39A-065 The Commonwealth of Massachusetts
• . Department of Industrial Accidents
41-7
Office of Investigations
600 Washington Street
...� Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business / Organization /Individual):
Address: 9 o d /6 7
City /State /Zip: 2,, Phone #: -g
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
emplo ees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
2. m 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 any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ 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.
1 do hereby certify under the pains and enalties of perjury that the information provided above is true and correct.
Signature: �?, / / � ® Date:
/ — /
Phone #:
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. B Department 3. City,/Town Clerk 4. Electrical Inspector 5. Plumbing inspector
6. Other •
Contact Person: Phone #:
..... - ..... -....
SECTION 8- CONSTRUCTION SERVICES
8.1 Licensed Construction Su • ervisor: Not Ap licable
//�
Name of License Holder : • ��e��,,/ / i ��
Lice a Numb
Address Expiration Date
7
Signature Telephone /j' / —L f I 1
%wow
ist+ered,.. ome; Improvement Cont r. torn R ;12?.: ., .. ., Al Not Applicable ❑
0 t
Com • an Tr e Registration Number
1 /7
Address Expiration Date
Telephone q-3
SECTION 10 WORKERS' COMPENSATION INSURANCE iAFFIDAVIT (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 ,_- ITom flw.nerk xe ,tio n
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
•
J J
SECTION 5- DESCRIPTIQN OF PROPOSED WORK (check all applicable) ,
New House n Addition ❑ Replacement Windows Alteration(s) I I Roofing t17
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [O] Other [O]
Brief Description of Proposed `t��', / fJ
Work:
Alteration of existing bedroom Yes No Adding new bedroo Yes
Attached Narrative Renovating unfinished basement Y- No
Plans Attached Roll - Sheet
6a, If.New House andror: =to existinglho`usrnq. complete the;;followrnq:
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 OWNERAUTHORIZATION TO BE COMPLETED WHEN
,:OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT . . ,.
I, ■ r-■ , /� ■ .4e/ pfd . ./A,(( _ , as Owner of the subject
property If hereby authorize _ , i -� ' t' /��
to act on my behalf, in all ers r lative to word= thorized by this building permit application.
., , _ 77 / 7 i - - 7 /
Signat 7 f Owner / Date
�� ` , as Owner /Authorized
Agent hereby .Aare 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 pen ' of perj _
Print N. `
�, _ 1l - / i `"//
Signat a Owner /Agent Date ,
k :
. .
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 - .1
Building Department
Lot Size , 1 y +{ , i
i
Frontage
Setbacks Front 1
Side L:' R: L:; i R:€ i
Rear i 1-^
Building Height t i
Bldg. Square Footage 1 i I °l 1 1 G i
Open Space Footage
i
(Lot area minus bldg &paved ° 1
parking)
i 1 1
# of Parking Spaces
Fill: 1____..._.._
(volume & Location) 13
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:I,
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page` i and /or Document # 1 I
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 0 Obtained , Date Issued: j
C. Do any signs exist on the property? YES 0 NO 0
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 0
IF YES, describe size, type and location: 1
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 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
• Depa emt "u =or y «;
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City of Northampton Sta u o f 'e 1 * '
&gilding D C C tJD y y P•er t ,
E CEIVED 212 Main Stree Se wer S ilabil ��
Room 100 Wate J Weil Availability j f` t ' 1 :.
r 1 62011 N rthampton, MA 01060 T wo e S'-'.! t t ru ctu ra i i- all , ,� � .
phon 41 - 587 -1240 Fax 413- 587 -1272 a S P arts
f au,rn,� — tth er t Speoify t k "tt Y t IHAMP - . k a ,.-m7. r z ,�
APP C1CAT tON TO TRUCT, ALTER, REPAIR RENOVATE OR DEM A O NE OR TW O FAMILY DWELLING
SECTION 1 SITE INFORMATION
This ection to be completed by office
1.1 Property Address: — � `�
t w
a P z _ " L U n61 � * ;'
ii
1 Z ' '• O D �:
k't w ` - '�
Elm St District "" CB Di
SECTION 2 -PROPERTY OWNERSHIP /AUTHORIZED A
2.1 Owner of Record:
Name rint) / Current f ailing Address:
■ ///� _ // i f Telephone
Signatuy .
2.2 Authorized Agent: --- e ,,L____47 .-- &)-z.__, ; ,.., ,Ar
Name (Frill' Current Mailing Address: f__.._
Signa�e Telephone
S 3= ESTIMATED CONSTRUCTION CO : '.
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
2. Electrical / (b) m T Cost f o
�R "Constru # rpm otal .( 6) , ..
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 + + +4 + 5) Check Number 'j
. .- ., . - - This Section For O fficial 0 se On . ly- .� '
Date
Suilding! Number I ss u ed: " . .
Signature -
Buildi Commissioner /Inspector of Buildings Date .
10 HAMPTON TER BP- 2012 -0482
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 39A - 065 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP-2012-0482
Project # JS- 2012 - 000812
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq. ft.): 58806.00 Owner: STILLWAGGON JAMES
Zoning: SC(49)/URB(51)/ Applicant: JAMES ROBERTS
AT: 10 HAMPTON TER
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527 -6078
W ESTHAM PTO N MA01027 ISSUED ON:11/16/2011 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 11/16/20110:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
II r>!