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12C-103 (2) The Commonwealth of Massachusetts DepOrtMeiEt JPE;: Accidents Office of investigations 600 Washington Street R ' TP Boston, MA 02111 sr- p c i ii)sw..mass.gov/tJla Workers' Compensation Insurance Affidavit: Builders / Cons - actors/Electricians/Numbers c• , _i.�.�ct information -ease Prim Name ( Business /Organization/Individual): C70, c;c Ti br4 Address: ' W- .. '"1.1 t= ' City /State /Zip: F E E r t u i U« L t Phone #: t t v 5 `r Are you an employer? Check the appropriate box: l Type of project (required): 1.11 I am a employer with 2- 4 . fl I am a general contractor and I employees (full and/or part-time).* have tired the sub-contractors 6 - 0 New construction 2. © I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub - contractors have g- 0 Demolition working for me in any a ity. employees and have workers' g t �pac 9. 0 Building addition [No workers' comp. insurance COMP p. insurance.. required.] 5. 0 We are a corporation and its f Ifl_E Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.0 Phmibinglepairs or additions myself. [No wonders comp_ right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152. §1(4), and we have no employees. (fi3o workers' I3.t Other corals_ insurance required.] Any applicant that checks hos 4=1 must also till out the =..sting below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing ail work and then hire outside cos;traaors must submit a new affidavit indicating such. t that check this box must. attached an addiioual shA stowing the name of the suh- contractors and state whether or not those entities have employees_ If the sub - contractors have a nployees, they mast prewide thefr workers' re . policy number. F am an employer that is providing workers' compensation insurance for ney employees. Below is the policy and job site information. Insurance Company acne: j — ( ----- Name: l � i? � � i��'i ..i Z.tkC. t � �; �,<�� � � rscr`: L-�'.` Policy # or Self -ins. Lie. _: S 4 C Z ti l 3 `� Expiration Date: ` I 1 1 + 2 Job Site Address: L City /stale/zip: (-) r=1 o to 6 Z Attach a copy of theworkers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.0&) andior one -year imprisonment:, as well as c •d penalties in the fir of a STOP WORK ORDER and a fine of up to $250_00 a day against the Violator_ be a rih -ised tirn a copy of this statement iftay be forwat to the Office of Investigations of the DIA for inquance coverage verification. I do hereby certify an tie ;` . and penalties ©f peafbary that the information provided above is true and correct: Signature: Date: lo • L5.11 _ bone #: 141 5 5 161 - Official use anhr. Do nal write in dris area, to be conwleted by city or town official_ City or Town: PermitfUcers # Issuing Authority° (circle ©rte): Y. Board ref Ilea ?i 2 ri1din Depart e nt .?. Citti'Town Clerk 4. 71 ec'tri-ca Inspector 5.. Phumbiag Inspector `• 6. Other Contact Person: Phone #: . . ..- . mp,achtp.,...tt-, - Dohnitn if public of BrAitiintt r-- and '.,t,Inthlilis Ucense: CS 74539 - , SEAN R JEFFORDS 13 TERRACE VIEW EASTHANIPTON, MA 01027 F..:t.ofraton 1112812012 Tr 5544 - — — 54 -,.. kille . 6/ ' . , ' ' '' , • f a' a #1.4/04•JadeAdee& vIZIY'I''' ri= Office of Consumer Affairs and usiness Regulation • -,. ., ,,- -- , r. --7 :-," 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 .. ,- Horne Improvement Contractor Registration Renistration: 131279 Type: Individual Expiration: 6/29/2012 Tr# 297765 SEAN JEFFORDS SEAN JEFFORDS 13 TERRACE VIEW EASTHAMPTON, MA 01027 _ _ _ Update Address and return cord, Mark reason for change. - Address Renewal Employtnent Lost Card DPS.CA1 0 5914.04 0 *AO , . ,..-.7. - ■ j„j ,, j "..' , Ofikei)reoirageTtaTrehltiSs iiilfeseP License or registration valid for Individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 131279 ----* Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Expiration: 012912012 individual Boston, MA 02116 SEAN JEFFORDS - e -Aar rAllillor SEAN JEFFORDS 13 TERRACE VIEW _ : !:■4•+ ,(, ....7.47. - 553._,--, - ,,-• - - . - --- ...----. __ EASTHAMPTON, MA 01027 Undergerretno Nut valid without sigunture 5.1 Licensed Construction Supervisor (CSC,) S ZA p l ,ecc-(-C27 S License Number Expiration Date Name of CSL- '[older 13 _ "6 H►,lj-- -if Wry et List CSL Type (see below) - -_� — — Address �� ' Type Description_ — �� �� U Unrestricted (up to 35,000 Cu. Ft.) l Signature R Restricted 1 &2 Family Dwelling ; M Masonry Only 3 29 j �{ RC Residential Roofing Covering 4, ; Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor (HIC) �CYoNO &i ' t t2vc tar! \312 71 -- HIC Company Name o IC t : -•, istrant Name Registration Number " I/4 �tip'jt v cro2q Address i� b- z " l2 lj 13 • SZ9 0 V y Expiration Date Signature Telephone ECTIOZ■1' WORKERS'r COM.1?ENSATION 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 f,8. No ❑ :41.4",040- r- Q ! M.34.1 1.04., IPIS1:1QB000MPC b'TED I EN r_ a. A;VgNt`OkrteMitkank ,CM S ORt Di14 PERMIT.. I, c%(1-0 r S dl e , as Owner of the subject property hereby authorize (* r1! C> p,Gp ty C �t z c. o t l to act on my behalf, in all matters relativ o ' ork autho ' by this building permit application. 44441. /0/3A Signature of Owner Date SECTIONZC; OWNER QRtUTHORIZED AGENT DECLARATION - . . I, A-14 C OS , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf., Print Name '�� _ Signature of Owner or Aut rized Agent Date (Signed under the pains an, senalties of perjury) 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively. 2. When substantial work is planned, provide the information below: Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/ porches Type of cooling system Enclosed Open 3. `Total Project Square Footage" may be substituted for `Total Project Cost" + _ The Commonwealth of Massachusetts and of Building Regulations and Standards FOR i� 7th MUNICIPALITY ��a; �`��vE�i usetts State Building Code, 780 CMR, 7 edition USE Building Pet mit.lpplication To Construct, Repair, Renovate Or Demolish a Revised January NOV I 8 2011 One- or Two - Family Dwelling I, 2008 - . This Section For Official Use Only 'B • :... Magi - Date Applied: - -- - Signature: - • — -- - Building Commissioner/ Inspector of Buildings Date SECTION 1: SITE INFORMATION , , , : , 1.1 Property Address: 1.2 Assessors Map & Parcel Numbers 3 6 ti -4,v_ D2. c ,21. 1aG — — -- — 1.1 a Is this an accepted street? yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use • Lot Area (sq ft) Frontage (ft) 1.5 Building Setbacks (ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public ❑ Private ❑ Zone: _ Outside Flood Zo Municipal ❑ On site disposal system ❑ Check if yes❑ -. , ::_ _. , .: S PROPERTY O WNERStIP' ,__ , 2.1 Owner' of Record: (5: N 'AV LeS ' FlteK t V Fe 4r 'aCC N nt) Address for Service: �( Al t �� �pi f,S (4 t3 , 5 - 6BZs S Telephone '-`- SECTXQN 3: I» OF'PROPOSE.D`WORK — Heel ai'.ft a a 1y) New Construction ❑ Existing Building ❑ Owner- Occupied ❑ Repairs(s) ❑ Alteration(s) lal Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': 1 r-kS'r'A u_ LGi.A- r ; c t � i v r- . 1 r4 l}-f-r-i L- . TT-) `R.' y iJ 1 44 - ',rLSe/4 L 1:•15s 1/4--- 4Je4 air s+►v-t A6, SECTION 4 ;ESTIMATED CONSTRUCTION COSTS = ' Estimated Costs: '', Oitaa/10e Only ° (Labor and Materials) 1. Building $ °6�a a 'f 1, Building PerrnitFee, $ Indicate how fee is'detenrnned: 2, Electrical $ Q Standard City(_I own Application;Fee ❑ Total Project Costa (Ifeit _ _x- 3, Plumbing $ 2. Other Fees: $_ 4. Mechanical (HVAC) $ List: • 5. Mechanical (Fire Suppression) $ Total All Fe • (., / Check No. - eck Amount: Cash Amount: 6. Total Project Cost: $ ( Eo ❑ Paid in Fu I ❑Outstanding Balance Due: File # BP- 2012 -0500 APPLICANT /CONTACT PERSON SEAN JEFFORDS ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416) 529 -0544 PROPERTY LOCATION 36 RICK DR MAP 12C PARCEL 103 001 ZONE URA(100) //RI/WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out '7/(_(„ Fee Paid llD�ll�� Typeof Construction:_INSTALL ATTIC INSULATION ,AIRSEAL,WEATHERSTRIPPING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 074539 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: pproved 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 ft/ Signature of Building 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. 36 RICK DR BP- 2012 -0500 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 12C - 103 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2012 -0500 Project # JS- 2012- 000835 Est. Cost: $4880.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: SEAN JEFFORDS 074539 Lot Size(sa. ft.): 62290.80 Owner: STAPLES ROBIN Zoning: URA(100) //RI/WSP Applicant: SEAN JEFFORDS AT: 36 RICK DR Applicant Address: Phone: Insurance: 13 TERRACE VIEW (416) 529 -0544 WC EASTHAMPTONMA01027 ISSUED ON:11/28/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL ATTIC INSULATION ,AIRSEAL,WEATHERSTRIPPING 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 11/28/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner