17A-196 (2) Luwe; 11/ 1L/ LVV25 25:31 : uy AM PAUL Z/ V03 rax berver
The Commonwealth of Massachusetts
Department of Industrial Accidents
to �
'•I ;: Office of Investigations
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600 Washington Street
• Boston MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization /Individual): K6y (_ S I (le_ C (()
Address: ').'-) 6,i1 l �/� � Sd� a a (
City /State /Zip: Phone #: /( g r
Are you an employer? Check the appropriate box: Type of project (required):
1.0 I am a employer with 4. ❑ lam a general contractor and I
employees (full and/or part- time).* have hived the sub - contractors 6. El New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 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 t 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.••
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
a. ❑ 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 r irs
insurance required.] t c. 152, §1 (4), and we have no [t�' ��� it ` ( C
employees. [No workers' 1S.()ther 'rl CS 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.
4 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 member.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: ?(_j S- 39q 61 6 ( Expiration Date: q" d 1t 1
Job Site Address: ) 1 ,hnr k n I e < 9 City /State/Zip: J (0 f t7 �(' �' J-lat, 6( (D('
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.
ignature: Date: 7- / & -1/
/
Phone #: { 13 6 G, -- 5 9 t 6
O 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 #:
Lib/ 26/ 28111 86: 58 4132573390 PAGE 01:'1=
gil
Board of iBa /l(lin!.! Regulations and Standards Q�Ce4 �iAIIAILiI!!IIEf�
Construction Supervisor License
License: Cs 96999 1 r, ,,, - -7 - r ,, HOME IMPROVEMENT CONTRACTOR
Restricted to 00 - ,'.� 1 ,: • Registration: : 16x5816 Type-
% t F` i r "7 y Expiration: . X012 LLC
TODD KORTEKAMP -e f : =
%"t - y4 °� '"' • KAMP TO _;;.;'`: ', '
27 SUTLER ROAD
MONSON, MA 01057 rij '}
• �` TODD KORTE � , i�a
27 BUTLER RD ' "
c;.-."7—,..---- ' `"`� � Expiration: 8/28/2012 AAONSON, MA 01057. Klndervecrctsry
i onu hisvion Tv*: 27751
Restricted to: 00 License or registration valid for individui use only
00 - Unrestricted before the expiration date. If found return to:
1G - 2 Family Bfomes Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Failure to possess a current edition of the
Massachusetts State Building Code I
is cause for revocation of this license r
Refer to: Not valid without si ture
W W W.Maas. Gov(UPS
ecc�a�
•" - -- Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
k
" OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
•
1 Office of Consumer Affairs and Business Regulation
r Registration: 148688 Type: 10 Park Plaza - Suite 5170
z= ti,: -' Expiration: 10/18/2011 Supplement Card Boston, MA 02116
LOWE'S HOMES CENTERS INC
JAMIE SPOFFORD
136 TURNPIKE RD. SUITE 100 4d— 41 01 � r
SOUTH BOROUGH, MA 01772 Undersecretary Not valid without signature
� . ✓fie {�arnmoruuea a`'. Z/aefi.a
Office of Consumer Affairs & Business Regulation License or registration valid for individul use only
* : OME IMPROVEMENT CO before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
NTRACTOR
e- c i , Registration: 148688 Type: 10 Park Plaza - Suite 5170
',;;� ,, Expiration: 10/18/2011 Su pplement Ca rd Boston, MA 02116 4
LOWE'S HOMES CENTERS INC l
1
1
RUSSELL POWELL +
136 TURNPIKE RD. SUITE 100 , 4' , ..--i------,<63.- - 7 _( 1t,„„_____
SOUTH BOROUGH, MA 01772 Undersecretary Not v without si ature
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) CS
1 6g K � .., � Number Expiration v / �� � License Numbe E tration Date
Name of SL- Holder �.�
a 7 t4 t r P t), / Kca )`t q 6 (C! S') List CSL Type (see below)
Address Type Description
U Unrestricted (up to 35,000 Cu. Ft.)
R Restricted 1 &2 Family Dwelling
Signature M Masonry Only
y1), - L c<e - S /S- RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered H,� qqme Improvement Contractor CHIC)
L2LiC Geri 7d� S ).�� l t,5sell �i.:C? tl Registration Q C
HI Company Name.or HIC Registrant N �'
) - l� r� l t k�, J 54 ._ /CO ,Ati",q, 014) //
Addr- /• //
'/ /"3 - � - �� �� Expiration Date
Si _ ature Telephone
SECTION 6: 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 C� — ■ No 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, . Z , as Owner of the subject property hereby
A authorize Pr, IQ., 424 64 /4:) to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
f
I, (de Ale y 64 )6, / u , 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
be .f.
■ .� / LA ell
P i. j , N e
,. I/ //
• Signature ' Owner or Authorized Agent Date
(Signed u der the pains and penalties of perjury)
NOTES:
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 room 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"
,
The Conmonwealth of Massachusetts FOR
,, d of Building Regulations and Standards
'r l assac usetG St<<te Building Code, 780 CMR, 7 edition M USE ALTTY
Inrnhtj htetuntP,.1 siltation To Construct, Repair, Renovate Or Demolish a Revised January
NORTHAMPTON, MA01..• - _ or Two - Family Dwelling 1, 2008
This Section For Official Use Only
Building Perm Nu ber: 6 p - l Z, - _7 Date Applied:
Signature: G 2k / i
Bui din Commissioner/ Ins ector of Buildings Date
g P 8
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
kSI ko rk b41k 54
1.1a Is this an accepted street? yes no Map Number Parcel Number
13 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:
Public ❑ Private ❑ Zone: — Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' Record: bote_,Ace J a' � \ 91 •,6, --\ l.51 .)Uo r I- L, f iectl� 51 i
Name (Print) Address for Service:
e e_ Co,. r a c_-1- / - `-t f 3 - <, 9 C -- 2 ? 5
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner - Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other l pecify: R4 ii..en'i i iirAt{„5
Brief Description of Proposed Work r.. ♦ . Q 01 ' • ./t-, r. 1 1 a
C \n_c1 er_ i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials) Official Use Only
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: _
5. Mechanical (Fire $
Suppression) Total All Fees: $
2_ Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ s3q / O q ❑ Paid in Full ❑ Outstanding Balance Due:
151 NORTH MAPLE ST BP- 2012 -0078
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 196 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit # BP- 2012 -0078
Project # JS- 2012 - 000116
Est. Cost: $5390.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: LOWE'S
Lot Size(sq. ft.): 9539.64 Owner: DEGNAN JOHN R & CONNIE
Zoning: URB(100)/ Applicant: LOWE'S
AT: 151 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
282 RUSSELL ST (413) 588 -0270
HADLEYMA01035 ISSUED ON:7/20/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:7 Replacement Windows
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 7/20/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner