17C-235 . :
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. The Commonwealth of Massachusetts
Department of Industrial ACcidents
Office of Ini
600 Washington Street
-,.., .1...-:-....= - Boston, MA 02111 .
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www.mass ovv/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information . Please Print Legiblv
Name pusinesi/Orgardzation/Indiviann1): ' 1 - 1
Address 4 . 17 . _...
. ... .
. : .,.
• • : .. r- .." v 7
City/State/Zip: Phone.#: , _ ---- A ' -
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Are you an employer? Check the appropriate•box: • . Type of project (required):
1. 0 I am a employer with 4.. 0 I am a general contractor and I
6. 0 New coistinetion
have hired the sub-contractors
ej/ prig:Iyees (full ancVor part-time).*
listed on theattached sheet. 7. 0 Pemodeling
2. ath a sole proprietor or partner-
These sub-centractors have
ship onc1 have no .3-loyees .8. 0 Demolition • . . -
working for me in any capacity. ePA)1PYPet§-_.441111.aYe Wortars' : • - - ''..-- - -• •
• 9*: 011iiTchi:Tgaditiori
No workers' comp. *urn= "
10.0-Electrical repairs or additions
, • 5. 0 We are a corporation and its
3. 0 I am a homeowner doing all work officers haVe4xerCised their . 11.0 Plumbing repairs or additions
. ,t •
myself [No workers' corop. • right Of exemption per MGL r--7 ... ..
12.0 /coot repairs • . -
. c'. 152, *1(4), and We have nO •
i n s ura • nce requiredj t ' • • r - .
. . employees: [No workers'. 13.0 Other
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' • • CoroP- insurance recluir' - ed./. ' • ' : . .
Any applicant-that checks box nmust also fill out the section belcrwshowieg theirsVorkers C 0170pcirmation policy infonaatiOn.
t Homeowneri who submit this affidaVit incficating they are doing all work and then hire outside contractors must submit anew affidavit indicathig such.
Contractors that check this box must attached an additional sheet showing the name of the subconttactors and state whetber-ornottboseentities have . •
employees If the sub-contraCtorxhaVe employees; they must provide their workers' comp poky number.
I ant an employer that tsp toviding workers' C ompensation insurance for my einplOyees. Below is the policyandjob 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 intiolier. and•expiration date).
.. . .. _ .. ... _._ . ......._... ....__ .......__,
. . . ; , • • _ , .. _ .
Faure to sect= coverage as reqiiiiiilinicteir SettiOir 25A 152 can lead to the imposition OfCrititin4liienaities of a
tine tip to $1,500.00 and/or oite:-yearimprisonmenc as well as civil Penalties in the form of a STOP wopic-QR.,DER. and a Ene
of up to $250 00 a day against th.e Be idyl:fed:that a copy:Of this statement may be forwarded to the:OiffoC4_,
EireiliatiiiiiiOftliiDtk 66i4riie _ • . . . - - : 7`... . ; :-:.., ...
_ I do Iterebycerrift under the pains p , ' . . olperjury that the inforrnatio' nprovideilabove,Li.ting_azp*0
_ .
&mature: .-4.1110 4 - - Date: . ., 1 • / • - - , •
. f - . . • . • Phone it: •
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Official use only Do not write tri this area, to be completed by city or town officiaL
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City or Town: .- Permit/License # •
Issuing Authority (circle one):
.1. Board of Health 2. Building Department 3. City/Town Clerk 4. E1ectricalInspector 5. Plumbing Inspector
6. Other , • . 6- . • '
Contact Person: Phone #:
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SECTION 8 -- CONSTRUCTION SERVICES
8.1 Licensed Construction Su • . rvi or: Not Applicable ❑
d Name of License Holder : �
License umber
/ Ad A rielrt 417
Add •ss Expiration Date
7 _ ,
Siena re Telephone
isltsred f frie lttt r roar` ®n ;.:.,. at e ' A .,, ..�.0 Not Applicable ❑ //7/z/
Company Name / Registration Number
Address Expiration Date
Telephone ~- 3/ /
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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 ❑
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 Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [O] Other [0]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
4.ifttilii aditionitogexistniatousing.zotnotete . the :fa[Itiiti ha:
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 CONTRACTO' APPLIES FOR BUILDING PERMIT
1, , as Owner of the subject
property , )
hereby authorize (1111
to act on y behalf, in a' ttters relat' - to work authorized by this building permit application.
Signat 'Owner Date l <
„ /`���,/%/ , as Owner /Authorized
Agent her$ ec are that the • "te °lents 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 pe(
Print
.me ,
/
• ig at e of Owner /Agent 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
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Lot Size 1 ; £ , f s
Y
Frontage 1 � � 3 ' � � ..
Setbacks Front [J
Side 1.,:'----1 .�_-.-. R:x.� L:? . R:1 ___i J
Rear L = ,
Building Height
Bldg. Square Footage I i% [ 1 L i i
Open Space Footage I % ----
(Lot area minus bldg & paved
parking)
# of Parking Spaces -
Fill:
....,....�. .�_.�...e �.. ....A ._. _ , ...� � . _.,v.W.�
(volume & Location)
1
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 i YES 0
IF YES: enter Book P age l 1 and /or Document # I
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q 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 0
IF YES, describe size, type and location: I
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: 4
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 O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton St I P 0 !
Building Department
RECEIVED
' q { � „,� ,-
212 Main Street 8 ; 41 ° . a ,It 5 r A "kt
q tl -4, ate ,: $ a + I .,.
n F
Room 100 �°
Aili " 2 010 N , rthampton MA 01060 ~ q q . ',1:.., : t �� r
'hon.= 41 587 -1240 Fax 413- 587 -1272 m q ,, am
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
1.1 Property Address:
'cf', Qw j7 Map Lot - Unit
'�___.. Zone Overlay District
1 ='3 / N / % ��/ Elm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: '
�� /`�L7 //
Name (Print) / / Current Mailing Address:
/j «..41 Lal / A Telephone
Signature /
2.2 Authorized ent: -_ 10 '
0 ›'' dfil -
Name (Print) . Current Mailing Address:
, If k ( 7 -- rJ7g
Signatu ( Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
comp<r0. eted by permit applicant
1. Building " , i (a) Building Permit Fee
2. Electrical l (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) Check Number 0
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings - Date
..
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139 NORTH MAIN ST - BP- 2011 -1006
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 235 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit# BP- 2011 -1006
Project # JS- 2011- 001636
Est. Cost: $15000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES ROBERTS 99404
Lot Size(sq. ft.): 11369.16 Owner: RYAN CONNOLLY C & MARYELLEN M
Zoning: URB(100)/ Applicant: JAMES ROBERTS
AT: 139 NORTH MAIN ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527 -6078
W ESTHAM PTONMA01027 ISSUED ON: 6/3/2011 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 6/3/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner