23B-039 (2) IF arm MASSACHUSETTS AMOUNT PAID: $
Fairly WORKERS COMPENSATION and INITIALS DATE
EMPLOYERS LIABILITY APPLICATION Undenviiter
New Business ❑ Rewrite Of Processor
Trial Application ❑ Binder No.
Policy No.: y,, j,, aci Payt,� n: Er �xpir ar! Dave Anniversary Rating Date
Agent's Name: airis t Age i � Percen
Secondary Agent: Agent No.: Percentage:
NAMED INSURED 1
p 01- Individual ❑ 02- Partnership' ❑ 03- Corporation ❑ 05- Limited Partnership' ❑ 06 -Joint Venture
O 10- Limited Liability Co. ❑ Other (Describe) *Indicate Names of all Co-Partners
First Named Insured mdMdual or business) Name 2: (individual or business)
7 le
No. & Street � PO Bon No. & Street ( PO Box
1 L"a e
0 ieT
City. l �, mss' State: Zip City: State: Zip
,Asi`!`&/Gl J _ Of 3,30 i i i i
County of Assignment:
Occupation: Occupation:
Home Phone # ( ,i /3,494 1 e - 33 1 75 - Home Phone # ( )
Business Phone # ( /d --/no Business Phone # ( )
FEIN # ( Mandatory): die Yi 1 da f FEIN • ( Mandatory):
I
Billing Name and �Address if different
Name: T "' ,, �ll� J' ^ G,�r�
Address: /2t t' &Ltp 3/ `'. WJIIiitmsbt„ PA if /U Ib — i ny
EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state as indicated above. The
Limits of Liability under Part Two are:
Bodly Injury by Accident Body Injury by Disease Bodily Injury by Disease
(each accident) (policy limit) (each employee)
$ kOftree $ $ 1ev
X -1286 0407 MA -1-
,Farm MASSACHUSETTS AMOUNT PAID: S
Fang)/ WORKERS COMPENSATION and INITIALS DATE
Record Speciaist
Gm").i - " EMPLOYERS LIABILITY APPLICATION
New Business 0 Rewrite Of Processor
Trial Application ❑ Binder No.
Policy No.: o f I lD Payt Plan: E Dat Expiration Anniversary Rating Date
� U .4
.../ /
Agent's Name: aanS
t a Ages Percery ,
Secondary Agent Agent No.: Percentage:
I NAMED INSURED i
p 01- Individual 0 02- Partnership' 0 03- Corporator 0 05- Limited Partnership' 0 06 -Joint Venture
0 10-Limited Liability Co. 0 Other (Describe) 'Indicate Names of a8 Co
First Named Insured individual or business) Name 2 (u c vidual or business)
Tea
No. & Street { PO Box No. & Street: PO Box
f do &Ale ; "-SET
City Stale: Zip CRY. State: Zip
A _ ) 0l330: 1111
County of Assignment
C,a
Occupation: Olt Occan:
tio
Home Phone # ( ,�/) 33"7.5 Nome Phone # ( )
Business Phone # ('Y13) ,cad - 1976 1, Business Phone # ( )
FEIN # ( Mandatory): d10 6/ /d y FEN # ( )
Billing Name and Address if different
/w[
Name: v f'.k+J'�°. .
Address: / 2 0 dapC S / - e e i - . L U , i / i i r i lib r g J64 d/6 b — /
EMPLOYERS LIABIUTY INSURANCE: Part Two of the policy apps to work in each state as indicated above. The
Limits of Liability under Part Two are:
Bodily Injury by Accident Soddy Inkay by Disease Bodily Injury by Disease
(each accident) (policy limit) (each employee)
$ /00,L $ 5NOX $ 1LY', ff
X - 1286 0407 MA -1- `
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occuvancv
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
i3o ermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, . Jl' /' understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to
Date (o/ ly %t o
Address of work
location j) 171,4
v -,
The Commonwealth of Massachusetts
Department of Industrial Accidents -
-' 1® a 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) 7;( hi 0 P - ( .
Address: ... e', , e-r , U c . , C V .
r
City /State/Zip: (9/0 - Phone. #: l'/ _ a /0 - 7 V 71
Are you an employer? Check the appropriate.box: • Type of project (required): •
1. ® I am a employer with ,< - 4.. 0 I am a general contractor and I
t ' have hired the sub- contractors 6. 0 New construction
employees (full and/or part time). *
2.0 I am a sole proprietor or partner - d on the attached sheet 7. 0 Remodeling
ship and have. r loyees These sub - contractors have. 8. ❑ Deaolitiion
working for me in any capacity. employees and 'have workers' -
[No workers' comp. insurance -- comp. insnran c e .. _ . ..- . - 9 Q __ _ _ ing addition
required] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have4xercised their . 11.0 Plumbing repairs or additions •
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required:] t • c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
- • comp. insurance required. }.
*Any applicant that checks box #1= must .also fill out the section belo' showing their workrrs'- compensation policy information.
t Homeowners who submit this affdavit.indicatng 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 nacre 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.
1 am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name: 'Pei r - nq Q p• •
1
Policy # or Self-ins. Lic. #: c )601 W(, P R. y- : Expiration Date: ��i)/ 7,-,9(2 i't
Job Site Address: 37 A/ki St City /State/Zip.• $ncdl p7� ► 1�1'I45v,
Attach a copy of the workers' compensation po declaration page - (showing the policy number and`eapiration date).
.
Failure to secure coverage; as required under. Section ofMGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1500.00 and/or one -year imprisonment, as well as civil penalties in the form of STOP WORK- ORDER and a fine
of up to 5250.00 a day against the violator Be advised that a copy of this statement may be forwarded to the Office of
Investigations of theDIA for instance coverage verification: .. 1 . -: . _,_
� _ _ _ .... _:.._w ,. :air _ - _ • - -- - - -.�^ _
_ I do hereby ce under the pains and penalties ofperjury that the i provzded:above_is :ue_an fcorcert_ __
Signature 1 _f `�-- . Date; le) /G
Phone #: (-/7 2, v 7 /n /5e'
- Official use only. Do not write in this area, to be completed by city or town
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 y ❑
Name of License Holder : iCi Q reo 1 0 53
License Number
� dOG C � -31' led- L0 t II6�S b cc` Ill .<. V' 7��'1
Address / Expiratio Date
` /% 3 . / /
Signature Telephone
9.' Reaisteri: dHome: lrrtpr04emenfCtinfrintai .; ,„ K . ' _._,., Not Applicable ❑
Company Name n Registration Number
PC-6 C4?; o,Z; tt./'� �����raSYj r +'14
Address A / ,p 0/ °) c Expiration Date
gc�M / 1 Telephone L //7 - J /9 - I`/)b
—
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 pp No ❑
1 nQme flhcru r. �rnNp .
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
ti
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [E] Siding [0] Other [q
Brief Descri ti n of Proposed fCeEtstItt. TEv'rv iT£ AfamiterE
Work: Qdi S,i /� � -r �� 0118 6{, t1lc // A'' '
Alteration of existing bedroom Yes X No Adding new bedroom Yes 4 No
Attached Narrative Renovating unfinished basement Yes - UX No
Plans Attached Roll - Sheet
sa„ Ef4terii iiiiiie aric 3 chit hAo eidiftii ioiusifilif ahiiiiete ttie fo` Iowh a:
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, (LCk. , ( • X , as Owner of the subject
property
hereby authorize 0 Pe
to act on
rrcbe
half, in all m elative to w rk authorized by this building permit applicafon.
Signature of Owner Date
I, { l / '---t-- , 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.
T4A 0 eel N- _
Print Name
/1 /,L
Signature of Owner /Agent 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
._._._.,.__.W. , 1 �..�_� ..�.�..�,..
Lot Size 1 ...
Frontage L l i .,_ _ _ _,
Setbacks Front ! 1 1
Side L: ' R L:,, R: i m
i
Rear
I
Building Height : _1 € ---
Bldg. Square Footage "'` "1 F-1 % I i = ' ¢
Open Space Footage %
(Lot area minus bldg & paved _ E
parking)
# of Parking Spaces
Fill: € Pi , �v �.�e��.... _
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW ® YES 0
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 I , Paged 1 and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW O YES 0
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 Q NO l
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO e
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 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
' - - '4744;:k.:14:,..str:t' ''',..:;'',1:1,10',.10(15,411:4?-%- t: A a ' -' , :4 -
r City of Northampton ,
Building Department . ,• ,� r
212 Main Street ; rt a
�G1G Room 100
r \( \ 4 G Northampton, MA 01060 ., , '
phone 413- 587 - 1240 Fax 413 - 587 -1272
f
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
1.1 Property Address:
This section be completed by office
3S D1 , S�"'c C Map Lot to U
1\0(1114 wrJft'1 ()h / : Zone , Overlay D
0 O Etrtt St District CB District
SECTION 2- PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 O`"er of Record
X % � rt� c n(�\c � �a�� G-\- () <\r•Ov -. Oil Mt' biOlv D
Name (Prin Current hA, filing Add ss
X A- COX"- r. Telephone
Signature
2.2 Authorized Agent:
icM 0 Qi rt r i ,L sal 'e i.v I ■ 1
Name (Print) Current Mailing Ad. ess: 01(1‘
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by p la 01 1 3 ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) Estimated of
Construction matTotal fro Cost m (6) _
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number /, 6
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0356
APPLICANT /CONTACT PERSON TODD D PEASE
ADDRESS /PHONE 1200 CAPE ST WILLIAMSBURG (413) 210 -1476
PROPERTY LOCATION 35 DANA ST
MAP 23B PARCEL 039 001 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 7 /
Fee Paid
T as eof Construction: 4tErAIR RO TED SILL • & REPLACE DRYWALL
New Construction . /,, _ . �.. _ _ i � /_ ♦ ! - �
Non Structural interior renovation
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 101384
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFIORMATION 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
Signa!of Building 0 '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.
BP-2011-0356
GIS #: COMMONWEALTH OF MASSACHUSETTS
?3t1 -039 ' 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- 2011 -0356
Project # JS- 2011- 000594
Est. Cost: $1809.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TODD D PEASE 101384
Lot Size(sq. ft.): 6621.12 Owner: STARKOSKI ANDREA
Zoning: URB(100)/ Applicant: TODD D PEASE
AT: 35 DANA ST
Applicant Address: Phone: Insurance:
1200 CAPE ST (413) 210 -1476
WILLIAMSBURGMA01096 ISSUED ON:10/28/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE ROTTED SILLS & REPAIR TERMITE
DAMAGE & REPLACE DRYWALL
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 10/28/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner