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37-093 (3) Information. and instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation 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 deemed as "an md:vidual, 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 shalli enter into any contract for the performance of public work until acceptable evidence of compliance with the insuranc requirements of this chapter have been presented to the contracting authority." Applicants please al s s. '• nu ar y 1les1 _ . . 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 Liaaility 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 completeand printed legibly. The Deparhnent 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 pnliry infnrrnatinn, (if necessary) and tinder "Job Site Addreaa" the applicant should write. "4.11 in (city o town)." A copy of the affidavit that has been officially stamped or marked by the city or town may provided to the applicant as proof that a valid affidavit is on ale for future permits or licenses. A new affidavit must be filled out each _. year where a owner or c tlzee obtpinxnta hcense orpeimit not to: any business_ or- commercial venture (i.e. a dog license or permit to.b im leaves etc.) said person is NOT required to complete this affidavit The Of cc of litveitigaliuus wuuld like Cu think you in adt►ance for your cooperation and should you have any questions, please do not bPcitate. tn a call__ _ -- T1ieDepartment's address, teleplione=and fax number. iT hee Commonwealth of Massachusetts i Department of Industrial Accidents Face of Lnyegatious Washington Street - 1oston, SSA 02111 • , Tel. # 617- 727-49 ext 406 or 1- 877 - MASSAFE Revised 11-22-06 Fax # 617 -' 7 -7749 www.mRse.aov /dia The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �� a s +per 600 Washington Street .:_ Poston, MA 02111 w ='� www.mass.gov /dia . -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Orzanization/Individual): F- T EN PC' 14 (e.. K L_at,'I\.,7 - fie_ "I tau f C.0 cj�' S , Address: 6 ? COC rtuit f,011,.., p,, 6 0100 City /State /Zip: WU A MPTO Iv Ft Phone #: -(3 - S 7 708 Ar , you an employer? Check the appropriate box: Type ofproject (required): /' 1. I am a employer er with Z 4. Q I am a general contractor and I 6. Q New cons onstruction employees (full and/or part- time).* have hired the sub - contractors 2. Q I am a sole proprietor or partner- listed on the attached sheet 7. Q Remodeling ship and have no a toy ees These sub - contractors have 8. Q Demolition work ri¢ _fa=me m any. capacity. employees _and have workers' - 0 Iltnl • ot [No workers' comp. insurance COIl7p._irnt�ransE.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers have *xercised their 3.111 I am a homeowner doing all work 11. Q Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Q Roof repairs insurance required.] t c. 152, §1(4), and we have no - employees. [No workers' 13,Other Ft uLSt-t 6,A st, i'b. T comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' coilipeusation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contactors 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 a m an e m p l o y e r t h a t i s p r o v i d i n g w o r k e r s ' c o m p e n s a t i o n i n s u r a n c e for m e m p l o y e e s Below_fs the policy andjob site i n f o r m a t i o n . 1NC L L ( = A t ( l ` - ' j C C : ; C T I r t C69 _i Insurance Company Name: VA- LC. Policy # or Self -ins. Lic, #: Expiration Date: Job Site Address: City /State/Zip:` Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration iration date). Failure to secure coverage as required under Sectio1 MGL c. 152 can lead to the unposition of criminal penalties of a fie 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 fire of up to $250.00 a day a! ainst the violator. Be advised' that a copy of this statement may be forwarded to the Office of Investizations of the .D • or -: urance coverage verification _ _ ;;. __ _.__ _ I do he by certiz' and, : i , and penalties of perjury that the of ormation provided_above_islrue axdlcarrect. - - — - f\( 2S / S 1 Signature: . ► e #: 1 . il' � ✓ `'�. Bate: -- . - Phone �_ . Official use only. Do not write in this area, to be completed by city or town offciaL C or Town: i e rm i tfLicense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectricalInspector 5. Plumbing Inspector 6.Other Contact Person: Phone #: NO0 -25 -2009 1?: 12 FINCK & PERRAS INS 1 413 52? 5970 P. 01 ,p .•• =En •- ■•■ •ter 11 • i -r • VIM N.�.•I••lIl• • IN ■•MI 'Er �• „ 11•VI 'VIP EMS 1 11 /£ /£WJ PRODUCER (413) 527- 5 520 FAX 013)527-5970 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Fi nck & Perras Insurance Agency, Inc. ONLY AND CONFERS140 RIGHTS UPON THE CERTIFICATE 6 Campus Lane HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE OOVERAGE AFFORDED BY THE POLICIES BELOW. Easthampton, MA 01027 Barbara Van Mouri k INSURERS AFFORDING COVERAGE NAIC # INSURED CCONTEMPORARY COUNTRY BUILDERS INSURERN MGM Insurance Company 14788.. .._. 82 COLESMEADOW ROAD muses 8 Guard Insurance Group NORTHAMPTON , MA 01060 INSURER C. INSURER D. INSURER E. COVERA 5 - .. _ INSURANCE POLICIES QF NSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUGY PERIOD B+IOICATED. NOIVWTHSTANLN$G ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHEH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CGNUITt0NS of SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM& f t PS2 TYPE OF INSURANCE POUCY NUMBER nTMDN - -- LIMITS _GENEeAL LABILITY MP017444 18/2009 07/18/2010 EACH CCC E $ 1 000 r I COAINIERCIAL GENERAL LPABEITY DANABE TO I OASIS MADE © OCCUR MED Em (Ter person) X 10 ' OASIS , $ A X PERSONAL E A1?V NNW s 1 000 I I t' DDER L A(GRGGATE $ 2.000. c 1 I ' GEM AGGREGATE Lima moues PER: PRODUCTS- COMP/DP AGG $ 2 000 P°LICY ri fl Loo AMMONIA LIABI.TIY COMBINED EAGLE LIMIT ANY AUTO (E ) ALL OWNED AUTOS . BODILY RLNNfY SCHEDULED AUTOS (Pellemer4 HIRED AUTOS 90OttY INJURY NON AUTOS (Per soeidere) $ PROPERTY DAMAGE (Pet G A R A G E LIAUIJTY AUTO ONLY. EA ACCIDENT 6 ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: A__ $ EXCESSAIMMIELLA L,IAMM EAOH OCcuRRENCE $ — 1 ODOUR mows wok AGGREGATE DEDUCTIBLE RETENTION $ _ 6 'TOWERS cor AND R0WC017748 09/02/2009 09/02 /2010 i mYs=T0 F RIPLAYERS LW/WIT 5 ANY EL EACH A 100„ I NTT $ EL. DISEASE - EA EMPLOYEE $ 1001 „ bIMv, EL DISEASE . POUCY LIMIT $ 500.1 1 1 OTNEI 16 0ORIPTION OF O P E R A T I O N S 1 L O C A N D I M / V E N I C U M INDI rl$,ONS AODIM YY PACNMEMENT/ PROVISIONS stiOutD ANY OFME OaSoRMED POMMESBECANc r.mEMU Ma. City of Northampton ETIPIRATIOI DATE THEREOF, ME ISSUING INSURERMIeJ. ENDEAVOR TO IWL Building Department 30 DAYS WITTEN NOTICE TO THE clIRTIFI ATE HOLOER NAYED To THE LEP% 212 Main Street Roan 100 BUT PALM TO MAR ZIICH NOTICE SMALL impose NO DBUGATION OR LMUt Municipal Building OF ANY R I ID UPON THE INSBRERME AGIBITS OR itismonV6TATIVIEE Northampton . MA 01060 A UTHO m O PEPRIESIENTAThia (trick SroucBl1AT LCORD 25 (2001108) RD COPS( MA'T4ON SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ 0 { G � C�i - `_ Z - 7 Name of License Holder : CALF : 6, '�,[ V v License Number f3 Z Cu & 3 i -tal bco �_j) Est= ¢-T - 4M Fri CI✓ ' OiOf Address Expiration Date t. ignature r. Telephone 9. R • iste • Ho a Im , r,- ment Contractor: Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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, Sta rli nd Local Zonin_ .ws • ndd to of Massachusetts G eral Laws Annotated. Homeowner Signature , SECTION 5- DESCRIPTION OF PROPOSED WORK /check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) J Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [O] Brief Description of Proposed Work: Ann cv (-147 toik) 'I _ccf,"[/ AATlAvao1 -4/ c___ U.') tit ]`S I N R SF 1-10-77 LEVUC. -- Alteration of existing bedroom Yes No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement X Yes No Plans Attached Roll - Sheet /E5 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, 0 A 0 b Es A.( , as Owner of the subject property hereby authorize -O `{ G 1 ) 600_ ( 0 to a on my behalf n relative to work aut •rized by this building permit application. Signature of Owner Date I, [ C) '"( GA } (.. CAA-C( G 2 T) , as fawner /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. 1 1 ‘. ( Z-0 /0 7 Print N. I' r NI Signature of e • gent ' 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: N L Rear �Hr' S 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 ‘25 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained ® Obtained O , Date Issued: C. Do any signs exist on the property? YES ® NO sue" IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES I© NO ♦�p IF YES, describe size, type and location: E. WiII the construction activity disturb (clearing, grading, ex avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: i �; Building Department Curb Cut/Driveway Permit -- 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability Novi '3 0 J( Northampton, MA 01060 Two Sets of Structural Plans phone 413- 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 C_► C? L cc- P 0 . V � Map Lot Unit IvC l T (-) /9EL'4. Q' r r l ci (4O(,() Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: n a-v 0 es o n i c k ) (Le 'p t r S v-r f C( 'LE P c: 4 C &wE Na (Print) / Current Mailing Address: ° .ill L .a/ Telephone Signature 2.2 Authorized A _ nt: R lk y tI NG 2 6c, Lc- - S CA 80V-- (z.t ame • = t) Current Mailing Address: t „ Cp_it 1 0)ti '� Mk4 C)O6( t Pint/ -- -s -ec 7 ?0e Signatu Telephone SECTION 3 - ESTIMATE b ONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ) 0200 c * (a) Building Permit Fee 3 2. Electrical 5c)G "`' (b) Estimated Total Cost of Construction from (6) 3. Plumbing `i UCH) + r Building Permit Fee 4. Mechanical (HVAC) ux. CI 5. Fire Protection N SOCO 6. Total = (1 + 2 + 3 + 4 + 5) `Z. 6 000 r "' Check Number 1 d 4e4 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0566 APPLICANT /CONTACT PERSON ROY GIANGREGORIO ADDRESS /PHONE 82 COLES MEADOW RD NORTHAMPTON (413) 586 -7708 PROPERTY LOCATION 49 ICE POND DR MAP 37 PARCEL 098 001 ZONE SR(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /� ��/ Fee Paid 7 / a / 0 /` (v Typeof Construction: ADD RECREATION ROOM /BATHROOM /CLOSETS IN BASEMENT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 062571 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: k/Approved Additional permits required (see below) ( 54? (-0,41 AxcE5 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 Demolition Delay "2/C 9 Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requiretnents 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. a � 49 I C E ° P O ' S i t t DI BP- 2010 -0566 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0566 Protect # JS- 2010 - 000792 Est. Cost: $26000.00 Fee: $1 56.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROY GIANGREGORIO 062571 Lot Size(sq. ft.): 23391.72 Owner: YASINSKI LORRAINE & DANIEL DESMOND Zoning: SR(100)/ Applicant: ROY GIANGREGORIO AT: 49 ICE POND DR Applicant Address: Phone: Insurance: 82 COLES MEADOW RD (413) 586 -7708 Workers Compensation NORTHAMPTONMAO1060 ISSUED ON:11/30/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:ADD RECREATION ROOM /BATHROOM /CLOSETS IN BASEMENT(SEE PLAN NOTES) 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 11/30/2009 0:00:00 $156.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo