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12-013 (2) ..,.... License or registration valid for individul use only '''' Office o consumer Aft f:. _ ) e - --1 ----- - -- - 3 _, (;6 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: :, _ .-; -- _t- - __; - .■ Registration: 156686 Type: Office of Consumer Affairs and Business Regulation ,) Expiration: 7/25/2013 Private Corporatio I 10 Park Plaza-Suite 5170 '->‘ Boston, MA 02116 Ji & SON INC JOSEPH GEORGE 64 HAYWOOD ST __47._,:g___ ,k I ". i \;g t (L. ' r■ \,, GREENFIELD, MA 01301 ( Undersecretary Not valid itbot signat re t)u..1..inun. ) ZL£66 -=- CLOZ/1 l/Z :uonendx -,------------ --9- .0£1.0 MAI 013IdN332:10 13323.1S 000AAAVH 09 30230e0 Hd3SOC # 01'SM :cri PaPulsaU 7,L£66 18 .PC . . 71 ` . ' ' asuoan toads ,)osuuadns uogonllsuoo _ 1).irptil pin 1/4tio!winr,am 7m!pi!ng to pirog ■iate..., mitind to itimilurcho - .iiasni.pr..,r it —c Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensati6fi for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states `Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this- chapter -have been presented to the contracting authority:" . Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub- contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ _. _ 600- Washington -Street Boston, MA 02111 Tel, # 617- 727 -4900 ext 406 or 1- 877 - MASSAFE Revised 4-24-07 Fax # 617- 727 -7749 www.mass.gov /dia The Commonwealth of Massachusetts Department of Industrial Accidents t Office of Investigations ;. 0' 600'Washington .Street . r . Boston, MA 02111 ° o' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information c Please leease Print Legibly Name (Business/Organization/Individual): --3 ; ` �` V� ����� =- V�(-,-\ � -\ WCO S Address: f City /State /Zip: e-e4A- -c NA O `3 l c \ Phone #: ` -1-1 3( Are you an employer? Check the appropriate box: Type of project (required): 1. ftl I am a employer with 4 4. 0 I am a general contractor and I employees full and/orpart- time).* have hired the sub - contractors 6 ❑New construction I am -a -sole proprietor or partner- listed on the attached sheet. 7. Q Remodeling ship and have no employees These sub - contractors have g. 0 Demolition working for me in any capacity. aci employees and have workers' g Y P - . t5' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. 9 We area corporation and its 10.9 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 12.9 Roof repairs insurance required.] t c. 152, §1(4), and we have no , , . ici employees. [No workers' Other �V�SJ& W ` 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. t 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. lithe 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: ( (\ S Policy # or Self-ins. Lic. #: \C 2 I S'\ Expiration Date: L i — ? d `4- y C oL V` k �t� City /State /Zip::,U(�AAC - � © l 6 , ,{ bop '-- Job Site Address: W �1v \�, 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 hereb ertify under t epai s and penalties of perjury that the information provided above is true and correct .. Signature: Date. 1 0)--i 3 -- I Phone #: e. 3J 4 3k,c) 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 S=-DESCRIPTION O PROPOSED WORD (check afl applicable) r New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing l i Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [Ca Siding [D] Other [D] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet a` .N, °House. ara`: of ad: ittton o'exis'`i ': k ` ®'uSin. 6iUD e. " a o n Cf: 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 OWN __TO BE COMELETED OWNERS AGENOR T CONTRACTOftAP. PLIES FO R BUtCDfNGPERMA I, , 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 I, , 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 SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : v V ( % � [ -SR- 6 193 - 1() n License Number t CA Ak k r Add ! Expiration Date _Okttt C am) 711 0E Signatur Te = eqi ere: , om rnpcave nen TCon ra ° or`, , ° ,, tf P.., , Not Applicable ❑ Com an Name , Registration Number G Addre Expiration Date iL.',• a Telephone ( 3 SECTION 10. WORKERS' C OMPENSATION INSURANCE AFFIDAVIT(M G L 152, § 2$C(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 RI No ❑ 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 • Nov 21 11 01:03p Lisa Gibbs Real Estate 413 584- 0536 p 1 • .7 New House D Addition ED Replacement iNIndows Alleration(s) Joi Or Doors CI Accessory Bids 0 • Demolition 0 New Signs (CO Decks DM Siding En] Che .191V tkAllat ' ,4 povi, ;'• Brief De • . • •11 .1 Pragosed 021111 Work 'VI Le- 6 42*■sk-1/4 kit.c: VAN ovt " 0 wt o k' Otre( .(-4 ckc 314 Migration of existing •bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes hi( Plains Attached Rod - Sheet .-.• -FP a. Use of building One Fawn* Two Famay Other 11. Number of rooms in each family wit Number OfBathrooms C. Is there a garage attached? d, Proposed Square footage of Ilthif construction. Dimensions _ a Number of stories'? f. Method cit heating? Fireplaces Or INOotietoves Number a sec g. Energy Conservation Compliance. Masscheek Energy Complance form attached'? — - - h Type of construction Is construction within 100 ft of wetlands? Yes Na. is construction within 100 yr. Noodplain __ — Ye No Depth of basement or cellar floor below finished grade k. Wi11 building conform to the Buittfing and 2oning regutations? Yes No . I. emote Tank City Sewer Private well City water Supply . . 1-7. , • , (D • • , as sr 4 the subject ProPeiti hereby . • ■I - • to act . behalf, in aN rff., to work authorized by this building permit applcation. - • cd °WM Date — . . %ewe , kuthc tura Agent hereby declare tM the statements Wid information on the foregoing application are true and accurate, to 'de est o my knowledge and belief. ...... _Signed osier the pains and penalties of perjury. . . Al 'TOD( - _ — Print Nam • 1 1 111 0C / "r Signakint of * .4/ • t Date Nov 21 11 01:03p Lisa Gibbs Real Estate 413 584- 0536 p 2 RECEIVE - DEC 1 2 2011 I ,.. -,.. . I „ A l L ,I,IlliIl ..,... - • " -- " Wilinallill . City.of Northampton . . Buikiing Department 212 Main Street . , Room 100 Northampton, MA 01060 i - -- t phone 413-587-4240 Fax 413-587-1272 i —^--• , APPLICATJON TO comsrauct ALTER, REPAIR, RENOVATE OR DEPAOLLSti A _. , — ate OR TV110 FAMILY *%E1 -MG — — — - :Li: ,,- , r; 7 - 7 171 5..'„: 7, ..'- - 1 - 2 . ! - .. ' 1 ''' -1 • - ' 3 •,'" "t , ::..',.. 1 -:,..r: )_.;1,n7:1" .1 , , 1' t ,- .tZ :d, .'" - • =a ...-r- F -' ,1 *". ::5- ■ .- . .-L.A...fl: -7.7. .rr'r........w=....' 7 p " ' , - , .i, , . ,.. - - . - , ... • • 1 , 1.1 ftrastraggatm: _... 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