17C-234 • b f7 T
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The Commonwealth of Massachusetts
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Department o f Industrial Accidents •
t ' = = Office of Investigations •
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a r _ 600 Washington Street
Boston, MA 02111 .
�� . www mass gov /dies •
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly 1
Name ( Business /Organizationfhidivic1 84 ' `_ ) ,-,il N 5 -v A•9 (.
Address: 5') ,,i, ire / (1,4& // .- - . .
City /State/Zip: 'PO 0 q. ,,,.,2 p rd Ai - Phone. #: ��/
Are yu an employer? Check the appropriate box: • Type of project (required): /
1. C�� I a m a employer with 4. El I am a general contractor and I 6. ❑New construction
employees (full and/or part-time).* have hired the sub- contractors
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling
• ship and have no loyees These sub - contractors have. S. 0 Demolition
working for me is any capacity �loyees and have workers' -
9: 0 addition
iTienranrr t . "�"b
[No workers' comp. insurance
CQII]�. — _ --
required:] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
officers haexercised their g
3. I am a homeowner doing ill work v . 11. PlUrnbin epairs or additions
r
myself [No workers' comp. right of exemption per MGL 12:[]Roof repairs
c. 152, ,
insurance required] t 1 4 and we have no § () 13.0 Or
employees. [No workers'
. comql insurance required.], - •
*Any applicant that checks box #1 must also fiIl out the section below showing their workers'- compensation policy information:
I 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 thoseentities have
employees. If the sub - contractors have employees: they must provide their works' comp. policy number. .
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. / ,y
Insurance Company Name: L .) . d2- /vr'.IJ U f� f 1� jU c`1 Cc
- C� •
Policy # or Self -ins. Lic. #: 1&U — 3/.5 — -54- 7 `" ' Expiration Date: -0 J. - .4 d l gp . Job Site Address: .50 A'`� f� 4 . c e � ✓ % 7 City /State/Zip :� /•c t /S G ,}r: • f1.�/ - . 4 6 ' ° ` J
Attach a copy of the workers' - compensation policy declaration pa ge•(showing the policy number and expiration date).
Failure tc' secure coverage as required `under.Section ° 25A ofMGL c 152 earl lead to the imposition of cr`iminA1 penalties of a
fine up to 51, 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 5250.00 a day against the violator Be advised That a copy of this statement may be forwarded to the Omce
Tnveiti ations of the DIA toi insurance` coverage verification. _ .. _._ :,:,
_ I do hereby_ certify under the paums.arsd penalties ofperjury that the information provuled bove istrue_andcorrt.___ _
l
Signature: A..- 7 2,— , . ,.i.�CZ Date - d l0 • . ,
.
J
Phone it: �‘ 7 _
_. Offrcidl use only. Do not write in this area, to be completed by city or town offciaL
City or Town: Permit/License # W _ „ ...
.
Issuing Authority (circle one):
:1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other •
Contact Person: Phone #:
OA 1h
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �j C Not Applicable ❑
f�"
Name of License Holder : li 4.0 ! 6 , A '
License Number
7g/ ' s/11 kg 4/ #.4 - rei°' 711 0 ,S.',‘
Add_ t Expiration Date
A:it."....- cf" ‘6 (4 6'"F — V76
Signature Telephone 0/ `"' i `od 0 1 x''
9 d-Hoinie,thii `rocement} rtia — o -- - 215kAvisatazammaila Not Applicable ❑
73 r' 5 .i /xi q -5 2» C-'
Company Name Registration Num r
7 ?16 -,i I� / d4
s U ;, 'o
Addr Expiration Date
NO 07'44h.�1 ra rrd' Telephone `s /sa-� O /9 0/)--
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SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavi , must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildin permit.
Signed Affidavit Attached Yes No ❑
The current exemption for "homeowners" was extended to include Owner - occupied Dwellino 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 buildine 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
I AL
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement W dows Alteration(s) 0 Roofing D
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [DI Decks [[] Siding [D] Other [D]
Brief Description of Proposed —r 3 / N' / ,_, , / R id v c
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa'if igAilii 14IMO `iadlit i stlr' pia i a,_ 'cirm to itiiita tali ka:
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
1, DM W L ROW N in 1 Pi , as Owner of the subject
property / / 7-37:70,4,,y
hereby aut rize
Lam, 1( ti C- —
to act on m half, in all matters r ive to work authorized b building permit application.
Signature of Own Date
I, ^gem ,, 6u L. 7 , aster /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 / u�nder the pains and penalties �o perjury. d
.., + -�._.� . / -- -4 v ' Z: 2' i cv i hl 1 V r/e/ 40 7
Print Name
„ 1:-- oe"....x/.54--es j Z al, 01 0 6
Signature oftier /Agent Date
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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
a # ,w ;
' Lot Size t a —,
Frontage I 1 ; I I
Setbacks Front j � �'
Side L:1 i R:1 1 L:= J R:1
Rear = 1 `
Building Height 1
Bldg. Square Footage = 11 % = i 1 t
I
Open Space Footage % €
(Lot area minus bldg & paved L `s, E EJ
parking)
# of Parking Spaces i 1 -._,
Fill:
(volume & Location) ? T l
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 0
IF YES: enter Book i
I 1 f P age and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ,Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: 1
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:
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 Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton
Building Department 414W4f .— QO 2 ?� Main Street '-'031:115 ,
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C t, a oom 100
fort pton, MA 01060
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phone 413587 -1240 Fax 413- 587 -1272 y ' '
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - S1TE INFORMATION
1.1 Property Address:
This section to be completed by office
/3 di/ ' S W 0 // .7 Map Lot Unit
a
'/ ;�, N C "Zone Overlay Distr
a ‘ y Eim St District . `' CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
0)4 of Q 0 m1l eo 33 ii A 2 o ro z,
</l S
Name (Pd Current i ng Addrg:
!// C'1YLL IssBC e )414, Telephone s __ Cv 7 a 6
1/C.--(.1../1/1 Signature 1/C.--(.1../1/1 S Li
2.2 Authorized Agent:
A-, LI3 s.ley 2 /Y,e ) , k, L .,,e1 ii‘g yob ,n3 )164 Y
Name P • ' t) Current Mailing Addre'Ss:
��� 1- / 5__ .- / / 7
Si nature Telephone
SECTION 3 - :ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ��� Q-' (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing f Building Permit Fee
4. Mechanical (HVAC) `...----
5. Fire Protection or
6. T otal = (1 +2+3+4+5) �� Check Numbe
7 3.
. 7
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
• r
4 • R
ST BP -2011 -0140
GIS #: COMMONWEALTH OF MASSACHUSETTS
tqaplmock:Trc,- 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- 2011 -0140
Protect # JS- 2011- 000234
Est. Cost: $6480.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 26179.56 Owner: DREESZEN CRAIG A & DIANE BOWMA
Zoning: URB(100)/ Applicant: B & R SIDING
AT: 33 BARDWELL ST
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers
Compensation
NORTHAMPTONMAO1060 ISSUED ON:8/19/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 8/19/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
. . Roofino
r.r.r
6 Line St.
Southampton, Ma. 01073 ESti mate Date
Phone (413) 527 -4775
Fax (413) 527 -8469 5/27/2010
Name / Address Job Location
Diane Bowman 33 Bardwell Street
33 Bardwell Street Florence, MA
Florence, MA 01062 Phone: 584 - 6706
r --
Terms Rep
Estimate valid for 45 days Chris
Job Description Total
Remove existing Garage roof. 4,800.00
Furnish & install 1/2" plywood to damaged areas only.
Replace damaged rafters.
Furnish & install ice & water barrier along eaves.
Furnish and install synthetic underlayment.
Furnish and install 40 year GAF Slateline Series shingle on entire garage.
All exterior roofing related debris to be removed by R.C.I. Roofing.
All work will be performed according to manufacturers' specifications.
5 -year RCI Roofing workmanship warranty included.
All related permits will be obtained by R.C.I. Roofing.
Labor & Materials: Furnish and install gutters. 175.00
WE LOOK FORWARD TO DOING BUSINESS WITH YOU.
Total $4,975.00
"PERMS OF PAYMENT
5% Deposit $ Z.L1%. 5
Balance upon completion r
Registration # 126235 Customer Signature L tAAC.Q / E.._.�U,l� CPr L
Construction License # 074334
Insured by lianas & Rickert Ins. Date / _ 1 7 - ( C
413- 527 -27U1)
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I. v_efi CS 74334
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MARK 1 DELISLE ,
33 FIRST AVE
EASTHAMPTON, MA 01027
1,117/, I( I 5/S2012
if 26357
Mho,. t)t Lttit■tittict Artatrs o, ttuNtIte, itevI//fl//I
HOME IMPROVEMENT CONTRACTOR
Registration: 126235
; Expiration: 5/6/2012 Trts 293949
Type: Partnership
RC ROOFING
MARK DELISLE
6 LAE ST
Sall HAW TON, MA 01073 t tidef sea Cial'■