24D-098 •
The Commonwealth of Massachusetts
..- Department of Industrial Accidents
" Office of Investigations
•
600 Washington Street
Boston, MA 02111
.,, :c www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information :7 s' Please Print Legibly
Name ( Business /Organizationfndividual): C O e (' n re'''b�c� h e
Address: 3 o / &t ( S S }
Cit /State /Zip: 6C -c- E(- ,u . Phone # : 1 3 " 7 'Z- - C
Are you an employer? Check the appr' riate box: Type of project (required):
1. I am a employer with r 0 4. ❑ I am a general contractor and I
employees (full and/or part - time).* have hired the sub - contractors 6. ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub - contractors have g. ❑ Demolition
working for me in capacity. employees and have workers'
g any insurance.l 9. ❑ Building addition
[No workers' comp. comp. insurance
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 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 Roofrep
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.4 Other._'i1S -tti t N f Z J
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: 1 Win C j Fire -I-1‘s Gti'1^ a■A &
Policy # or Self -ins. Lic. #: O R" kJ e C t._._ £ r v (P Expiration Date: q 11 t - 2. d
Job Site Address: 7 O cro jo.. -,y„ City /State /Zip: /tie 7 , f ,
Attach a copy of the workers' compensation policy declaration page (showing the policy number and exp ration 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.
1 do hereby cer • under the 'ns,,and pe lties of perjury that the information provided abo e is true and correct
Signature: Date: ..7D L f
Phone #: ( 72-- — e 1 O
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):
I. 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: :able ❑
Name of License Holder : Licensed Construction Supervisor:
Paul Schmidt mber
24 Chestnut St.
Aadr Hatfield, MA 01038 sate
/ C # 103635 U
Exp. 5/20/2013
Signature Telephone 413- 772 -8898
9. Registered Home Improvement Contractor: Home Improvement Contractor: licable ❑
Co -op Power Inc. / Paul Schmidt
Company Name 324 Wells St . _tion Number
Greenfield, MA 01301
Address # 165217 ti4n Date
Exp. 1/21/2012
413 - 772 -8898
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 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 Lop 1 Zoning Laws and State of assachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing n
Or Doors D
Accessory Bldg. [17 Demolition ❑ New Signs ID] Decks [p Siding [D] Other ID]
Brief Description of Proposed BB ( � S
Work: -I )— ' 4 A it'c 4 1„) .
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _No
Plans Attached Roll - Sheet
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. 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
I, OZ ,- ► \ 01 , as Owner of the subject
property
hereby authorize t./D �h > Pa w' i / Pw✓ f £' M j
to act on my behalf, in all matte s relative to work authorized by this building permit application.
Signature of Owner Date
1, fa, ( s t, n,,, T- r/ -,0 Po t.-✓`e , as Owner /Authorized
Agent hereby declare that the statements and i formation on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Pow t SLA A 1
Print Nam
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 Zoni 1 I
This column to be fille in b suss r L I
Building Department i T" r
I
Lot Size _ .1
Frontage
Setbacks Front
Side L R L :I R:i_.
Rear
Building Height
Bldg. Square Footage
Open Space Footage % : .
(Lot area minus bldg & paved 1.__
parking)
i
# of Parking Spaces
Fill: 1 ,._. I
1
(volume-& Location) : _.. (.. __. .
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW (3 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW `.J YES O
IF YES: enter Book Page. and /or Document #,
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , 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 O NO O
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
(e A erro
IN frY\
RECEIVED Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
JAN •• 4tit 212 Main Street Sewer /Septic Availability
Room 100 Water/Well Availability ButwiNG • N 'rthampton, MA 01060 Two Sets of Structural Plans
rt otrmu M : - - 587 -1240 Fax 413- 587 -1272 Plot/Site Plans
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
/ Map Lot Unit
�.- ((..)411; - -
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 02 tDr K' t.
5 7 W0-0(1 y "
Name (Print j Current M ilin Address:
�� aka /� ' ?
i- ��- Telephone
Signature
2.2 Authorized Agent:
P,/ S n,. :�� P,D, 60X 6 $ G «e -NO MA 0/30i
Name (P 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 .Z (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2 +3 +4 +5) Check Number c2 75 7
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0626
APPLICANT /CONTACT PERSON PAUL SCHMIDT
ADDRESS/PHONE 24 CHESTNUT ST HATFIELD (413) 247 -5739
PROPERTY LOCATION 57 WOODMONT RD
MAP 24D PARCEL 098 001 ZONE URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out n
Fee Paid d /5 '7
Typeof Construction: INSTALL ATTIC & WALL INSULATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
O wne Statement or 1
3 sets of Plans / Plot Plan
THE F OWING r/ ACTION License HAS 03635 BEE TAKEN ON THIS APPLICATION BASED ON
INF A TION PRESENTED:
Approved 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
- zf / //
- gnature 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.
57 WOODMONT RD BP- 2012 -0626
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 098 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 -0626
Project # JS- 2012 - 001078
Est. Cost: $2000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PAUL SCHMIDT 103635
Lot Size(sq. ft.): 1180416 Owner: RICE DEBRA
Zoning: URB(100)/ Applicant: PAUL SCHMIDT
AT: 57 WOODMONT RD
Applicant Address: Phone: Insurance:
24 CHESTNUT ST (413) 247 -5739 WC
HATFIELDMA01038 ISSUED ON:1/5/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL ATTIC & WALL INSULATION
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 1/5/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner