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Maycxichusetts - Department of Public Safet}
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 80442
Restricted to: 00
GERARD J RONAN
PO BOX 675
EASTHAMPTON, MA 01027
c =e-- --� — !�•t� Expiration: 3l19/2012
Cmonsimiueer Tr#: 18580
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 /Organizationn/Individual): L `JC ((C (0 S `I-� L( J -71: C
Address: 7 Liu PS *J 'J 1, +! L^-'
City /State /Zip: /V-' /S ( - e /7 0 /0 Y 0 Phone #: i7 l -2 2 0 / 6 S
Are you an employer? Check the appropriate box: Type of project (required):
1. hi am a employer with S 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in capacity. employees and have workers'
g any p tY 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.t
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 11.0 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. P mac A
Other - L, , - 1'
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: Co ry 7 ( --.t < -1 ���'"` I ` t t
Policy # or Self -ins. Lic. #: ' b € O3 Z Zj _0 ( - 1 Expiration Date: 6 Z -/ Z_
Job Site Address: /6 7 'V' - -6 0. tt` City /State /Zip: /VO4_414,, ?qv , `�'¢
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 of perjury that the information provided above is true and correct.
Signature: --- Date: " S 1/
Phone #: 4 ( ( 7 9 ( 6 S l
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 #:
.:.......av t �c[c[ i! [� l ( .i3ClCId.1@GIl L. J _. /
�_, Offce of Consumer Afi o B inessg
�2eWa
HOME IMPROVEMENT CONTRACTOR DEP. I R /`.1/ N, / l e ITD / / ( ° HON
- - Registration: 152467 Type: HOME IM PROVE(. / e NN/ T CO wo / NTRACTOR
Expiration: 8/30 /2012 DBA DANNY S LAR
m 7 WESTERN VIEW OCHELLE RD
LAROCHELLE CONTRUCTION
HQLYOKE, MA 01040 -9782
DANNY LARC"HELLE
T ARQ(�p7 T g CnNCTR tlN
8 BRIAR SPRING LN. '''''''1---'"624.6.--- LIC. T R N6. E CTIVE EXPIRES
SOUTH HADLEY, MA 01075 Undersecretary HIC.0605058 12/ 11/30/2012
SIGNED -..
). lla...uhu•ctt. 1)rl. .. P uh . lt� — _ w
_ . __ _ _„
Boar(I Of Builder; Kr � uLrN�m t . u lir ul � ta�nd r :u r d. a, lA smaty ow Nom*
° i :r.,ct �. t
License: CS 69121 This card acknowledges that the recipient has successfully completed a
• :; 10 -hour Occupational Safety and Health Traini Course in
`, Construction Safety and Wealth
DANIEL S LAROCHELLE;
7 WESTERN VIEW RD I
HOLYOKE, MA 01040 - -- DANNY LAROCHELLE ---
- - Expiration: 6/13/2012 Michael Millsap 11/4/2010
r •munh.h•nrr Tr 279
(Trainer name –print or type (Course end date)
'' L.
Atwater Associate
"
1'40 Atwater TCYV'ACC, $pringeld, MA 01 (413) 747 -53.3
This certifies that
liN`Da Larochel
- ,, ° °,'. r t 7 Western View nny Road, Holyoke Mle
A 01040
has successfully completed
. Lead Renovator - Initial English
r , !, 1 Certification #0
'' 1 , M; '
�R'''`� � �,� Per 40 CFR Pat 145.225 RE -I- 19835 - -00192
Co Due:
g • 0 Expiru ion Date: 5 /26 5/26/2010 /2015
' - , /2810
�� per = ° .. ' 7' 51
0107 _ �
— —
` Sco B1�OUr Tr1on Mam�et /Pondph Train& !
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
I License Number
Address Expiration Date
Signature Telephone
9. Reaistered Home Improvement Contractor: Not Applicable ❑
4. AROQ (le / SZ < <�
Company Name /-,, Registration Number
T i(w Vt l' LJ �� /41 J ��C ✓�'✓� 0 0
4 tJ °.1 0
Address .0 �� � % i t t ti 5�; ., �—L , �; lc ; Expiration Date
Jam.._.... Telephone 1? )9 /sue /
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 building permit.
Signed Affidavit Attached Yes No ❑
11. - Home 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 1083.5.1.
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) Roofing Ej
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [Cl] Decks [[] Siding [0] Other [ej
Brief Description f Proposed n n
Work: K cpV,re I i A; I�ec�., k t.'t. Est, t-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes n No
Plans Attached Roll - Sheet ,/'v
6a. If New house and or addition to existing housing, complete the following:
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. 411 Dimensions
e. Number of stories? r
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
MPLETED WH
` e - • -'e • -ACTOR APPLIES 1EIL IT
( i 1?-,u I) a ZA Co J6 o Pi I , as Owner of the subject
property /
hereby authorize 4 t9c l / �' CO `-e\" (4 C
to act n my behalf, in all matters relative to work authorized by this building permit application.
Date
I, ._ S c'L r(( , as Owner /Authorized
Agent 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.
1,1 i (� V Q q =14 r
Print Name
(Z -- //
Signature of Owner /Agent 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
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
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 Q DON'T KNOW - YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW G YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW ; YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q ,Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO ria
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 Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
^
_ *"* 7- .7'
|
_
.
Department use only
City of Northampton Status of Permit:
RECEIVED Building Department Curb Cut/Driveway Permit
212 Main Street Sewer /Septic Availability
DEC — 6 2011 Room 100 Water/Well Availability
orthampton, MA 01060 Two Sets of Structural Plans
OWE OFeutaao_e • 13- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
• - • 01060 Other Specify
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
/6 7 R kv C2 S ' t 7 ` }� Map Lot Unit
R -� ��+� Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
24 1 .
/}4..V •rQ. Z� 2a ' t g v ib a QR N? �,���.�u� lr o o
t G Z
' S a(i 2964
• Telephone
2.2 Authorized Agent:
Name (Print) 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 / `e9 (] (a) Building Permit Fee
2. Electrical a (b) Estimated Total Cost of
Construction from (6)
3. Plumbing 0 Building Permit Fee
4. Mechanical (HVAC) 0
5. Fire Protection y
6. Total = (1 + 2 + 3 + 4 + 5) Y / 2 0 `' Check Number
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
167 RIVERSIDE DR BP- 2012 -0552
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B - 054 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation BUILDING PERMIT
Permit # BP- 2012 -0552
Project # JS- 2012- 000923
Est. Cost: $1900.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LAROCHELLE CONSTRUCTION INC 89442
Lot Size(sq. ft.): 48787.20 Owner: ZAGRODNIK CHARLENE GERTRUDE E ZAGRODNIK
Zoning: URB(100)/ Applicant: LAROCHELLE CONSTRUCTION INC
AT: 167 RIVERSIDE DR
Applicant Address: Phone: Insurance:
7 WESTERN VIEW RD (413) 781 -5651 WC
HOLYOKEMA01040 ISSUED ON:12/6/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE PORCH FRAME & DECKING
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 12/6/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner