17A-111 ''' u The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
, „ft
1z
600 Washington Street
Boston, MA 02111
' 71 ' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): EL) i--i i)
Address: \?, \ E_- 9--> - \/ -, v
City /State /Zip: t = 5 C\-1 _1 «ruN , VC, ()WO Phone #: 1Z 5 ()'+4-
Are you an employer? Check the appropriate box:
1. ( I am a employer with Z-- 4- ❑ I am a general contractor and I Type of project (required):
employees (full and/or part-time).*
have hired the sue- 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 any capacity. employees and have workers'
[No workers' comp. insurance comp- insurance.# 9 ❑ Building addition
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
self [No workers' co right of exemption per MGL
myself. [N comp. 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. {� 1
Insurance Company Name: E1 I t'_ IL S. PE i212-A -S t I Sv °'siL • A +.6 C' — G 'A F.D. .
Policy # or Self -ins. Lie. #: S c C Z 1 3 i 1 Expiration Date: '-[ 1 2 1 I . t Z
Job Site Address: 1 C 6 C ' 1 ' 1'1 a e. City/State/Zip: ( n (1A/ d 10(
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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office, of
Investigations of the DIA for insurance coverage verification.
I do hereby certify unde e nd penalties of perjury that the information provided above is true and correct.
Signature: Date: fl ( / / 1'?
Phone #: 4 t S 5. 2A _ 0 59- 9
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
..�.l4li.al %.VafOU 44uvfl VY,f{i V WVa ��.VLJ
- - t ' i `f C
'cr ;� t, ' � License Number Ex on Date
Name of CSL- Holder
List CSL Type (see below)
� i r ;e .r �a8 � � i „
Address r 1 x rDtintr<
0.11. Unrestricted (up to 35,000 Cu. Ft)
Signature
R Restricted 1&.2 Family Dwelling
‘111 M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor (HIC)
HIC C' mpany Name or HIC Registrant Name Registration Number
1$ T ietic L s_c.3'�k– its ,
Address (� p �- `l
E4iratilon Date
Signature Telephone
'141 6 WO RS' 3MP1 3S tiON NS l Fly T .( G L. c, 5 (
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 .......... Q No ... - -- _ - .._ ❑
1, CA Q; ?' " t't. , 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 Other �~ w Date
1'fl►'' i}lkHQlt1�T IlkRA''l�F
I, j icrvl t � , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
c rtl tit
Print Name p QQQ$ t
` 1 J t ; ? t
Signature of Owner or A . . , —gent Date
(Signed under the pains and ' ou ties of perjury)
1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (Sq. Ft.) Habitable mom count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks / porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
• 3
Board of • 1g Regulations and Standards FOR
JANCOOzteletts tat' Building Code, 780 CMR, 7 editi--von —MUNICIPALITY
USE
B ding Permit Applic tioi To Construct, Repair, Renovate Or Demolish a Revised Januaty
OFBUILDING • je sr Two-Family Dwelling 1, 2008
_ .
.• . - • : SC k SflE 1N . _ r _ _. • :
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
1 rC:Li-f Act
1. la Is this an accepted street? yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M_G_L c. 40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Outside Flood Zone?
Public 0 Private 0 ____ Municipal 0 On site disposal system 0
Check if yes0
2.1 Owner' of Record:
Cd1041Vi C tk Tic C.. rt,
,
f ,„ I.
Name (Print) Address for Service:
Lto, --sV1
Signature 0 Telephone
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 1 0
Demolition 0 Accessory Bldg. 0 Number of Units — 1 Other 0 Specify:
Brief Description of Proposed Work ! 7, ccr'u2
. .„:
•... . • - • _ .
Item Estimated Cests: n) OffrtaI Use Only
___(Labor and
1. Building 8 1 BwhbngPeumiFee S3ndicate howfrisdeternuned L.:.
2. Electrical
To ta1Prect Cost(1
3. Plumbing
k Mechanical (HVAC) $ Lisi
5. Mechanical (Fire
.0 E
Suppression) 361
elitekNo::. , 1%.40:
$ („•-- : , .,:•,„::,-
6. Total Project Cost: 6 E „ •
- • - - . - - •,-
File # BP- 2012 -0672
APPLICANT /CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416) 529 -0544
PROPERTY LOCATION 15 CLAIRE AVE
MAP 17A PARCEL 111 001 ZONE URA(100) / /RI/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out -�
Fee Paid `70. 0
Typeof Construction: INSULATE ATTIC & AIR SEALING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 074539
3 sets of Plans / Plot Plan
THE FOLL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION PRESENTED:
pproved 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
jS on Delay
. gnature of Building II fficial 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.
2v
15 CLAIRE AVE BP- 2012 -0672
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 111 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 PERNIIT
Permit # BP- 2012 -0672
Project # JS- 2012- 001159
Est. Cost: $4279.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sq. ft.): 9016.92 Owner: CHOQUETTE MARGUERITE A
Zoning: URA(100) //RI/WSP Applicant: SEAN JEFFORDS
AT: 15 CLAIRE AVE
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (416) 529 -0544 WC
EASTHAMPTONMA01027 ISSUED ON:1/25/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE ATTIC & AIR SEALING
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 1/25/2012 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner