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18C-031
., The Commonwealth of Massachusetts , Department of Industrial Accidents e — 4/1.... – Office of Investigations k , ; 600 Washington Street Boston, MA 02111 www.mass. /dia VII -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LegibIv Name (Business/organization/Individual): . LT e 1 Address: \ (.!t C,JOkt INOQ. 01 OC9-U City /State/Zip: IQ 0 CzT1 NN pi-el.,) 'ik Phone #: 413- 's - g ti [ c(3" f Are you an employer? Check the appropriate box: Type of project (required): i 1.0 I am a employer er with 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have hired the sub- contractors listed on the attached sheet. 7. 0 Remodeling 2. ❑ I am a sole proprietor or partner- P .'rp lo�,ees These sub - contractors have 8. El Deinoluion ship and have. no for me in an c aci employees and have workers' rk� Yap ty 9 Btuldin addition cG u -anc� o workers' pomp' insurance - �' nst 10.0 Ele trical repairs or additions required.] 5. 0 We are a corporation and its ❑ eP o czrs_havelixercis�d their —i i. • ••bin repairs or additions 3. I am a homeowner-doing-all-work — ❑ ' - g eP 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' 13.0 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. Iam an employer that is providing workers' compensation insurance for my employees. Below Ls 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 and/or one :year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fire of up to $250.00 a day against the violator. Ele 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* ce: fy under the p i : n • • penaltie perjury that the information provided :above_is_tr • _and_correct _ _ _ Si • I attire: __ � i.L�L A ‹ � Date ■ P h o n e ft: rl 13 — i 1 1 : T Official use only. Do n ii write ti thin aren„to -be comp eted y city or town offu laL City or Town: Permit/License # Issuing Authority (circle one): -.'I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical _Inspector 5. PIumbing Inspector 6. Other Contact Person: Phone #: , # • 1. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9.'ReniStered.HomelmproVetrierittiontriAlt ...T. a n ; . ,i 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 ❑ p aC" OIMMU The_current exemption for "homeowners" was extended to include Owner 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 ort amp on rim. a EatYZ-e . A I ,nw iui. + e • • e s-General- Laws_Annotated. Homeowner Signature Ea ; ■• tma 9 • .... SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ly( Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [D] Other [D] r Brief Description of Proposed ^� Work: ee on c N(r- jays~ I 1 pru C f P(Q teak: 5 1, � ► 1 8' Les � . Alteration of existing bedroom Yes No Adding new bedroom Yes No ,/ Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll - Sheet 4.' If.Naiiv'houuse'arid :ar' ddiiiort to existiiiti hoe sintt:vcoinlilete #he°.fotfuwfriq: 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? 1. 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 T - I ©1'vi ' Cr- USL , as Owner of the subject property t hereby authorize to act on my behalf, in al tter�ative t work authorized by this building permit application. y � �(,I, mnO t g l iii 109 Signature of Owner Date -Ti 1 Cr- , as Owner /Authorized Agent hereby declare that the statements and in ormation on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perju r\ hiL G JJ0J Print N me f VV A Signature Owner /Agent Date A Air• 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 .._...._., Frontage _ Setbacks Front Side L. >_ ._. "_ Rear ..." Building Height Bldg. Square Footage __ % Open Space Footage (Lot area minus bldg & paved, " parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO ® DONT KNOW 0 YES IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book I Page! and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 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 0 NO IF YES, describe size, type and location: "`�"`v="" - `I):y" e here ahy proposed changes to or a Itioris o s>gris intended for - the property ? YES 0 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 0 NO 4 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , • --- - „,-- ,..:,..., \„, ''•';::\73-..ir-ft,AtiAii0.f„f:.,..0ft7)1,914,*,01PArlik••,W1-4,:.:•:.:: ,- \'' -- City of Northampton :ki00**1',..rehiii7 Cur _.,...,',.%V.-6"..?,::','VU,,F,f,',:v .„;/' Building Department urbi:rtiort*:6!■itiAY.R / 21 . 2 Main Street ,.,1311414,4424t4,,,n-'P,,,..,iilegrtda;fite,s;Plf-Aii:OVii...4-.,'"1:7, ,oe„vve,,,,,,p,,,,,,,m„4„,....„tt t c . ,,,,V,t-44-.1;a:7*.x.<-:„ Rkom 100 wa„te474,41P rtt:":!tdilMZtMrPtRtNkal:V;' •R Npilham n, MA 01060 , ,..... . Pjtg-i'e-*',iti,A;..-!gftiii,itetwlp'at-t-i-op'f.4-W:, phone -1240 Fax 413-587-1272 10401Site:r.:1,•:'-,• ,-. c- ,- t1 0.**, & ,,,, w .0.41vt a .c., , ,, v .,,:4„, , R7RTAty...,, , ,,„..,iott., , ,,....,,,..., , ,,, , ,,, , ,'„ tel P.;ciftw: \ ,„,-..•:`,, ,- 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: l C o CcoVe, AQ t_ Map ' Lot Unit .. 1,) MI\ C i ()Cc° -lorie ' ' . Overlay District . . • Eirm!t.- District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Taln•664--&---Za-SLewti&- t (0_ COO VC, koR , ki ‘tno 1 Name (Print) Current Mailing Address: _ O , A -41 , .1 , -..• • l & l A . .........14...- ; 2. ../1 II. .:...0 it-Id-Z Telephone Signa ure 2.2 Authorized Agent: - -- 11/0 MO C G— R e4 v c C--oc)Ltt. i\ik sU 1 illA Name (Print) Current Mailing Address: --- T - A r AtAitA-4.A.A ( i.A.A A l/3 — ,5 / Sig ature Telephone SECTION .3.-:ESTIMATEDCONSTRUCTION 'COSTS • • Item Estimated Cost (Dollars) to be - . Official Use .Only completed by permit applicant 1. Building A' 7 otx) (a) Building Permit Fee .. . 2. Electrical (b). Estimated Total Cost of onstruction from (6) . . ... .. .. . 3. Plumbing . Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection . . __,,,,..- z . 6. Total = (1 +2 + 3 + 4 + 5) Check Number ?! --- 35 — i • - ThisSectionfor:OffiCiii uieoriry. - • Date Building Permit Number: Issued: Signature: .... . ... Building:Commissioner/Inspector of Buildings . .v - --- . Date 4, + r% AVP BP- 2010 -0278 GIS #: COMMONWEALTH OF MASSACHUSETTS 4- 1SC103I , :irk. 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- 2010 -0278 Proiect # JS- 2010- 000358 Est. Cost: $2000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 19340.64 Owner: BUSHEY THOMAS G Zoning: SR(100)/ Applicant: BUSHEY THOMAS G AT: 16 COOKE AVE Applicant Address: Phone: Insurance: NORTHAMPTONMAO1060 ISSUED ON:9/14/2009 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 9/14/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 16 COOKE AVE BP- 2010 -0278 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C - 031 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- 2010 -0278 Project # JS- 2010- 000358 Est. Cost: $2000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 19340.64 Owner: BUSHEY THOMAS G Zonincr. SR(1O0)/ Applicant: BUSHEY THOMAS G AT: 16 COOKE AVE - Aoplicant Phone: Insurance: NORTHAM PTONMA01060 ISSUED ON :9/14/2009 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: "x , l- a THIS PERMIT MAY BE REVOKED BY THE - ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL IONS Certificate of Occupancy / Signature: FeeType: Date Paid: Amount: Building 9/14/2009 0 :00 :00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo