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18C-066 • : • ' • The Commonwealth of Massachusetts -- Department of lndustrialAccidents . �'l�i� a ' Office oflnvestigations ±:_ . y 600 Washington Street Boston, MA 02111 � � www.mass gov /dia • - Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information • Please Print Le'bIv Name ( Busines s/Organiaation/Indivianal) rd //e Af e e e---St/t.-r fey-. 3 _ • -Address: I-1 4i ie.S 5 -. ) ere i i c OA- • City /State/Zip: . - Phone. #: 9 3 .T4 Z 7/ - Are you an employer? Check the appropriate"box: • . •Type of project (required):. 11 1.0 I am a Moyer with 4.. 0 I am a general contractor and I 6. 0 New construction employees (fall and/or part-time). have hired the sub- contractors 2 I am a "sole proprietor or partner- listed on the.atthrbed sheet 7. 0 Remodeling ps ' - and have *_io e loyees These sub - contractors have. .8. 0 Demolition - . . • 1gee y and. ave workers' _ - __ working for me in any cxpacrty. -.. 3 • r w�rarii -e _. CQn�. inc�iranrr . _ .. �BUI fiIng a ltl . corporation and its ❑ repairs or additions required] 5. We are a co 10. Electrical - 3. 0 I am a homeowner doing all work officers have xercised their 11.0 Plimibmg repairs or additions • myself o workers' co rat of exemption per MGL comp. IZ:Q. Roof repairs • c: 15, §1(4); and we have no • insurance required.] t 2 - employees: [No workers'. ' 13.0 Other r • comp. insurance required }. : ' . • .. ' • • • , • .Any applicant that checks box #1= must also fill out the section below showing thettwork s'- compensation policy iafarmatioci . - t Homeowners who submit this affidavit:iadicatiag they are doing all work and then hire outside contractors must subimt a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub contractors and state whedie•ornotthoseentities have • employees. `If the sub contiactors have employees, they must provide theme workers' comp.poficy 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 /St a te/Zip: • Attach a copy of the workers' compensation policy declaration page the policy number and expiration date). Failure to secure coverage, as required under Se attvn''25A ofMGL c :' 15.2 can lead to the ituposition of!. " i' penalties of a fine up to 51, 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 5250.00 a *against the violator Be advised 'that a copy of this statement may be fog to the Office of - vesti ons ofthe DTA�for msurau coverage verffic atton .. -. _ ,_=x ::.:..,_.,:.... : ., w _ I do hereli_y_ ccrtcfy under the pains and penalties of perjury that - the rn, form atroR provided .aba � . _ _. -. Sisnat ire -�-- : Date. d'/ % •1 / . • • • , . Phone if: 82► ?/ I .. :.- ' , . - • . • . . • - Official use only Do not write in this area, to be completed by city or town 'officiaL " or Town: .. PermilfLfcense # • _ Issuing Authority (circle one): :1. Board of Health 2. Building Department 3. City/Town Clerk . 4. Electrical,Iiispector 5. Plumbing Inspector 6. Other Contact Person: Phone #: • s SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: /�� Not Applicable ❑ Name of License Holder : t---P Y� E ( 6 79 ) �n1 License Number Lr ✓/4 u e -tea S 1 ,Sd a°.c4 44 /1 4 1/4 / 1-- Address T. Expiration Date • e r ure ` Telephone I:BttiSllllltUiw1�11 Z « z= prCi!v@rrient�iatitratft" „ ?.`��_� -����� -���,� Not Applicable ❑ Company Name Registration Number � � � �6^¢ ✓� 4 Address Expiration Date eke— T elephone S � 71� .. SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L c. 15z § 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 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 ❑ Replacemen W do ws Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [I=] Siding [D] Other [0] Brief Description of Proposed' -- -- 1/1A-‘7°C.... / " Work: - l�-S /. (6 ..) J`c 164cem eke Vii/! TS Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet s- ff Ne'w`h --- , , -,,,, i r, aditiloiciii xisti`nq ltol sine c©!»pietati fondidila: 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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , 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 l K _ . �1'`J�(t , as Owner • uthorized ereby declare that the statements and information on the foregoing application are true and accurate, to the best of _ .o ' - .ge an ef. Signed under the pains and penalties of perjury. Print Name / Yi Signat er 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 t / ' Lot Size i 1 k 1! _. r 1, Frontage 1 1 ' .. Setbacks Front = i Side L:$ i R: - -• -_ L:! I R: =._...__�. 77 1 { Rear 1 1 E i i Building Height f 1 __.__j i I Bldg. Square Footage % 1 i Open Space Footage i t % 1 (Lot area minus bldg & paved ? t i = 1 g iw. .._! parking) # of Parking Spaces 1 _, Fill: •� - � ... , �.,�_��..,...�..� � ,_.... ..�w.�...,.,.,� (volume & Location) 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:; 1 { IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book � P age ! ? and/or Document # ^ B. Does the site contain a brook, body of water or wetlands? NO 0 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 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 Q NO 0 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • e • �% City of Northampton 0 t , 4 r Building Department 4 v 4' - `m : Z�` 212 Main Street = � �� � �� ��� ���` ° � � ' � { s Room 100 - r ,� i9' o�N �o "orthampton, MA 01060 , , !� ° {�:r� , o . of ; hone 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 Map Lot Unit Zone Overlay District Elm St. District CB District SECTION 2.- PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: G 1 srjr,�/ �' �— r c rti 5 < ` r x-c •� Name (Print) �t Current Mailing Address: 6,6 96 G _�"' _ Telephone cP Signa ure 2.2 Authorized Agent: Name (Print) Current Mailing Address: ................. Signat Telephone S TION 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (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) 7 -'--� C heck Number j �� , S Th s Section For Official Use Onl Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Bu Date I 6 ALLISON ST BP- 2012 -0193 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C - 066 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: windows replaced BUILDING PERMIT Permit # BP- 2012 -0193 Project # JS- 2012- 000298 Est. Cost: $2760.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN CORBETT 078297 Lot Size(sq. ft.): 6882.48 Owner: GLEASON THOMAS J & KATHLEEN A Zoning: URB(100)/ Applicant: JOHN CORBETT AT: 6 ALLISON ST Applicant Address: Phone: Insurance: 56 Dimock St (413) 586 -8712 LEEDSMA01053 ISSUED ON:8/24/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 8/24/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner