15B-038 •
The Commonwealth of Massachusetts
• Department of Industrial Accidents •
t =510= Office of Investigations
='ie= ' 600 Washington Street
= , R. Boston, MA 02111
?'•x www.mass.gov /dice
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information -- Please Print Legibly
Name (Business/Organization/Individual): / , 7`�� �, L �� tr0? =,AB 1 1 C
t
Address: q L( Li,-714.,,, 4•24,
City /State/Zip: N :«r�^ , (- IC .) Phone. #: x`/13 ._ C
Are you an employer? Check the appropriate box: s Type of project (required):
1. SL I am a employer with 44 4. D I am a general contractor and I i
employees (full and/or part-tme).*
Dave hired the sub- contractors ¢ { b New construction
listed on the. attached sheet. $ 6 7. J Remodeling
2. E I am a sole proprietor or partner-
These sub-contactors have
ship and have no employees 8. Demolition
wor for rate in an capacity. employees and have workers' i
8 Y Y 9. E Building addition
[No workers' comp. insurance comp. insurance.
required.) 5. 0 We are a corporation and its { 10.Li Electrical repairs or additions
3. E I am a homeowner doing all work officers have exercised their 11.D Plumbing repairs or additions
myself. [No workers' comp. right of exemption per lv£GL l 2. V Roof re s
insurance required.] t c. 152, §1(4), and we have no (1.: employees. {No workers' i 3..L3tlier ;i1 Th
comp. insurance required.] u-r4 ,
' applicant that checks box #1 must also fill out the sector below showing their workers' corrtpersation 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 subcontractors have employees, they must provide their workers' corrp. policy number.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. '
Insurance Company Name: , Y'1 + �� ; 1-N �' G- . '2-11\ t a'1 (- (,1ZA •
Policy # or Self -ins. Lic. #: L / Li i .. ( - 3 - c t ` � c r E Date: / t / 2_ ,� 6 f 2 _ . /
Job Site Address: ' t^ `_ (U )l.w {-� j City /State/Zip: ll✓ cw " 4,t, - /zA , !" 6% 4. 64
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 IVIGL 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 5250.00 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 of perjury that the information provided above Is true'and correct. .,
Signature: /(Ct /0 1 Date:
Phone #: L /13 3�c. _ _ /7_. -- (t /(l.
f Official use only. Do not write in this area, to be completed by city or town official I
it
1
1 City or Town: Permit/License # ?
$ Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
i b.Other i�
, l Contact Person:_ Phone rc: j,
•
A) Cir :1—eAt'‘ .
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Constructio ( Su rvisor: ,, �-, Not Applicable ❑
j
Name of License Holder : V `t.(, XL `�k a•'1� /..-- /02/6q
/ � ` V V License N / Z.-. --
A ress ( Expiration Date
' yi "') ( t
Signature Telephone
;fReglistei dflaiiie jiiii %enieiiil iiti#rai tar - ,'ri <h a r 3_ .y , I - Not Applicable ❑
( y (;- vne__ P ��e._._ ii," 2 ` -
Company Na a Registration N mber
V.1 a 1 W ' / to m - s .— '4 (i3
Address Expiration D
- a
..) fi r e MA OlO 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 b ildd g permit.
Signed Affidavit Attached Yes No ❑
g , 0 it wne "�. enin
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 ❑ Replacement Windows Alteration(s) Aga Roofing
Or Doors D ►
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [I= Siding [0] Other [0]
Brief Description of Proposed b .� l
Work: "is {- gar r crn- i 4�-1L-terx ( ,W (�,, + 1 -\. f ` , W.1.4.cs' LA -5
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
s "l � �r1i iit:ar ld li iii, ii ii ii -6ain efit - aite...tiiItilitA014:
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 cogtruction. Dimensions
e. Number of stories? '\
f. Method of heating? N\ 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 \ls 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
I, _ / , as Owner of the subject
property �
hereby authorize C a—r - 7 7 - 4 " --+-�
to act on my behalf, in II matters relative to work authorized y this buil ing permit application.
Signature of Owner Date
„ 5<, j
I. 9 , 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.
Signe under the pains and penalties of perjury.
, - L (.A,-
Print Name
k aA.. "4 ._ 'S3),z_i_524/..--- / 2..--/ (_71
Signature of Owner /Agent Date
e
,' '
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Informatioid n
Existing Proposed Required by Zoning ii
This column to be OW in OW 1 " ,. ,,:
Building Department
Lot Size I
Frontage 1 ° 1
Setbacks Front 1 i 1 ---- 1 i P
Side L:' R:1-----1 L:L___j R:1 z 1 7 ! 4
= ,
Rear I I '
Building Height { = i
Bldg. Square Footage = I [ I% 1 I 4
Open Space Footage 1 oz. i
(Lot area minus bldg & paved - , - 1
parking)
# of Parking Spaces I € ,
Fill: __ _ W m
(volume & Location) I
A. Has a Special Permit /Variance /Finding e er been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry • f Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book 1 i P• : e and /or Document #'
B. Does the site contain a brook, body of water or wetlan • ? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from he Conservation Commission?
Needs to be obtained Obtained ,Date Issued
C. Do any signs exist on the property? YES 0 N '' 0
IF YES, describe size, type and location: 1
D. Are there any proposed changes to or additions of signs intended fo the property ? YES 0 NO Q
IF YES, describe size, type and location: I \t
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.
i D city of Northampton ®� �a
Building Department bm �� �, a.. Q iv
DEC 12O�I 212 Main Street • m � K
Room 100 .F.
aF ECEIVE aua a rm u�sPECnoHS
N• rthampton, MA 01060 . =
� MA i I - ' 587 -1240 Fax 413 - 587 -1272 . h
¢ • � , w , ,% 4, ,.-,,,,14-4 -- ,..7 -. ., - .,. 4. s
.:, ham - . ,i `, ,mss .',
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be comple ed by office
1.1 Property Address: ` � m , r
2 S S V ""''"`' P)) Ma p Lot '✓ Unit
— 1
Zone ° Overlay Distr ct
Eirri St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: � r' 4 irlet l (..v`
s-(4.-)-.2.....6.1 A Artor A 1
Name erint) LLZ(rvt Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
. L- 4,,4--2-- 1_ L yr'yr p.( / /Ves� -� 44.7
Name ( int) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building / L �`L
( a) Bui ld i ng Perm Fee /
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 17-
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number 5 - C, c
This Section For Official Use Only
Date
Building Permit Number: ed:
Vii► � i,- �.-
Signature: %J�/ //�!
Building Commissioner/Inspector of Buildings; Date
Z .-"1.....„...
228 CHESTERFIELD RD - 2 SHEPARD'S HOLLOW BP- 2012 -0538
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 15B - 038 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 -0538
Project # JS- 2012- 000898
Est. Cost: $12000.00
Fee: $72.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANTZ 102169
Lot Size(sq. ft.): 119790.00 Owner: RAGHUNATHAN UMA & KARTHIK
Zoning: RRC45)/URA(56)/ Applicant: MARK LANTZ
AT: 228 CHESTERFIELD RD - 2 SHEPARD'S HOLLOW
Applicant Address: Phone: Insurance:
74 LYMAN RD (413) 320 -7611 WC
NORTHAMPTONMA01060 ISSUED ON :12/1/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPAIR INSULATION/THERMAL BOUNDARY IN
ATTIC /KN EEWALLS
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 12/1/2011 0:00:00 $72.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner