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17D-047 .' 7 The Commonwealth of Massachusetts __ a Department of Industrial Accidents • = iW M Office of Investigations • r +i 7 �, =::14..... 1= y 600 Washington Street Boston, MA 02111 ,, www mass govidia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Indivirl „at) Et t.q-?—I k,,, Address: '71-( Sir,..) 4V6 • oI Z . City /State/Zip: ��►2�Cc - Phone. #: CZ� 2S2 -6 Are you an employer ?.Check the appropriate box: • • Type of project (required): / 1. I am a employer with 4.. 0 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. Remodelin ship and. have no e, loyees These sub - contractors have. .8. 0 Demolition working for me any capacity employees and have workers' No workers insurance _. comp• insuran t_•. 9. ` Building addition comp: regtired =] 5. We are a corporation and its 10_❑ Electrical repairs or additions officers have4xercised their 3 I am a homeowner doing all work r myself [No workers' comp. ri it of exemption per MGL 11.0 Plumbing repairs or additions Roof repairs - insurance required] t ' c. 152, § 1(4), and we have no employees- [No workers' 13.0 Other comp. mcitrance wed- /. *Any applicant that checks box # must also fig out the section below showing their workers' compensation policy information t Homeowners who submit this affcdavit.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 eatities have employees_ If the sub - contractors have employees, they must provide their workers' comp_ policy number. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information • Insurance Company Name: • Policy # orSelf 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 ofMGL c 152 can lead to the iriiposition of criminal penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties is the form of a STOP WORI(-O:RDER 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 finvestieatioris of theDIA for insurance` coverage verification _ _. _ Ido hereby certify under the pains and penalties ofpedi ry that the information provided' rovided :tib..ove_tstrue_and.correcr • Si' acre: �� � _ _ Da te; / (2 2 /[ _ , • Phone ##: C264.11 1 2 SE d 6 ? ” O rein! use only. Do not write in this area, to be completed b }f y y city or town official City or Town: # Issuing Authority (circle one): .'1.. Board of Health 2. Building Department 3. City/Town Clerk .4. Electrical, , Inspector 5. Plumbing Inspector 6. Other E- Contact Person: Phone #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone S. Reaiste atHaii*Iiriitrovetnpntn aiiiiii n ... i ,, ES_ ._ .0 Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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 ❑ r .. 3 5:S 9 3 Y '!�'YS i . i > , f� ., ee °,. $. tit 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. A Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) - Roofing ED Or Doors ❑ Accessory Bldg. ❑ Demolition El New Signs [O] Decks [[] Siding [0] Other [0] Brief Description of_Proposed Work: .GM -b( Alteration of existing bedroom Yes > No Adding new bedroom Yes le No Attached Narrative Renovating unfinished basement Yes � No Plans Attached Roll - Sheet isa If l► c�. t nc r clltlo tv:e #stll • �o slrn rrl ®`le f6llOWhh a. Use of building : One Family Two Family Oth b. Number of rooms in each family unit: Numbe • 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 Compli- « Masscheck Energy Compliance form attached? h. Type of construction i. Is construction wi n 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of ba - ment or cellar floor below finished grade k. Will b • ding conform to the Building and Zoning regulations? Yes No . I. S- .tic 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, — gR -LA*J , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date 1, a_ (.o�. -• �C � � t , 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 pai s and penalties of perjury. L 4 E1 4i1/4? Print Name -e."‘ 17-Z- / Signature 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 T h is column to be filled in by Building Department Lot Size i © • I ic ,t-C; —.. Frontage . _. . Setbacks Front € j 1 Side L: $ R.` L:f # R: -, f t __-__ Rear — -- Building Height f f E"'" ` 1 Bldg. Square Footage '""" l 1-1 % I i 1 1 i i Open Space Footage (Lot area minus bldg & paved ( _ I 1 1 1 t parking) # of Parking Spaces i --- Fill: �- ,...._ __. _ (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW YES Q IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES Q IF YES: enter Book g Page 1 and /or Document #. B. Does the site contain a brook, body of water or wetlands? NO op 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 Q ,Date Issued C. Do any signs exist on the property? YES Q NO t o _1 . 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 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 Q NO r.a IF YES, then a Northampton Storm Water Management Permit from the DPW is required. + • �` - a ' City of Northampton Building Departmen 212 Main Street Room 100 Northampton, MA 01060 phone 413 - 587 -1240 Fax 413 - 587 -1272 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 lq 5 1-4--/ )4 Map dot Unit fL ,'&C1, //1-A Zone Overlay Distn Elm St District . CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Recr4d: _ Name (Print) Current Mailing Address: Telephone 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 / c6 Q (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) y5 e2 Check 'Number j/7 / This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP -2011 -0266 APPLICANT /CONTACT PERSON HAGAN BRIAN ADDRESS/PHONE 74 STRAW AVE NORTHAMPTON (207) 252 -0637 0 PROPERTY LOCATION 74 STRAW AVE MAP 17D PARCEL 047 001 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 ��� Fee Paid Typeof Construction:_REMODEL ATHROOM New Construction Non Structural interior renovations Addition to Existing, Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN ATION 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 dier/lefr s► )ela e 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. • 74 STRAW AVE BP-2011-0266 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17D - 047 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-2011-0266 Project # JS- 2011- 000439 Est. Cost: $4500.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 5183.64 Owner: HAGAN BRIAN Zoning: URB(100)/ Applicant: HAGAN BRIAN AT: 74 STRAW AVE Applicant Address: Phone: Insurance: 74 STRAW AVE (207) 252 -0637 () NORTHAMPTONMA01060 ISSUED ON:9/23/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL BATHROOM 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 9/23/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner