38B-239 Information and Instructions
P �
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensati6ii 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 burn 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 • •`
i� = t Office of Investigations r. '
'T 600 Washington Street
M;�
_. Boston, MA 02111
s...o- www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): t( c
Address: (CO C,4 J `leFi c Z.rw � ?flo
City /State /Zip: \P\(.5-\ AN ZCLi- b1 01( ,wi one #: 1 1 a6 q(9c)
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
6 ❑New construction
employees (full and/or part- time).* have hired the sub - contractors
2. I am -a sole proprietor no or partner - listed on the attached sheet. 7. ❑Remodeling
ship and have e no employees These sub - contractors have g. ❑ Demolition
working for me in capacity. employees and have workers'
g any P tY $ 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10. ❑ 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. ❑ Roof re ai s
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13)ther
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:
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 date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fme 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 fme
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
Investigat ` ens of the D • for insu . ' e • . verage verification.
I do here, . 't unde a pains ' , d pe , Ides of perjury that the information provided above is true and correct
Signature: ) Date: g " tl `
Phone #: 1 t o l V ""
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 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
r-
Name of License Holder : 4:61i 11 v 1 &L.— 5 L19 ()
License Number
(P4 (4154 6ZFFFr,D 20 Au.1415bvti 144 010'6 -1 - 12 • l"
Ad. -ss Expiration Date
113 8 7acc
Sign. ,\ �\ Telephone
9, Reaistered IA°me I provement Contractor: Not Applicable ❑
l 'ILLE 61—- Company Name 1 e Registration Numb
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- occupie I % , elllines of one (1) or two(2) families
and to allow such homeowner to engage an individual for hire who does not p s - ss 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 ch he /she resides or intends to reside, on which there
is, or is intended to be, a one or two family dwelling, attached or = -tached structures accessory to such use and/ or farm
structures. A person who constructs more than one home ' a two -year period shall not be considered a homeowner.
Such "homeowner" shall submit to the Building Official •n a form acceptable to the Building Official. that he /she shall be
responsible for all such work performed under t • ' uildine permit.
As acting Construction Supervisor your prese • - on the job site will be required from time to time, during and upon
completion of the work for which this per • 's issued.
Also be advised that with reference to - . pter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resultin • Death) of the Massachusetts General Laws Annotated, you may be liable for person(s)
you hire to perform work for y. • under this permit.
The undersigned "homeo ,. • r" certifies and assumes responsibility for compliance with the State Building Code, City of
Northampton Ordin. • - - s, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeown ' ignature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 0 Roofing ZI
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [CI Siding [0] Other [o]
Brief Description of Proposed �^
Work: �v` \ p ""400...F `�prz>4 — 70:), cF
Alteration of existing bedroom Yes 1C No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
Ba. 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, `j �' E £%t k iv h ,, 6 , as Owner of the subject
property
hereby authorize > L-Lh i (J; L L-
to act on myalf, in all matters relative lo work authorized by this building permit application.
S of caner Date i . > <4.
1, 4LL- 4 t— {l.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 . n 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:
Rear
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 0 DONT KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO l� DONT KNOW ® YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained ® , Date Issued:
C. Do any signs exist on the property? YES ® NO OD
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NOS
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 ® NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
1
Nr
re...4 r . 5
r
t
4 1
1 i r• ;.
3
Department use only
�� 2 4�\ ity of Northampton Sta s of �cE VED
� 2 Z. B ilding Department Cur Cut unvewalj tilt
12 Main Street Se r /Srptic Av it� i kty�
�;,,' Room 100 Wa rNVNI bit �
„,_..-:°`' Northampton, MA 01060 T Sets of Structural Plans
_
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plo ite P r t
• Oth r specify
APPLICATION TO CONS RUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
/ C*7
SECTION 1 - SITE INFORM /Uri
1.1 Property Address: This section to be completed by office
I G o� v �J l Map Lot Unit
Zone Overlay District
Elm St. District CB District
/
SECTION 2 - PROPERTY OWN I P /AU � ORIZED AGENT
2.1 Owner of Record:
tt
1, f E La C ii, t E b Cr -, L (i 4'* . S `r✓ ji j' '( c etc,-.), 41 ii- 0 tit
Name (Pt " °' Current Mailing Addre +
i G - - - Telephone
g nature
2.2 Au horized Ascent:
- , 0 4 f a■ 6„; (.0657-6.-ze i Guo fzeloki) —W)u-10144iNeci
Name (Pri , Current Mailing Address:
;`l! 413 d 'goo
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Rem Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
. r
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) 10ex3 Check Number i ‘/31,0. 4
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature: ...,-- ii--4---- e// Vi /
Building Commissioner /Inspector of Buildings Date
26 OLIVE ST BP- 2012 -0184
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 239 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2012 -0184
Project # JS- 2012- 000283
Est. Cost: $4000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALLEN GUIEL 054248
Lot Size(sq. ft.): 11935.44 Owner: LICHTENBERG JULIE
Zoning: URB(100)/ Applicant: ALLEN GUIEL
AT: 26 OLIVE ST
Applicant Address: Phone: Insurance:
63 CHESTERFIELD RD (413) 268 -9200 ()
WILLIAMSBURGMA01096 ISSUED ON:8/22/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE APPROX 770 SQ FT
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 8/22/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner