38C-023 (2) 04/16/2009 13:40 14135250126 PROSPECTBUILDER PAGE 03/03
LIENS
Under Chapter 254 of the Massachusetts General Laws, CONTRACTOR, and any subcontractor that has a written
contract with, may obtain a lien, commonly known as a "'mechanic`s lien " agatitat the property where ttie is iretiTg pet fix med.
CONTRACTOR presently has or intends to enter into a writte=n ;u luact vent, ~ttrt; subcecitmea. listed sm page 3).
CONTRACTOR will give OWNER the name of all subcontractors CONTRACTOR enters into a written contract with. OWNER
should also be aware that any person who performs work on OWNERS property may also obtain a lien upon OWNERS property
under Chapter 254 without written contract.
RIGHT TO CAE c ONTTRACT
OWNER MAY CANCELTHIS AGREEMENT IF IT HAS BEEN SIGNED BY A PARTY THERETO AT A
PLACE OTHER THAN AN ADDRESS OF THE CONTRACTOR, WHICH MAY BE CONTRACTORS
MAIN OFFICE OR BRANCH THEREOF, PROVIDING OWNER NOTIFY THE CONTRACTOR IN
WRITING AT CONTRACTORS MAIN OFFICE OR BRANCH BY ORDINARY MAIL POSTED, BY
TELEGRAM SENT OR BY DELIVERY, NOT LATER THAN MIDNIGHT OF THE THIRD BUSINESS
DAY FOLLOWING THE SIGNING OF THIS AGREEMENT.
SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT
(see page 9).
By signing this Agreement, OWNER acknowledges that OWNER has received a complete and original signed copy of the entire
Agreement and attached Exhibits. CON'T'RACTOR may not start work until this Agreement has been signed.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. THIS IS A LEGALLY
BINDING AGREEMENT, IF THERE ARE ANY PROVISIONS WHICH OWNER DOES NOT
UNDERSTAND, OWNER SHOULD CONSULT WITH AN ATTORNEY BEFORE SIGNING.
This agreement is signed and sealed on date of signing below.
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Information anti Instructions
Massachusetts General Laws chapter I52 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,
expte s 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 numbers) along with their certificate(s) of _
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (I T" wi n atrthe
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 and under "Job Site Address" the applicant should write "all locations in (city or
town)." A copy of Elie : affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof lhata affidavit -iron file for future:permits or licenses_ A new affidavit must be filled out each
year Where a home owner 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
l ep went of Industrial- Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617 - 727 -4900 ext 406 or 1- 877 - MASSAFE
F7221749
www.mass.gov /dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
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): 4 /3Li✓6....- —
Address: /0 / dx
City /State /Zip: ,y , L c��� -J �t� Phone #: 552_ — ? �)
Are you an employer? Check the appropriate box: Type of project (required):
1. Ekram a employer with QC) 4. ❑ I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [g- Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
Y p tY . $ S. ❑ Building addition.
[No workers' comp. insurance comp. insurance. repairs required.] 10. 5. 0 We are a corporation and its 0 Electrical ep or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' ri t of ex tion er MGL
comp. P p T2. ❑Roof repairs
insurance required.] t c: 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
tHo meowners who submit this affidavit indieating'they are doing all work then -hire outside contractors must submit anew 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: A) G
Policy # or Self -ins. Lic. #: (/G 00 6 5' f5 Expiration Date:
Job: Site Address: 3 City /State /Zip:
Attach a copy of the workers' compensation policy declaration page (showing th policy number and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152-can leadto the impositton of cnminaipenalties 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 ofperjury that the information provided above is true and correct,
Signature: / Date: o
Phone,. #:
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 ❑
Name of License Holder : D 7 /O G
License Number
/a0/311 3 e> Z C'. G JV(aat�7: >:� / /y n _ t) 7 ///
Address Expiration Date
��ulG :f Z 5-= 3z7r..
ure Telephone
. Not Applicable ❑
/ bv 2/ G
Company Name Registration Number
/` /3o L 7r, 2.- ce. I- /v;.. , u 2_ S.- / / 2 / G
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M G.L c ;` 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 ❑
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 Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all aDDl la)
New House ❑ Addition ❑ Replacement Windows Alteration(s) 1 Roofing ❑
Or Doors El
Accessory Bldg. El Demolition ❑ New Signs [D] Decks [El Siding [D] Other [D]
Brief Description of Proposed
Work: ..c� (v. -e'.2 /.24 .2• /e.r- i /t'is //r h.ac."2, i - ,;.,,.) / — /'(7? �i -G/ -i-
Alteration of existing bedroom Yes 4/No Adding new bedroom Yes z--- No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
thi.; r 1 11i.ki. 1o..i.. .Lly- i_ °,0 . ,'. -, J. 64 °,.toJ . ;1 , ..4 , 4 %., ,.. r ` <k %1, -4,$,,
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
f/ I, /OH lt1/1 / ry. /f 1 , as Owner of the subject
property
hereby authorize i 4 C.%t r /3u ! Lv (-7/2-
to act on my behalf, in all matters relative to work authorized by this building permit application.
/61 7
yr i
Signature of Owner Date
I, /2 U /.3 c_ — 7' T /- JZ 4%i) c rte , 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.
perjury.
Print Name
/Z4'.0 z L f .T%X Li" V ' 7c.>" yI/ /6/ p c.
Signature of Owner /Agent Dat
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 I H I I I I
Frontage I I I I I
Setbacks Front I I I
Side L:I R: I L:I R:I I
Rear L I I
Building Height I
Bldg. Square Footage I % I I
Open Space Footage
(Lot area minus bldg & paved l I I I I I
parking)
# of Parking Spaces I 1 I I
Fill:
(volume & Location) —
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO ® DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW ® YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO -' DONT KNOW O YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained ® Obtained ® , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location: i
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO
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.
F,
City of Northampton
Building 212 Department
Main Street
Room 100
Northampton, MA 01060
phone 413 - 587 -1240 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEM
Fax A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Ad dress: # t 1.
"gym v , � ,c �. ..57..
.,,, , ?? a ° �' £x , kr r _ r u x° v* ,. ,l ax
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZEDAGENT
2.1 Owner of Record:
"%G L1 lr aiZ /6-4/ SO .5 7
Name (Print) Current Mailing Address _
Telephone
Signature
2.2 Authorized Agent:
12e'491-'1'1-- T i = 11L�j >/ '�G- /1:2(.) /30! 3 v --s: L . , 4.t .-iY.3.� try .s/ a/ o zC
Name (Print) �� Current Mailing Addre
f �,� 1��� 5Z - 3 e :?rte
Signa or Telephone
SECTION 3 - ESTIMAT CO COSTS
Item Estimated Cost ( Dollars) to be Offic Use only
comp leted by pe rmit appl
1. Building 3 Z �� (a) Build Pe rmit Fee
2. Electrical 7 ��� (b) Et C sst of
Cartstttta lmr�t f rom
(6)
3. Plumbing p t%'(..," BuildingiPermi
4. Mechanical (HVAC) Qi'v
5. 5 . Total = e ti t +3 +4 +5) 3�,, Gib Che N ntl t s
3
This Section For OfficI � U8 ±
. Fire Prot O IY
Building Permit Number: s ued
Signature:
Build Commissioner/lnspector.of Buildings ' Date
File # BP- 2009 -0842
APPLICANT /CONTACT PERSON PROSPECT BUILDERS INC
ADDRESS/PHONE P 0 BOX 302 EAST LONGMEADOW (800) 486 -4976
PROPERTY LOCATION 349 SOUTH ST
MAP 38C PARCEL 023 001 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 g
Fee Paid 30 FP 1 1
Typeof Construction: REPAIR WATER DAMAGE, HARDWOOD FLOOR & KITCHEN CABINETS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 017699
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQl(MATION 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
Demolition Delay
S / /) / / / / eal
Signature of wilding O icial 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.
�aIn a S L- !�• .' ' r j � . i
349 SOUTH ST BP- 2009 -0842
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38C - 023 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovation
BUILDING PERMIT
Permit # BP- 2009 -0842
Project # JS- 2009 - 001054 .
Est. Cost: $50000.00
Fee: $300.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: PROSPECT BUILDERS INC 017699
Lot Size(sq. ft.): 4530.24 Owner: WRIGHT THOMAS
Zonine: URB(100)/ Applicant: PROSPECT BOULDERS INC
Applicant Address: Phone: Insurance:
P 0 BOX 302 (800) 486 -4976 Workers
Compensation
EAST LONGMEADOWMA01028 ISSUED ON:
TO PERFORM THE FOLLOWING WORK: REPAIR WATER DAMAGE, HARDWOOD
FLOOR & KITCHEN CABINETS
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:, ° i ` � ` 0 , Rough: ;,� / �cy p
House # Foundation:
/ Driveway Final:
Q, /inal: '4" yr , - p �b v 1
Final: 2 6 r„ / (1 F — e ,�► a b tl +c � . pl I3 i - � l l
747/0 f Je��` Rough Frame: S l
(oUb p < ois;6 /4 Ott rub E 1at5 ca.N
Gas: Fire Department Fireplace /Chimney: I .
Rough: :3�:: I.: ulation:
Final: Smoke: Final:® // z ,y
THIS PERMIT MAY BE REVOKED BY 'THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. 1
�_
: --- " -- —des,,,>•"',),"
Certificate of Occupancy /, signature:
—
FeeType: Date Paid: Amount:
Building 4/21/2009 0:00 :00 $300.0038394
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo