32C-127 .. s
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The Commonwealth ofMassachusetts
Department of Industrial Accidents -
5, :7::: r Office of Investig,ations •
"
600 Washington Street
9
= = t f- i Boston, MA 02111
www.mass gov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers -
Applicant Information - I Please Print Legibly
Name ( Business /Organization/Indiviiltiai): &. .4210. lark / I t .o
al
Address:
Ffr . 61c 6R_ ;
C i t y / S t a t e / Z i p : 9 M Phone. #: 1 1/3 °6 75 - 7057
Are you an employer? . Check the a� ro riate•box:
Y P . Type of project (required): /
I.0 I am a er with toy 4. 0 I am a general contractor and I
Y 6. ❑ New construction
employees (full and/or part-time).* have hired the sub- contractors
2_ I am a sole proprietor or partner- listed on the attached sheet. 7. r2 Remodeling
ship and have no .loyees These sub - contractors have. .8. ❑ Demolition
working for me in any capacity a Iayees atidPhaye workers' 9 Q Butldmg addirion
[No workers' comp. insurance comp-
required. 5. We are a corporation and its 10 0 Electrical repairs or additions
additions ] have xeroised their 1 L PIunnbin repairs •
3. ❑ I am a homeowner doing all work ❑ g ep or •
a dditions
myself [No workers' comp. rigbtof exemption per MGL 12: Q. Roof repairs
insurance required.] t ' c. 152, § 1(4), and we have no • .
employees. [No workers'_ 13.I Other
• comp. insurance reqUirJ. • .
* Any applicant that checks box # must also fill out the section bclatvshowiag their workers' compensation policy information:
t Homeowners who submit this affidavit: indicating they are doing all work and then hire outside contactors must submit a new affidavit indicating such. -
Con tactors that check this box must attached m 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.
,/ an employer that is providing workers' compensation insurance for my employees Below the policy and job : site
information. .
Insurance Company Name: -
Policy # or Self-ins. Lic: #: • Expiration Date:
• Job Site Address: City/StatelZip . -
Attach a copy of the workers' compensation policy declaration page•(showing the policy number and.expiration date).
Failnre to secure coverage - as required MidCr.Section 25fti OfMGL - c 152 can lead to the iirciosition`of penalties of a
fine up to 51, 500.00 and/or one -year imprisonment, as well as civil penalties in the form ofa STOP WORK -ORDER and: a fie
of up to 5250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Office of _
Investiigations of the DIA Ii3i insurance coverage vt rdcation. 7 . .._ ,:.,.,
Ida hereby certify under thepaurs penalties of_perjumy - the information providedsrbove_istrae au LcorrPrt _
S u. • to re - _ ���. - _ _ -�' late /.. 3 o - , • _f
Phone if: 5�
: '3 , 94 7n • .
rail l use on Do not write It: this area, 10 be co town
oft � y. mpleted by city or
City or Town: Permit/License # ._ _, ,.
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 #:
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SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder • r 96159
License Number
63 ?l- t Um/ E ah.4 PA O/ iCC.. 71 /3 d0/,
Add Expir lio ate
4de q/3 -' 9.5 - 7o.�y
Signatur Telephone
8,;l i akteiitfi >'xn iiiigrci remitit ttrif actaW �,. '`'V .4- Not Applicable ❑
4420 -cL. Rai T /508'/O
Companv Name d Registration Number
Address MA Expir 0 0-
Telephone_ 9/3 -Os-
I
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M,G.L. c. 152, § 25G(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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK! (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) [ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [IL] Siding [0] Other [0]
Brief Des rip '• n of rop�Qsed 1.
Work: 1GGnufL tk d�duru, /� i I Anr ®� 3 .l�ekniu�.
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No /
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll - Sheet
6 C eW br US I� it ac i anti r s �+ r I, iit i :
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 to - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
t ) . , -.� , as Owner of the subject
property r
c
hereby authorize , _ -� ,f-.....-, 3 Z. -
to act on my behalf, all matters Ave te .rk a orized by this building permit application.
Al G
Signature o: ner ■ l` Date
I ire /70,/ /a.�1 t ( , as Owner /Authorized
Agent hereby declare thaistatements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief. v
Signed under the pains and penalties of perjury.
17-a t/A R1) Rickt.' —
Print Name
_, ., - _ / 1. 61/ —
Signature of iv , 'r /Agent - ,! to
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
' Lot Size 1 (; ,_ _ _...._ . . �.�. . _..$
F
Frontage 1 ' 1 ' ---n
Setbacks Front LJ EJ i 1
Side L: i R:= L: R:?
Rear 1 . 1 i
Building Height ;
Bldg. Square Footage [ 1 1 1% 1 1 =1 i 1
Open Space Footage %
(Lot area minus bldg & paved ? 1 , j
parking) I
# of Parking Spaces
Fill: 1 . 1 ,
(volume & Location) ,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 Q YES 0
IF YES: enter Book 1 7 Page I and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ,Date Issued:
C. Do any signs exist on the property? YES (J NO i
IF YES, describe size, type and location: s
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:
i
E. Will the construction activity disturb (clearing, grading, ex ation, 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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City of Northampto
Building Department taiLL
212 Main Street
I
Room 100 r fie€ ;z.
Northampton, MA 01060 • r
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: 38 This section to be completed by office
Map Lot Uni —
Zone '' Overlay District
Etrn St. Dlstrlc CB District
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
X >C jaAVUL —
Name (Print) Curre t Mailin� Ad�
G iee Telephone
Signature
2.2 Authorized Agent:
4v14/AR Pc. &* Ex 2tie + 772 0 / 0
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 (2 I 386 on (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
a ( ) � /r
... Total= 1 +2 +3T4 +5 Fes, Number
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 -0609
APPLICANT /CONTACT PERSON EDWARD RICKEY
ADDRESS/PHONE P 0 BOX 62 WILLIAMSBURG (413) 695 -7059
PROPERTY LOCATION 38 FRUIT ST
MAP 32C PARCEL 127 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out . � inl � c�� Fee Paid Q( ",1Q
Tvpeof Construction: SHEETROCK & INSULATE OFFICE SPACE 1 ,(�'�'�., 7 L ( Y�.
New Construction /
C� met 5 � 2 ''" 1I C
Non Structural interior renovations N35/ r(C11 r
Addition to Existing A (W 5e`t`e�
Accessory Structure
Building Plans Included:
Owner/ Statement or License 96159
3 sets of Plans / Plot Plan
THE FO WI G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
I O 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
Demolition Delay
% -,"
/— 5 //
Sig ature of Buildi g / 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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38 _ BP- 2011 -0609
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0609
Project # JS- 2011- 000973
Est. Cost: $2380.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sq. ft.): 11 107.80 Owner: LYNCH VALERIE
Zoning: URC(100)/ Applicant: EDWARD RICKEY
AT: 38 FRUIT ST
Applicant Address: Phone: Insurance:
P 0 BOX 62 (413) 695 -7059
WILLIAMSBURGMA01096 ISSUED ON:1/6/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:SHEETROCK & INSULATE OFFICE SPACE -
MUST MEET STRETCH CODE R3.5 /INCH AIRSEALED
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 1/6/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner