38D-042 (2) 11 41 •d :1:, : : , .. i. ; . .:.. r .ii, ,,, ' ''.. , : w i
I ii: ■, :li '.g1 II
L
;.■ , r.l. ..
r l':, to r . 1:1 i , ,..,, rh col o■ ci 1 .11
11: .1". - •;:' 4..
3: :•1 .., i Iii '.", ', •: .•:: a, .:4 tit 1 itt 1:i' i'',i, :b
, 11
I: .E -.I
iil IIII 11, HI !8::! li!; ii l ,i. i . 49: iii 44; ;14 y p.r1 :I, i.; ( .4 U P ,i...
e,.., 1 i4i 1 ii ci c.1 i• rEq :': :!! ^il ci Pi: j! g S PI fl c: ' ■ I:P 1 1 In
1 lit 1 :
In ' , , ' .
ii1 1.1 Y i i ! • ■ • • 0' iji . It 1:![ 1 I 1 111 1 ;1 , ii: 1 1 1141 1 161 1 341 , i 16 1 0 I [ 1 1 43 .„ , In
• -I :
It• . 4 4.6 1 d : 1 0 1 i ;II i.
1; 41 1'.
i l'
I:: 1•1 1 in
1 : ,i 4, 31 :ko 2 hi 4; 17 . p.: 1. 01 „III, 1
X 1 .0; l 'i : li' ,. :IP a '11 1
1 1 . 1
ICI 1 11 1 ' I P' I'l 111 ' 41' 4 Ci1 ::: Ili i;J,I 1 : : i ;I:II i(11 t:1 ,., .11 1 t. It" 4; :: It:I . 4 4: 5 r 1 P, ! ," I :1; II :44 • . 4 ... 01 ' 'C1: 1 111
ill ki: ill 11: 1
• .1 14 ' 1 1 11 il!
. 1 41 1 1. ,71 1,1' CI 1 ,4! ,4: I t' 1 "./! IC; ii' iii ' :.' PP one!! • ...1 :-. ..:
:: •• i
i:' iP1 1.:: 4.1 v. 4 PI: : I l i], 1 1 4 : .::: F i. ii: II! i ; : . ,. 21 . ' riii i': '.■!:
0 6 no .. .
; 1 Il .::: o.' ii. I': (t) ' 4p ii. p 1 41 :,: 111: OP 1 11:r 1:1 .1 ,
0 r . : ..., '4;.i IT NI °
1
a 1 .1. 4 4.. r.i 4:4 ,.. I 1 I
: ii 1 .:.:,, gi ,.. „ ,:: ...: - r • • 1 " 4: V. ..17 , 141 14 111
1/1 1Il
„ I,:1' IiI, ;;. (3, l'"
7. ill 1:1
:'•.: 1. 0 ..: r,r, 04 .! ':'.. III !ill 4.."It 0 l
latt.•.-1... 4••• : 1
I
0.1 4 •
L! ...: i:: ,.., ,,,,. .,,,
1.': 1'; 1 ,: kk i 11 14 k!: i.; vl '111 too 1.1 ;1 Ilo a vi
4fr. 13 DI
,.. 1 II 1 ' ;•.: 14 ; on
;11 :-. ..: ..iv i1 Oil kk,j/ "11 I 444 184
P 4 ":.: :: ::: ,...., i' wi 1 - .-• 10 Id m. pr.■ ... pm i ;;; d 1... •::i .. i 4_1: 4"
CV 11 31 '.'., 111' ov i . „;', ii, . „, : . ili: ,,„ T ;,. ',-.14 1,17401
„.,
,..;
li.: a '. -6 :.:1 a tt• li, :Ili 1 1 Ii
1:1 Mk 1:1, 1.4 0 .:1; 13 -11
•I ;4: :1.41 rl 1i; I I,” .. ..... t ; id,
1V1; 11
13 1 111 41 1.1 11,
1- 111 ; :r• ' ji :
' 11: :/. l'j 1 -; rirl
1•1 f ti ri• 1
.0 'oil - es ;et •A :' 1.41,4:r4 •
,1 • . , -. ,■::; i. D
ID '111 11 1
' „k
. : ::k . okk
1, v; Pri : 1 1 il? : ,.. no no 1 /5 41
I
..,,, 1% 3: :-..; II 1411 7
1,i,1 IP IP 141
34,
.4 .4: : i ------ `1 1
I 3'
k!': oE1 '.1 '1 0 ko': 1 il I i "...I k 11
it 1 .
111 14 1 .1 1 . k: '::: :r. ;:. 41 '' 1:1;,P1 PI 1,', 14 113 mull
..
17.1 r•1 1 13 ' ••: 1 1 : 1 lf; 4 2 ;:. :: tti ,1 ti:'
13; IP 1:1 1..i
CO 01 0
D' II I 1 li loa ID
ID a ...' .
''' I 1: 3:: Ini 1:d I:Ii 111 '» ::; '
111 14
1.1 01014
ic■ pit ..'y :a :I: l_rri ir '
'X •11,41
:In
•I '1 :::: IT
ri 4.31 4...., id. i,:, :i...4 ,.,1 43' i..,
444. 4::. .441 di iiri :. ,r;
1•:I 1:11 1•;- 0, 11.1 1; 4.1 I .14 •::: 1
0
t i
44 ii, 1» 7 ie a Ilik
11
131 1.0 411 1.4 ,..; t ot t,1 , 1,1 1 ,11 It
' ••:1 4 ••:1 1,1 '.1 .(' lr (0 :11 :4 MI 1"In
el ft:
(.. 0
1 ::( C .: 1 : : ( ..'1 114 ON
el 1 141
1.I 1 1
1, iir
,.,„,
,..: ,...., :i: ! ...! 1 .1 '7' '71
1 kg, 1.c.• 'di
HI ::• lil 1' .; .k
,;!.1 111 I,
13
1:L 01 ;;CI ,...., :
4
I..1 : :11 1 ' 1 , •1;
1;1 CC
1;• i• 111 ::I 14114
' 3:4 1
;11:1 14 :•.
";;.
1;
13 II: 14 :1 11J! C:II
41 11C .
, i! ;:l
MOM
17,
(
11 01
1 :;;;1 . 1 1 ..4 0 41, r11101 ni
'If,
.
Iv
it v.:, o t:: 43 4 3 ilit;', - '4 i.... iii ... .,..,,, ,..,
ILI 4.
,
.: .., ... " 34 4i4 3: a a :I1 .. r. %It ti:',1 , .11 i '.;. ,,,,, ;■:, ;4, ri; 4, .111 1 I%
tro 1
' 'k 1 4 in '11i a D ; D h
o "fro.: o„ IP; l; 1 III: ;Pi ::1: 4',:t -.I
il■ 4 I: - ili :ii I:t 141 ::.1 l ,';'; lil: ,.I:
14: a4 Kt 1,q41 31 :1; 'MI:: I I ' :
op ...... o• Iry on
:
::. III .11V ',.., ..,.. no
iko "
k v 3 , ;,... ii . r „ , , ,.[,., .,, ,:, In , 1 . 1 6,
4:3 •d4::: -1 :.; .i'l • .' ittl • I' 31. iIII I t t pn
, t 1;1 '2: t ' t 4;) 1 n, 1,” I:» tn• •:::
.6.41 71 .!, .. to:1 ..I :gl .., Om,
... • 4.• •;:i o
ifi 7!.' :0 3. 4P iil, .. p. 1 ; ic
,.c 141 ■I;• .■141 '. '111
„I 1 E„ ; .
4 1 tn. 4: .61 1. Ld g
r pl
111 1 qi? 411 'I, •::' ,..4 '
1;171 :.; .-I ,;;; 1 :41 1:i l 't . 1`1 ' '' • • •• rt• 6 '
ill lii ?■41i( 1:4:
l,S: 3 . 3 .:3 1 3 : 1 :
.33 id 1: 3
13 ' II : k t.• rvol ..v.
it ak al 13 a
.„;/ . '1 0 4
o v - .- fro lot i:: :V n:'
6.1 1»
31■ 4:? 3: 1:: 11 61 111 .11. I»
itt
i l'il Ill 1
;e: 'A: ',.. ..... .,..,, .-.., '''.... 1 10 ,-4 4 : 0 ;... , 1.... 0.: :.: 1, , , en In •:•
" 1.41 'Pt PP ■::: 1, 1. 4, .(I (I:, :
4,8 (..) 0i (' : (I el lr a. I ;
il; A HI 1 0 1 V P i.r,b Ill '4 '4 (,... 4i9 ., 3 111 411 Pi
4:(, '..., „ :,,, ,..;p1 0, V,3 Il I.1 0 1: 1 . .0
, 1..' .4 1...h. t 1■4634 •
t 4
"'
!it [I■ :a :4: I 1 44 . .1 ; iil I41 Pi . 1 1 110 t. 'ft, 1 • 1 1...' 1
111 . 4 •• 1 IA ,It nt
-,
l 1:1 ;i1 :II ,, 1 •;;/ : i. I F I pn
33 1 i
....., .4: :::, 1.4, i ,,, ; I : ,., , 1,3 ,
4:: , 41 •I• ; 71 111 111 4. on 4., v; ; VV: . :4O ''11 ::kii 111 iii i:: . 1 . og 41 /VI k ii: . 41 1 1; . .;,1 ort
. 41.: 1 11V ;3 '. - V r' 10 4 (.:'. i,i! ai ;': el, ii :;::: : ii: ";!: ;'," ;;. ii.; : 7, "5 ,i, 1 ..:
4, I: iig. :ii .:4 1 41 ; .,i,, i .i, 4.4: c) •41 ;:-.; p it ci ,:t, , 1., ;:: ,.., , ! j r ji 1;. , 3 , i :,: :..1 .. 44 i ',. 1 : iii' : , ;i::: ..:.': j
13 ,. ...
...; a
11 4
!:: .9 441 ;!; 1::!.::
114 ed
tl 01 111 II1 J :,.,; 1 0 :0 :: 4,1r. ii„ :.:: . ! ,i,I .,' : , : t .!t 4 i
, !it I "4, D'1,:', :,,.
cn 1 4 ;4: ;-: 2: il.:.: r.:14: ' ::' !1: iii in , : ..1 4. .'t; 1 1 . LI; 4,' l'- ig it i
i!1 Fii El ' 0, 0, 1:1 1 ' :i: :PI' 4.41 .: '
14; 4j4 i 14; 31'
1 III
10
3:1! i t 4 1 '
11 13 I• 141 no 31 r" f . • . In ,..1. 1.4 f ,l 1,-; „4 , q it , ::. E;; .:, LI . ] 40 .4, I" 1 II; --.: 6. HI I Ilh " •••• '11 • 1 1
1 ;•• . 'i 1tt III
171 41 1 1 11'11 1 , tit 1 ;1 ":. .g: .1:o li:, k i/i 1 k : :: On on ' kv. Iii " :1:1 (.1 t.,4,
1 ( j, .1 Id' INI0, 41 ; 1 ., 0
1,1
"14 .1. , 111 ,:,1,
11/ " ,p• VI,
" ri ' ' . ,;. : : . Lit. ,I, ; i'' , V:,:j
:C."I Vio iii ;i Ii k4 (. .v1 no l o : j:,,,, : ,1 (11 0 (1. -1 Q . (.] l : I» .1
(' q LI, .! CO 31 '
I:: !I:, 1 : NI 4p 3., ::
....i..0 431: .4.
41 :
.: 4 r :11 a r:
V: f:1 1 ql ''' l T
, ..i ,? i: r . : i 1 ((: : ii: r tj ..: a
n : ; 1 f 04 ' 44 ;I 44- , 0 ; :. ,.. ...: 1 ;D:' o : '"' :p• :', 1 1•1! 01 3:
11 t o ‘, .•.!i 'I i In . al: i r l i ': : i',i .,!• i': : 4 ii ::: in a: .
ill ' I''' lin ..., , To .. 11
lie / :oo k3: ,JI, 4
II! • , lj :id 1 I l i. 1
11 I
' N I 1:: C;1 r.: i t"' •I1
.... ' 1 4 1i 1 4 i '41 I Ei 1 ' 1:', [P. l' iP -I 1 1 it; ;.: • :'. ';'' r.. 11 1 11 y I 01
'.11 ;'' ■.• pl: ::: ::: :-.:9 ' : 11: 411 : a r •• 11 •••. .
; 1 ;": -1 l
I . Ir■ 1 1 41 ,„, , , ............ 0
1: ..i 1.. :.1.1 -I Ill 01 In :(1::: :
Ilf4 :: ( 11: 141
i ! ...! .
I
' 441 , 1,if :.!!
.1 01 111 0, 1 VI PI 1 14 01 01 01 00 0. 10 01 (0 I 01 0; 61 ' 61 66 4.. FIFI ....1 :21;2 III
I:I
111 1 [ .. I:» "111 1 1.. 1 1 10' 10 161 i.ti 1,11 1,01 4; 0
'I* 16:
1;11 41 113
1
' :ii ( 110 411. I.' 4.! 1.!•' 1
- 1 1
lli I 1 :: ilt 'r• 441 1.I. 1.1.11 1;: 1;: 1 .14 1:1, 1::, 1 44 . ta■ g::4 4::4 4:4 al Ir. INI :it :IP PIP in' to 1
, i,t■ In •• r.pi ra: la) : :::4: 411 . :a 1 : 111 131 4:1 441 441 141 1 11 11. 411 1:.: "'I 41 4. •:;; '1
41, • 3 , a 3; .., 14 CC; 1::1 ID 1;41 : : 43. 1:1; 1;:o ; , 1:4! J7: 1;:r I::1 17.1 ;::1 , ,;,) ty 10 1 ,„: •...„, 1,•: 01
I 11.1 '' 1 0 1,3 1 0. ,, III
.11• I 1 ..,4 1. .4 4 6 41;1 1:3 1::. 44:1 , 'I:: I» , Iii■ 1 I 1:1! 14 1;:r .:;1 CI
. '31 111 0.1 : 1,,' - .1
C1.• HI 1 .1 I;'' ' . 131 1 :: , 141 14. .4: : 43 13 1
; ' 4; 1 1 7,7 ; 1:4; 14/ ,::1 „!, ii! • 11
.1.
rri 13 vo a .. k a 44 a
1
, :3 ak ; o'.:k ; k 31 a Co
: )
' :to
liv 1 .: : :
1.0 n
(I:
.41 el ! i
, 1
I
;( ,
it, j : I 1
(
1 (11 ;V:11r;
(, ' 0 .,. .. •
1 , , IL(0413 : ,` : •,• i .,orielrii.
,
1 , , ,H F11;40 : , v vo
.,Nlife11;11Ti ' 1 3 i 1
i 0 f,11.1 5 '
,,o
/'
I" ' A
) I t t 1 k
1 t 0 i ' i, i ,o I .
1 1 f k 1 i■ „:, , ./ 'S
I
r
li ki
1 t •
■ i kit i
■ 1,
f' ..
1 ..11'31,1.1
1 ■'' 1, *141' 'll 11'31114Y* 31;1:113 :" Viirlitl i, ,,a ; r: ' ,1,:1::;. "111. 1 1' 1 " 1:
I11.1 El.
i° 1
...I 1
i
10 11 .i• ;■, i oi:;,1 q! 1 k • r) , ri 1 I 11 • . '''H I ' I 1 \
i
"il fi:alicii ii. :iii,:i !:,1, i
LI.) ii
.,,. ..1.,.1 1..ti•it (.;f::Eil:: !iiI.I pf:!1".' i:i.i:fl L :.
CI
•
1 r : l',.:,z.;
1: 1':!1:111. 4 ::1 ED:1 10;
f;;;I:k. 1 1 0 1 ? 1;:ilq 1.1 N ::::1..1.1:: . .. ' - I:
' • '
'I 25 C. Filii:!:11 1..1',1 .
MA [1'1
IN
mi Ilmoliko,,
,.. ,:::.,.....,:,:., ........ ,.....„:,„„,.,:„,..
,,.„,.,....,,..,„i
+I
irl 1 i ,
1
,„ ......
,■',,
111 ! l' '', i' / 1 t ,11 ... ,1 t e , „` 1 1' . ,, il
1.• . „_. ,
' 1 ,1.11. •" 0 1 r,•,1::■,,( , •;;',r,( 1 0? f r'411,, 0 , 1 l e,,'r,,e,,,Itii ) ,11: 1 0,;',1,11:?,0 11 , 4 1 4:1,
.,•,, ir.Vielj=1;rrirr:1,,1? II...1 ., 1 ,. , .!...,' ..-• 1 i , ...f 40 , • :,. .1$ ,•,..•. ( -., I
, .. 11, , iiri,4 ' ., :, ',,,
4 ,11.$1.1.1 1. li'l, eV., i.11 ll'i.)11;::; 4:113(.1'. , .!4;1.1 I .11/4.1.4,
.1 I:1,
IIJ CI Till : i'lgilli ,:lil • „ ,k , ., .. , , 111,,, -, :I, ,„ V, ,i , i ', 1 3 0 1
it L1,11 .(,.. A. ■. L/ If IA :
.
I / I el 1
1... ID St01 .: Si;;Ic,it - I I 1I I . 1 1 1 '' ' 1 1 1 1 :I
"o 1
Cdr.' I .1P.1 11 I I
E.,
.".. .„ 1::1:11.111: ii,t,,f,',:ii.;d1,5, a 4 1,,,, 1,
.t.i'
c.)
:)i r a':icort: 5a:112:Ci'l Cr MI 26.;12iN
i..:•.. ',f"111!..: f?it Ili" ti' ,1-i: I::: li:;', 1::;IES
1.T:i■e1,1:r El R,I.INJ;;:t.,1..E.
■•••1 $
tn w, ;;;;I: NI (, 1::11:,H1.1.),
1.. I .
17,.(1)(1„,„. ,4 (la rifiii turd ri!lItcrn 1; m41:1, 11•1:21 iii: IN:ini.,Dri For ell:a11111::,
iu
1
1 ,i■ a El il:si 1 RiNlevi.p.1 ........ 1 ,1■.,nri14,1):, ineut. .. .... 1 1.t.s.1 i:',.J11•,•,1
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 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 confinnation 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 bum 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
Fax # 617 -727 -7749
Revised 4 -24 -07
www.mass.gov /dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
.1= Office of Investigations
600 Washington Street
Boston, MA 02111
kM� www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers
Applicant Information Please Print Legibly
Name (Business /Organization /Individual): i'(Cy f / )2E S t'v „. p,5 i Dt7A} -i t auJ [V[,
Address: (e EL 124- t3E — H S'
City /State /Zip: W .5/or /Z14 D /D/ Phone #: y i 3 - 75 -- 32,(30
Are you an employer? Check the appropriate box: Type of project (required):
1. M I am a employer with / Z 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. ❑ Remodeling
ship and have no employees These sub - contractors have 8. MI Demolition
working for me in any capacity. employees and have workers' 9. n Building addition
[No workers' comp. insurance comp. insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. n I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.111 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 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
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 j under the ins and penalties of perjury that the information provided above is true and correct.
,
Signature: 1,�,.4.44 Date: 3-- (! //
Phone #: (� S ( ' 76 S
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 #:
MAR -08 - 2010 09 52 NORTHEASTERN UNIU 617373551y r .r LW"la4
18 ttat Restoration, Inc. �
WORK AUTHORIZATION AND
West Springfield, MA 01089 ACE TER DIRECT PAYMENT REQUEST
Phoney (413) 750.5200
Home Improvement Contractor License #151246 RES INC.
bowed Name & Loa Address Ming Address If Different:
_ 3 P 1745“01.0 652, 4 Atrwtivv 9Vd 1"rolto ,r<
. 't .
• .07.7.74117 , .! r .,. ..
The general scope of work Wilt be: OL,2 . 1`" i..sr /`'7ra0L. Afiwayy Cja 911/7.34.
34
In coasid of the agreement of Ace Fire & Water Restoration, Inc. to provide services required to preserve and protect the
personal and/or real property, which I own, control, or lease;
1 - I btreby assign to Ace Fire & Water Restoration, Inc. all of my right. fide, and interest in and to a portion of all insurance benefits
or proceeds to which I may be entitled, and assign any and all claims which I may have against any insurer, to the extent of the
amount of the bill for professional services rte to me and/or my property referenced above; and I hereby grant a lien to Ace
Fine & Water Restoration, Inc. on any insurance benefits or proceeds that may be due me.
**Due to what 11 deemed to be an Ewergeney Situation, Owner hereby rescinds the right to cancel this Agreement for
Emergency &vices -
2. I hereby authorize and direct the payment of such insurance benefits or proceeds directly to Ace Fire & Water Restoration. Inc.
and direct the above referenced insurance company to pay to Ace Fire & Water Restoration, Inc. such sums as may be due upon
receipt of a statement for services rendered.
3. I understand that I am primarily responsible for the payment of all charges related to professional services rendered by Ace Fire
& Water Restoration, Inc. to tae and/or my property referenced above and the authorization contained herein in no way releases
me from personal responsibility to pay for such charges.
4. I hereby request and authorize my insurance company to furnish Ace Fire & Water Restoration, Inc, with any and all infor-
mation, including without limitation, payment information and estimates with regard to work required to preserve and protect the
personal and/or real property which .1 own. control or lease.
5. Any individual or entity shall be entitled to rely on the original or any photocopy of this document as if it were an original.
6. It is understood that the estimate is subject to the approval of the adjuster or a representative of the insurance carrier.
7. The liability of The Company is expressly limited to the total amount of the services authorized herein and in no event shall The
Company, its agents or assigns. be liable for consequential and/or collateral damages of any kind.
8. nutlet understand that any and all deductibles and/or betterment from our insurance cattier shall be due and payable by us at
the completion of services rendered. If payment is not received within 30 days of invoice„ a delinquent payment penalty will be
charged at 1.5% per month.
9. In the event this account is referred to an attorney for collection, I agree to pay reasonable attorney's fees to Ace Fire & Water
Restoration, Inc. s attorney, and cotnt costs, in the event a suit is Weil.
Intending to be legally bound, I sign this day of itia toa. , 7- to •
Do not Nign tide contract M than we any blank wawa.
3igaatuee Y,,,:•C_ AFV1{RI Representative
Print Name S re e Tt4A 1 G ��-►t 1��'
ID#
Title. ytoN,�h. Fed 204384724
Date 4%. 1®' ( Date
WHITE - FILE COPY YELLOW - OFFICE COPY PI - CUSTOMER COPY
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
G A ,2 y rz v r• ec l..L�' O -7L L-1 1 Cam
License Number
IZ� C l 5 >✓N
Address Expiration Date
Signature Telephone
Not Applicable ❑
IC) Zy 1p
Company Name f Registration Number
ec ,),)41- 5 Iv C.
Address Expiration Date
l g C A 13G rrd s; � , 5/I U) 114A Telephone qi 3 "A
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 ❑
.A r OTT ` "l 1' `i 4 t r.
The current exemption for "homeowners" was extended to include Owner - occupied Dwellines 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, von 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
New Hew.. 0 Addition 0 Or Replacement vYNndow. Alter aon(s) ❑ Rooting [7)
CI
Accessory Bldg. ❑ Demolition New tiffs tea Decks tO Slang lb) Other 03
$fief Desalption • . Proposed P`
Work
MA* F , l;(4
Aterellon crediting bedroom Yes )c No Adding new bedroom __, _ Yee _
Attached Normative Renovating unfinished besen�ent Yes) No •
Plants Attached Rod - Sheet •
a. Use of bulking : One Family Two Family Other
b. Number of rooms in each tinnily unit _ Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
a Number of stories?
t Method of heating? Fireplaces or Woodutoves Number of each
9. Energy Commotion Compfence. Messchedc Energy Compliance form attached?
h. Type of 'Construction
i. Is construction within 100 R of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
1. Depth of basement or cellar floor below finished grade
k. Will building conform to the Ruilding and Zoning regulations? _ Yes No .
1 Septic Tank CAS Sewer Private well City water Supply
$ECIIOtt 7a • QIMNEdt AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, nt r-�, d as O ner d the subject
hereby etrlhorize ,A GQ. � wit Wa t( tra1D'i h C
to - • my behalf, In a I matters = - to • authorised by thfe btril •. , • - application.
t6
11 • . - �r�• . / as Owner/Aulhorfzed
Agent - _ , . - • , : that the statements and Information on the foregoing application are true end accurate. to the beet of my knowledge
and belief.
Signed under the pains and penalties of perjury. •
Print Name
Sigma,. of Agent Date
TOTAL P.04
City of Northampton
•
Bonding Department
• , W, 4 ' •
212 Main Street
Room 100 *OgiNgitittailatit„
'7,010
- - Northampton, MA 01080
phone 413-587-1240 Fax 413-587-1272
Aftc*ft
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOUSH A ONE OR MG FAIRY DIVELUNG
SECTION ent wismanioN
1.1 Emoskialtat: --- fma motion Nibs completed erg Moo.
\ 41-e- Ma • • Unit . •
aiihtelfo, Kg tt40 Zone . . Ow* District .
&est amnia; • cs moist
worm 2 - PROPERTY OWNERMIPNWTHOFtIZEO AGENT
11211111101.825120 (055 1 4 1 414% 0 6 4 ao€
&416eyi Bow+ov, rid OAIIS
Narn-211924"14— hbarNislress:
be 7— 751-1451
Telephone
Zahibidiaaaget
PC m g ' 5; Asa .) t_ee ( Pik t • At $\' %.*‘/' a
Name (Print) Cent MsAny
•
AMA, T -
•
ligelila&ginenalifigiganiMan
Item Estimated Coet (Dollars) to be Official Use Only
bbelleted bY own* applicant
1. Bidding oc
ri 0 , (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from
3. Plumbing Bing Permit Fes
4. Mechanics' (HVAC)
S. Fire Protection
B. Total=(1+2+3+4.5) • 1 Check NuMber 4 Yf;
ThIs Won For Official Use Olde
Building Pam* Num Dat
bs,:
issued:
• _
Signetunt
Whine Commissioner/Wpm:Syr INAdings Date
•
File # BP- 2010 -0787
APPLICANT /CONTACT PERSON ACE FIRE & WATER RESTORATION INC
ADDRESS/PHONE 18 ELIZABETH ST WEST SPRINGFIELD (413) 750 -5200
PROPERTY LOCATION 38ARLOW AVE
MAP 38D PARCEL 042 001 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
Fee Paid � t 36
Typeof Construction: REMOVE 1ST FLR BATHROOM CEILING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 074416
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
V 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
31 10 110
Signature of uilding Official VVV 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.
38 HARLOW AVE BP- 2010 -0787
GIS #: COMMONWEALTH OF MASSACHUSETTS
: "D: 2 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 -0787
Project # JS- 2010- 001174
Est. Cost: $950.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ACE FIRE & WATER RESTORATION INC 074416
Lot Size(sq. ft.): 5706.36 Owner: SCHOEN STEPHANIE COOPER
Zoning: URB(100)/ Applicant: ACE FIRE & WATER RESTORATION INC
AT: 38 HARLOW AVE
Applicant Address: Phone: Insurance:
18 ELIZABETH ST (413) 750 -5200 Workers
Compensation
WEST SPRINGFIELDMA01089 ISSUED ON:3/11/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE 1ST FLR BATHROOM CEILING
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 3/11/2010 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo