Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning & Development for more information.
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42 HIGH ST BP-2011-0803
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 167 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2011 -0803
Project # JS- 2011- 001323
Est. Cost: $12450.00
Fee: $74.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: NATHANIEL DAVIS 084975
Lot Size(sq. ft.): 31798.80 Owner: GOSS LEE W
Zoning: URB(100)/ Applicant: NATHANIEL DAVIS
AT: 42 HIGH ST
Applicant Address: Phone: Insurance:
18 PLEASANT GREEN (WEST) (413) 529 -0608
EASTHAMPTONMA01027 ISSUED ON:4/11/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE PORCH WINDOWS /DOORS & SOME
FRAMING
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 4/11/2011 0:00:00 $74.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner