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The Commonwealth of Massachusetts
Department of Industrial Accidents
1 =_- ...,„•trii- Er' Office of Investigations •
5 ,,var, 0. 600 Washington Street
- ,=4:1= 0 .
f, :11,114..... gr Boston, MA 02111
www.mass aov/dia
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Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): :leTtyt.i 1-(_ .." 1E2A /...--‘ 5 KI 6a t( DEW_ f---.6
Address: 0 (_,OC 01) #e-f 1)(,,c
i
City/State/Zip: e- t) HO - tat, 3F Phone #: '1 13 2—f 3 iqa
Are you an employer? Check the appropriate box: Type of project (required): l
1.@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 R.emodelinz
2. Ell I arn a sole proprietor or partner-
These sub-contra.ctors have
ship anti. have no enTloyees 8. 0 Demolition
working for me in anycapacity. employees and have workers 9 , ... .. . .
. 1 cling addition
_
[No workers' comp. insuran.ce comp. insursncET
requirec1.1 • 0 We are a corporation and its
g 10.0 Electrical repairs or additions
3. Iii -I am- a-homeo ---- - -- - -°- ha-v--cis- — 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.j
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidivit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
f ___ , _ _ _
___ ,
Insurance Company Name: ik- courri b PVT' v Lev L Co .
Policy # or Self- ff: i...t)(6.- cO6)600 Ce i 2- I 0 Expiration Date: - g I I/ 0
, i
Job Site Address: 7i3 P-1 06E TEX_ cit Notz7-74-4,,o r(4_
Attach a copy of the workers' compensation policy declaration page (showing the policy ntunber 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 $250.00 a day against the violator. e advised that a copy of thig statement may be forwarded to the Offiee of
Investigations of the DIA for insurance coverage verification.
_ I do hereby certi& under the pains and penolaPs ofperjury that tire information_providedUbove_a_true.and correct. __ _
Si• • . tire: NI It • Date: • - -/ 0 • ' •
Phone 4: q (3 2--1 ei - t 0 •
OffiCial use only. Da not Write in this area, to be cornplitidby cityor toivn officiaL
City or Town: Permit/License 4- _
Issuing Authority (circle one):
1; Board of Health 2_ Building Department 3. City/Toyvn Clerk 4. Electrical Inspector 5. Plumbing Inspector _ _ _
6. Other .-
Contact Person: Phone #:
I
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : C7 c' / e‘,/ ...-/ r f$ /e-/ a)` 78e j
License Number /
PP 4/ 2 1Zx- C,, 44-77 /7 oi� ,' z-1/2_3---/„,e,
Address Expiration Date
�-U � _� " (3 -- / 3 i5 4.
Signatur Telephone
to r : = Not Applic ❑
9... Re` 4istei�eC7 :Home'ImprovementCor►tracto r , � , + �•` + ,. ;: ,
.7'4 />� - ‘ 3 `2--- /2.--z-1 r X 5/47 . /"oc) /33
Company Name Registration Number
1 /.-,2 ,6 ✓i-> /),e, e-fx _ _ �� o -
Address 1�� c� Expiration ate
/j - 7 l�� /7 d-- '/ f Telepho e 2 / 3? f
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 X No ❑
1 1. E m e e> T;Se n
_The_current_ for "homeowners" was extended to include Owner 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.
r _
The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of
_._.
r o i amp on e r. mances; , a -e : . - , • : - - _ -. , v • ° .. - • _ ; . a::. • tts-Genera ... auks nnotate
Homeowner Signature
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors .i7 0
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [El Siding [El] Other [D]
Brief Description of Proposed ReP�si rie �i�nd� /J i�f L..) /1 5l��KizK /..) / 7G 7"_��`'1>�
Work: S / ,3936 6 :4 -- ADD ,ppimvutG- 0,955 45" P 3.- /hT D /S7u -0# 1 ,e,9 - 7 -- )e- / e.-S
G.r"N • 7 tviJ 7 •c 5- 7 7:: O 77 S A"
Alteration of existing bedroom Yes pC No Adding new bedroom Yes S<' No
Attached Narrative Renovating unfinished basement Yes ye. No
Plans Attached Roll �t, ee )
sa If New and ,or addition=.to:existinq housing, .complete the.folloinriiiq:
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
S L� —. "7714--c- ej6-2> "_-yr --7., t.sse cw . --7-7-----,e, _, as Owner of the subject
property
hereby authorize
/f' 7/ 7/ &- -2--z, / mi sn--i"
to act on my behalf, in all matters relative to work authorized by this building permit application.
r✓ E- &" / / s- _ /
Signa lirleM Date
I , asldwer /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.
��l/ 1 / /cr j4, S /ei
Print Name
N it: 5 C / - /f- /b _
Signature of 0 0 .ent ent Date
•
•
Deparrtrrient use r�nlyt
City of Northampton Statt%s of Pernntt
• Building Department CurbtatlDnueway Pernt
212 Main Street
\ \ Room 100
Northampton, MA 01060 Tivcs Setsctructu aT P1ans �'�
-'
phone 413 - 587-1240 Fax 413 - 587 -1272 E?ot�Srte Plans
Ot#1er S`pectfy a
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map Lot Unit
oC -z i-
�
GL ,,� , , 7?l h� "Z one..' Overlay District
DR_-(
' �" t EIm St?Districtr CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
itTT7 P E � uc 155, 0-s Ac3;- S�
Telephone
Signature
2.2 Authorized Agent: Lc.- 'nDK' -1 6 Cr0( l7 d
\_J& 63 07e) 3P
Name (Print) Current Mailing Address:
'- j3 2Jci 3ig .46 Telephone
SECTION 3 :ESTIMATED NSTRUCTION ..COSTS'
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (a) Building'Permit Fee
2. Electrical (b) Estimated Total Cost of
3 C) -> �' ��' - Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) 0
5. Fire Protection U
6. Total - (1 + 2 + 3 + 4 + 5) „2 / (j' 2 y � Check Number >fj5
This Sect For Official Use Only'
Building Permit Number: Date
Issued:
Signatures
Building (Commissioner /lnspectar of Buildings Date
File # BP- 2010 -0684
APPLICANT /CONTACT PERSON JOHN ZIEMINSKI
ADDRESS /PHONE 8 WOODRIDGE CIRC HATFIELD (413) 247 -9014
PROPERTY LOCATION 78 RIDGEWOOD TER
MAP 24A PARCEL 030 001 ZONE URA(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 0 0'
Typeof Construction: REMODEL KITCHEN (COUNTERS & CABINETS)
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 'IATION 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
1L
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.
78 RIDGEWOOD TER. B P - 2010 - 0684
GIS #: COMMONWEALTH OF MASSACHUSETTS
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 -0684
Project # JS- 2010- 000996
Est. Cost: $21974.00
Fee: $132.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN ZIEMINSKI 017889
Lot Size(sq. ft.): 7535.88 Owner: GONSKI WILLIAM W & ALICE C
Zoning: URA(100)/ Applicant: JOHN ZIEMINSKI
AT: 78 RIDGEWOOD TER
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247 -9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON :1/25/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK :REMODEL KITCHEN (COUNTERS & 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: 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 1/25/2010 0:00:00 $132.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo