18C-086 The Commonwealth of Massachusetts
=-..- -- Department of Industrial Accidents
k rMt, : ' Office of Investigations •
- 1= i 600 Washington Street
Boston, MA 02111
www.mass.a ov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): ) cp_A„ 7 vcc_ it , ht o
Address: 10 - c : 7, 0 ■ n ,,., ,Q -
City /State /Zip: / I+ (,) c, i., f, -. /1 /-1 . Phone. r: '113 5 a it - 5S 7
Are you an employer? Check the a box: Type of project (required): /
1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2.g I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship aid have. no Pployees These sub - contractors have g. ❑ Demolition .
employees and have workers' -
working for me in any capacity. 9. ❑ Burlrii a addition
[No workers' comp. insurance _ comp.- :nsurance_#
require&] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ 1 am a- omeowner- doing-all- work o c_ rs_lave x ercis_e it _1_14Q-)?lumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 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.
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 $1500.00 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: Ile advised that a copy of this statement may be forwarded to the Office of
Investieations of the DIA for insurance coverage verification.
I do_ hereby ce - under the p ' and penalties of perjury that the information provided above_ rs_true.and_correct -_- .
Cif �� S ig nature: . 1 u hate: t a i 2)I 0 _
P h o n e #: ` 1/ 3 _ . c 1. t / .' 3 b = )
µ__
- Official use only. Do not wine in this area, to be completed by city or town official
City or. Town: Permit/License #_
Issuing Authority (circle one):
I. Board of Health 1 Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other -
Contact Person: Phone #:
� 5
w ' L
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : S�� L */,‘ 7 l9 :c " /` i 111. C5 --/35
License Number
c ,/„.,5„.„
Address Expirat n Da e
it),di P- 74 - 7^, , h4 Ji J6 , U
Sig .t Telephone
' - (J - c S'/- 3vW
9.. Registered . time (mProvemea Goritractor er g. ... ,. Not Applicable ❑
(Jai /
Company Name Registration Number
6.ti � /IiJ20 /0
Address Expi tion date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M. G. L. c. 152, § 25C(6)) _ J
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 ❑
L16lf. p Y ome ex x t on
The_cuuent_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
I nrt amOm e T inanccs, a C` " • • -* Its-Genera-Laws-Annotated.
Annotated.
Homeowner Signature
r
d Ilk
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replaceme W Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [I]] Decks [E] Siding [0] Other [0]
Brief Desc � do of Proposed ._
�4 �" J
�� 3 P Y� )1 ,� 1N a ►`�
Work: 1 t,iw� G�� {1 Fc,e C' +i�?r Fi it �•I (asiHcPx - i, sGr .J ,,,F, F . , •, .
0 JJ I t/
Alteration of existing bedroom Yes 3 ( No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes 3 ( No
Plans Attached Roll - Sheet
6L if,New holase• and o r add tlorrto existiricr ousmq :complete thdfoliowinq
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: 1 u • of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new cons uction. 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
I, r J J �✓ et�G3f'r as Owner of the subject
€
property -7
hereby authorize 9p Le ! ve L ) li o
to act on - behalf,, in all matte illative to work authorized by this
1 , building permit application.
,0 (A) L Ai
Signature of Owner_ Date
1, S- 3 (+/.'^1 7i, cc. 1 , ,, bu , as Owner /Authorized
Agent h ereby 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.
f e L./cc I I ; IA 0
Print Nam -
Signat re o f Owner /Agent Dat-
,
Section 4. ZONING Att 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 - ..__. R. .._ ._. R:1,......._
Rea . .:__ „.__..,
Building Height^
Bldg. Square Footage r ---- ; — > % € --._ r
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 0 DONT KNOW 0 YES
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Pagel and /or Document #
B. Does the site contain a brook body • wa er r wet nds? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been nee. t. •e ob ained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
ID - Are there any proposed ranges to or a rtions of signs nteli ed the`property ? YES 0 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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r +
go '
Department i on y vF
City of Northampton
Building Department C rb�D ay P mit ;
212 Main Street Sew ��ailatx,t�r 3
r �1 - f �.O Room 100 W v ability �
Northampton, MA 01060 ra� �ys� +�
.phone 413 -50 -1240 Fax 413- 587 -1272 la s� N1 5
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
�C f<5 JI, fYtfi
Zone Overlay District
Elm :St CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:.
ff 1 L
1�-4; r J L1Q L'��E � — �� J` c -G S '
Name (Print) '� CurrentMaitiria Addre
Telephone
Signature 5 S 6
2.2 Authorized Agent: I / , -'11 .soti 4.1
Name (Pri! , / Current Mailing Address:
.. `if SO- 3
Signat re Telephone
SECTION 3- ESTIMATED ONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building IY .- 7-) • 3 J (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) C heck Number � 7(o —
This Section Ft►r ciai Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
• a
•
218 JACKSON ST ' BP- 2010 -0695
GIS #: COMMONWEALTH OF MASSACHUSETTS
A 111C441C CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateooli BUILDING PERMIT
Permit # BP- 2010 -0695
Project # JS- 2010 - 001019
Est. Cost: $3877.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEVEN ZUCCHINO 021356
Lot Size(sq. ft.): 8537.76 Owner: WEBBER LAURA -JO
/oiling : URB(100)/ Applicant: STEVEN ZUCCHINO
AT: 218 JACKSON ST
Applicant Address: Phone: Insurance:
70 Gleason Road (413) 584 -3878
NORTHAMPTONMAO1060 ISSUED ON:1/28/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 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 1/28/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo