17B-015 The Commonwealth of Massachusetts
' -- Department of Industrial Accidents
Office of Investigations et
600 Washington Street
� 7....1=7 +
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization/Individual): LDw4 g J j RIG k.t= y s CO.
Address: P, 6 6 2 V aatet.h; / 7224
City /State /Zip: Phone #: 5/13 - 615 - 7051
Are you an employer? Check the appropriate box: Type of project (required):
1. g I am a employer with j 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. El New construction
2. ED I am a sole proprietor or partner- tt have on the attached sheet. 7. ❑ Remodeling
These sub-contractors ave
ship and have no employees 8. 111 Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.] 5. n We are a corporation and its 10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 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.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: % /.6e. .44 Date: /74' 20//
Phone #: 9/3 - ' — 7
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. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
SECTION 8 CONSTRUCTION SERVICES
r. .
8.1 Licensed Construction Supervisor: , Not Applicable ❑
Name of License Holder : f/OWARO glace y 7057
License Number
p. 13, 4 z ZtGiZzeo4,A L1 , V� O/ 7 / /ion
Address Ex�irat- TAI/ Z
a4 .,€ V/3 -Z 95 -7059
Signature -; Telephone
9' eMtte redRkfomee.Iiri tractor.° -3 ' a.• ,, ' Not Applicable ❑
Company Name Registration Number
P ge.1t ZZ 7 7'44 di a V s/� Zvi Z
Address Ex ra on Date
6.1 Telephone 4l,3 76 - 5 1
,,
S ECTION 10- WORKERS' INSU AF (M G L c 15 § 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 o ".omeowners" was extended to include Owner- occupied Dwellings of one (1) o o(2) lies
and to allow such homeowner . -ngage an individual for hire who does not possess a license, provided t the owner acts
as supervisor. CMR 780 Sixth ' ' : , n Section 108.3.5.1.
Definition of Homeowner: Person (s) wh. , , a parcel of land on which he /she resides • ends to reside, on which there
is, or is intended to be, a one or two family dwe '. •, attached or detached structu ccessory to such use and/ or farm
structures. A person who constructs more than on . ' ome in a two -year . od shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official, .. a form a - . able to the Building Official, that he /she shall be
responsible for all such work performed under the bui ' • • • : • mit.
As acting Construction Supervisor your pres- • - . the job site wi .: equired from time to time, during and upon
completion of the work for which this p- •:.1 is issued.
Also be advised that with referenc . Chapter 152 (Workers' Compensation) and . ..ter 153 (Liability of Employers to
Employees for injuries not -: ing in Death) of the Massachusetts General Laws Annotat- : ou ma be liable for person(s)
you hire to pe • --- or for you under this permit.
The :. - rsigned "homeowner" certifies and assumes responsibility for compliance with the State Bu g Code, City of
.. rthampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annota - d.
Homeowner Signature
•
4
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) , , , s
} i
New House ❑ Addition ❑ Replacement
Windows Alteration(s) n Roofing
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E] Siding [El] Other [D]
Brief Description of Proposed e
Work:_ ,ef, ti d p rey, '25ci.c✓G �P• ..•,z. oil Awe an. 14.)44.;4'
Alteration of existing bedroom Yes li No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes ✓No
Plans Attached Roll - Sheet
f{ a , i itiii ilitsor addition # :,axis inq h`ousitiii comPletethe.0r0wing:
a. Use of building : One Family Two Family I.V
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 n .
OWNERS AGENT OR CONTRACTOR: APPLIES FOR' PERMIT
I,x P . ✓ (/ /(1 / c l 0-- r, / / v ) ._ , as Owner of the subject
property
hereby authorize 6/'l'A R RiC ICR Y I Co,
to act on behalf, in all matters r ive to work authorized by this building permit application.
on
- < fir/ ~,� 1 /1 y /1
Signature of Owner Date
1, -ie2w.4eP Q( c (c 1 6 . , 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 pains and penalties of perjury.
4 g a to c /« y
Print Name
/ ' ' ZZl/
Signature of O r• gent Date
!r
R
Section 4. ZONING All Information Must Be Complet rAnit Can Be Dented Du To Incomplete Information
�
Existing Prip equired by 'Zoning
This column to be filled in by
' Building Department
Lot Size 1 ' 1 / LL
I =i
Frontage
Setbacks Front I t i a
Side L:. R:" I L: : R: j
'
i___
Rear
3 I i
Building Height ! ( I : I
I
Bldg. Square Footage 7-1 I I % I
Open Space Footage
(Lot area minus bldg & paved I _ I ( 1 I______
parking)
# of Parking Spaces I I —:
__
Fill:
(volume & Location) t 1
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: E
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ei DONT KNOW 0 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:
I
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: 1
E. Will the construction activity disturb (clearing, grading, exc tion, 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.
•
C o o • - pton t o u s� o f"I er mit:
`
•
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Buildin Depart t \ � � u Jrye y '' ` ' , .
212 in ' tr a e e icy a labil�fyy "
Roo 110 �NO�NSPOosp ® er a l bil
d9 ON Mp` "m .. ; �
Northamp , M ; ' ± '^ �` .;,,,p,.,--.,S..,, a ura
phone 413- 587 -124 - 587 - 12721 ® eci „� `�
M spfy & iN .. # 'r . tA q , f y F_
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH 'A-0-NE OR TWO DWELLING
SECTION 1 S IT E I
; > Th sec to b co mpleted FAMILY b office k w
1.1 Property Address: Ytzz o ,=: k .,
g ,,�f) ;: su ra ,�h2 , igi ,,„$, "'-.. , Lot'” �".. -§"-� ., ,'s€„, i Unfit ss.. "* £�
s Zone i .�'i.vn ;; Overl District :i ' ' t k sR
�� 5`s , k - + A . r : r e v
i
G /Q6Z
E lul Sf D�s#rict " ' „ ` C B D strECY .....
SECTIO 2 . P ROPERTY OWNERSHIP /AUTHORIZ AGENT ..
{
2.1 Owner of Record:
Na P .n0 . v 16A Current M ng Address •
Telephone
Signature
2.2 Authorized Agent:
0.
Name (Print) Current Mailing Address:
/l- - Y/3 -4(9.5 79i
Signature - ` Telephone
SECTION 3 - E STIMATED CONSTRUCTION COSTS ,
Item Estimated Cost (Dollars) to be Official Use Only ,�
completed by permit appcant ` `
1. Building °o (a) Building Permit F
4 yy6.
2. Electrical (b) Tot Cost of
Co ns truc tion : from (6) .
3. Plumbing B u r ldmg Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) ` yy(� °O Check Number
r t : This Section For Of Use Only
Buildin Perm Number Date
9
' Is s ued..: .. . .
Si
Building C /lnspectorof Buildings , , Date
399 BRIDGE RD BP- 2012 -0487
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17B - 015 CITY OF NORTHAMPTON
Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP-2012-0487
Project # JS- 2012- 000818
Est. Cost: $6440.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EDWARD RICKEY 96159
Lot Size(sq. ft.): Owner: OSTRANDER DENNIS W
Zoning: Applicant: EDWARD RICKEY
AT: 399 BRIDGE RD
Applicant Address: Phone: Insurance:
P O BOX 62 (413) 695 -7059 WC
WILLIAMSBURGMA01096 ISSUED ON:11/17/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE REAR SECTION OF ROOF UNITS E &
F
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:
FeeTvpe: Date Paid: Amount:
Building 11/17/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner