25C-114 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
v Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):
Address:
City /State /Zip: Phone #:
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. New construction
listed on the attached sheet. 7. 11] Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
for me in any capacity. employees and have workers'
working Y p tY• 9. n Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing 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 $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 ofperjury that the information provided above is true and correct.
Signature: Date:
Phone #:
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
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
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9 egisfere :RWri e;Improvement:Confracto «. A v- „� _ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT T(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 ❑
11 . -dome Owner Exemption
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)
h r
New House n Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [ii] Decks [p Siding [O] Other [0]
Brief Description of Proposed 9(
Work: ((t \�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
Sa lft .Newhouse «andocirnaddition. stinckrhausina; car n plete:,t he.follow.in cl:
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 7a 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
, 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.
Print Name
Signature of Owner /Agent Date
..
✓. J 'i
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
e
Existing Proposed Required by'Loning
This column to be filled in by
Building Department
{i 1 ii
Lot Size
Frontage
Setbacks Front i [
1
Side L:' R: 1 L:' . i R: s
Rear 1 I nrni
Building Height 1 a
Bldg. Square Footage n1 li I
Open Space Footage
(Lot area minus bldg & paved a i I I ( E
parking)
# of Parking Spaces
i I i j l
Fill: ;_..____
I s
(volume & Location)
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:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book 1 Page'; i and /or Document # I
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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:
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:
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.
'ECEIVED {; ' k {De art ellltuse� r
Cit of Northampton S tatus4a f6 rm it a x � ono .
But sing Department D ''b fret Permi ,
NOV 2011 a� ;�
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Room 100 Vi e � la f '-~ . -4 .
DEPT OF BUILDING INSPE Oft ampton, MA 01060 WO g St F a P atT x 1;4.444*
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
Th section to be completed by office ,; s ,
1.1 Property / A / d ` dress: �+ �./�, , n , I , i 4 4 � _ f '.fit ` , ` " c
V I ` f e \ 7 x '"� x 'r�5 s�'h . � '� i � � ',� '�ka �, ,a y�
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SECTION 2'- PROPERTY OWNERSHIP /AUTHOR AGENT
2.1 Owner of Record: f ,, //
Name Print) Current Mailin A d d r e s s :
C---400-- Telephone p 1 /� � ^ Q
Sig ture �-� �"l ��) C / � J G) ���
2.2 Authorized Agent: �CCJ.�
-- ° V .. lux l YtA- 1^-e .
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 — ESTIMATED CONSTRUCT COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
(a)` Building Permit Fee
1. Building
3,So 0 -
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fe e .!
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5), �, i Check Number
Thi Section `F Off icial Use Only
Date
Budding Permit Number . Issued
Signature:
Building Corn tor of Buildings Date
56 GRANT AVE BP- 2012 -0527
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C - 114 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2012 -0527
Project # JS- 2012- 000877
Est. Cost: $3800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 5445.00 Owner: SIMMER STEPHEN CRAIG & REBECCA MARY ASHE
Zoning: URB(100)/ Applicant: SIMMER STEPHEN CRAIG & REBECCA MARY ASHE
AT: 56 GRANT AVE
Applicant Address: Phone: Insurance:
56 GRANT AVE (413) 586 -0145 O
NORTHAMPTONMA01060 ISSUED ON:11/29/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL PELLET STOVE
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 11/29/2011 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner