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The Commonwealth of Massachusetts
Department of Industtial Accidents
Office of Investigations •
600 Washington Street
=... —
t: =44- a Boston, MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Indivicloa I): 7e7 ■
Address: 4, 7) At 2> ce es -
City/State/Zip: e 11) /"/- Phone.#: -- /
Are you an employer? Check the appropriate box: Type of project (required): 17
1. I am a employer with / 4. 0 I am a general contractor and I
6. 0 New construction
have hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet 7. 0 Remodeling
2. 0 I am a sole proprietor or partner-
These sub-contractors have
ship aTiel have no employees These 0 Demolition
epvIoyees a.nd have workers' _
working for me in any capacity. 9 Er Building addition
[No- workers' comp. insurance
10.0 Electrical repairs or additions
5. 0 We are a corporation and its
required.)
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
corop insurance requirecLi
• *Any applicant that checks box #1 must also fill out the section below showing their woricras' compensation policy information.
• t Homeowners who submit this affidaVit inclicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
1 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-Ms. Lic. #: 5 Z Y Z' 4 :" e 7'C/ Expiration Date: - - i /
Job Site Address: ijg / 1-/ s.. 57 - r - 4 A'4 City/Stafz/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 ofMGL 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
Fnaisestientions of the t•Lk for insurance coveraie venfcalion. ,
I do hereby certify under thelains and penalties ofperjury that the information pro ruled above_isirue
Signature: - vate: _ - //-
Phone #: ••2-- / 9C •
• Official use only. Do not write in this ai-erz, to be completed by cityor 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: J - 1 ) / f - 7 1 " 4 K 2/� ., S% / / 'T��'j
p / License Number
7 v✓�iPO /: f Gf/L / - °, 2 z r' r/Z
Address Expiration Date
Sign at u Telephone
9 ReistdreilHoms:lit rtnieient onitracfor•
Not Applicable ❑
/cc)/ -3 3
Company Name Registration Number
,727/ ./ -- ) .- ' '£
"' /G. 2./41i L , c—aC i
Address Expiration Date
-/.
t5 ) a )1) , s ' C /sc . � =i (c. //i— �� 3 /
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 Imo-. 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 applicable)
New House ED Addition ❑ Replacement Windows Alteration(s) El Roofing D
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks {Q:} Siding [0] Other RD]
Brief Description of Proposed hgAz „rye t.' 3j�.�e - br /. _ ;� r,-y `,, c= leJ D
Work: . e6 ; DL /4 5".1-7. 5, i' //'0) 44, cs4-77e.T ...; (-177--'--
Alteration of existing bedroom Yes iC No Adding new bedroom Yes ) e No
Attached Narrative Renovating unfinished basement Yes x No
Plans Attached Roll ( Sheet')
6a. if New house and or addition to existing houslnq;- complete the foiiow na:
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 Go / 4`4- /ifrw7 / /.‘', :H'3rs,�z s 7 ) "J 6 i' , as Owner of the subject
property
hereby authorize 7 a11i 2, C--S, c/e /
to act on my behalf, in all matters relative to work authorized by this building permit application.
i j
Date
I, ; ' 7 /fi-v /C.;- . r Sief , 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.
d.? /h-v 2 16- s ie/
Print Name
Signature of Owner/ e t / 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 s — FI Z -? 3 i t 7 __ _..... L._,_. `
Frontage I I Z `. f I P 121.5 _ i t I
Setbacks Front i 1 I 1 s 1
Side L: I R: i L:__ R:' __
_' Y I i i
Rear
1-1 _
Building Height ; /t I
Bldg. Square Footage 1 4 DTI % j /Gal Lig g1 1 I
Open Space Footage _ %
(Lot area minus bldg & paved LAW 1 r i I ailiif. a Epi,i i ....7
parking) / 3 891 % } 4
# of Parking Spaces 1--911 _- �_
Fill: , _.._.vv�..�... -
i G I
(volume & Location) i l I : €
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 Q
IF YES: enter Book P age I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO @ DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q ,Date Issued
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
IF YES, describe size, type and location: 1
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 Q NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
p, , , , t Depa u o nly
City of Northampton t�attus of Per
RECENED Building Department Ct C uf / D ri veway Perm
212 Main Street Se,Arer1Septtb 4
�((��{ Room 100 Wa}erN� eels (valiabiiify i. ` !,
• rthampton MA 01060 Two Sett:Of, Stru Pl ans Y
�� :._,�- - ;' 41 - 587 -1240 F 413- 587 -1272 �e fl to € Pan s ` " F "
• . • � a� Y 7t b(� Z , { i I
DEFT 'hk 3 - �
.: .....i;u'., u . • a Puler Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -- SITE INFORMATION
This section to be completed by office
1.1 Property Address:
// r' ,-/J 5/ Map :Lot Unit-
�1.-v,,` 4,„—,-,...,4" /y�"i% e ' /e, 2` ~ Z , ! Overlay District
Elm St Di CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
/2": c G. ,,/r • /5/fx' /$.r9 'Go' J 6= / � //I ii' L ,JJ .5 T=
Name (Print) Current Mailing Address:
'I' -// 3 3" V' % — 7-
--a d- 1
y ; yp�V Telephone
2.2 Authorized Agent: 4/c5-4..e
z) /f.J ,44 :2 - / / -- )•i ".^111 / a ..' i ; ,.: 2), '-,,/ /) 6 C G // 1 . � /Y,¢
Name rint) Current Mailing Address:
Signature Telephone
SECTIO 3- ESTIMATED CONSTRUCTION` COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building L a� (a) Building Permit Fee
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) S 2 — : ‘I Check Number /
This Section For Official Use Only
Date
Building, Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2012 -0010
APPLICANT /CONTACT PERSON JOHN ZIEMINSKI
ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413) 247 -9014
PROPERTY LOCATION 118 BLISS ST
MAP 23C PARCEL 069 001 ZONE URA(100) / /WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST I
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out RV $0 '--
Fee Paid RV
Typeof Construction: DEMO & REBUILD 10 X 12 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 017889
3 sets of Plans / Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
Signature of Building Official
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.
118 BLISS ST BP- 2012 -0010
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 23C - 069 CITY OF NOIZTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: Deck BUILDING PERMIT
Permit # BP- 2012 -0010
Project # JS- 2012- 000017
Est. Cost: $4572.00
Fee: $60.00 PERMISSION IS HEREBY CANTED TO:
Const. Class: Contractor: License:
Use Group:
Lot S e(sq. ft.): 16117.20 Owner: JONES LLIAM P & BARBARA
A & STEPHEN JONES & M W JONES
Zoning: URA(100) //WSP Applicant: JOHN ZIEMINSKI
AT 118 BLISS ST -
Applicant Address: Phone: 1 Insurance:
8 WOODRIDGE CIRC (41 3) 2479014 Workers
Compensation
HATFIELDMA01038 ISSUED ON :7/7/2011 0 :00 :00
TO PERFORM THE FOLLOWING WORK: DEMO & REBUILD 10 X 12 DECK
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. 1 Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House # Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace /Chimney:
Rough: Oa: Insulation:
Final: Smoke: Final: t7-; 6 - / C C iV/- )
THIS PERMIT MAY BE REVOKED BY THE CITY O,,NORTHAjMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RE ..
r )1• a+r4
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 7/7/2011 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissidner