24A-030 (2) The Commonwealth of Massachusetts
Department of Industrial Accidents
i� 1 Office of Investigations
w _°IRf!� t 600 Washington Street
e�
e = � ,g Boston, MA 02111
�" www.massgov /dia
-Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): j0(4-1,3 (4, 2 /C - ' ..--r5 /f( /3d . + 6-- G
Address: e Gvc >vo Ale. r c :per , . -
City /State /Zip: % --2 eZ. -'' N y Phone. #: - u, 3 / .1
Are you an employer? Check the appropriate box: Type of project (required): /
1. 1 er with / 4.. 0 I am a general contractor and I
® I am a e 6. ❑ New construction
employes ( and/or part-time).* have hired the sub- contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. R'Remodelin
ship and have. no e..loyees These sub - contractors have 8. 0 Demolition
working for me in any ca act employees and have workers'
Y P ity —_ -^ 9 9- Budriing addition
[No workers' comp. msurance comp: ;ns an�e_
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.0 3 am- a-homeowner -doing I --work — ___._ officers 1�aye xeercisedtheir � : 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' 13.10 Other , j/e--e r,17,C,
comp. insurance required.}.
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. .
I Homeowners who submit this aff davit: 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: / 0 a "fr /.-� / ' J . '' ( I). •
Policy # or Self -ins. Lic. #: 1 6 cee 4 e1 o y o t 2 .p C / e . Expiration Date: S/ �) /c'
� 1 >
Job Site Address: 2 g /u,l1G � L -� '� % EX City /State /Zip:' � 71772 n'7 / td - t ic 41
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. L e advised that a copy of this statement may be forwarded to the Office of
Investisations of the DIA for insurance coverage verification.
_ /do hereby: certi r under the pains and penalties of perjury that the infonnation provided_above_is-true and_correcL -__ __ _
Si. . ature: �' Date. - 2 1. /„� _
-
Phone #: V (3 ?--(e It q e) / 4 ,
O f fi c i a l use o n l y : D o ri o t w r i t e in t h i s a r e a , t o be completed by city or town ociaL
City or Town: Permit/License #
Issuing Authority (circle one):
I. 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: tr Not Applicable ❑
Name of License Holder : ^34,14/ r) , 7 J', /
1 License Number
�✓G(- ) C? ' U(�I IDE Ctie eat r /f /�I /I— t�? /oyf' L / 2 Y/ / Z
Address Expiration Date
Signa4u Telephone
3..,Registered:Hornb lmpr'oventier►t:a�ontractor. . ....,- Not Applicable ❑
v 1 h-- i/ :2 A.:iv ~'�� / / L �� t G - G /0 0/ 5-
Company Name 9 Registration Number
9 / oi7 �' / D E C, s 6/V iL'
Address Expiration Date
/12 7/7 LIZ /D. Telephone e7` 7 i' 7
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 ❑
FJ! loe ( ner E enlipttoi
lhe_current_exemption 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, 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
ort ampton r • manes-, a - an, - • _ • i a i • ' Its-General-Laws-Annotated.
7eneral-Laws- Annotated.
Homeowner Signature
,
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
Frontage _
Setbacks Front
Side L:---....' R _. .._ 2 L:,______ R: _____: ` _.
Rear _ _..._.
Building Height
Bldg. Square Footage r "--
% ; 7
Open Space Footage
(Lot area minus bldg & paved
parking)
'
# of Parking Spaces --- _ ...._
Fill: _.
,
m
(volue & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW Q YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Y 0 YES 0
IF YES: enter Book i I Page: and /or Document #„ ._.
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 , Date Issued
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
_.._-- - -_ D:A re there any proposed` changes fo or _ad 1 ions of signs intended for theproperty ? YES 0 NO Q
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House [] Addition ❑ Replacement Windows Alteration(s) IKI Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [p Siding [0] Other [D]
Brief Descr Pro 5m�'L Sfl 1�� i '0 (50 6 , 6e r ieC P i� lit t.....
Work: Lr3 -? . /1/E Vi A. 5 i .&')/J6:- ( Ems'' 64x ,fret)
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa:F t e tiiitise iii sic addi on.to� iciiiit q 1i auslnq thWipike ,thE fo[[owinq:
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, 4 ,( f- 1= le; ,,,-.51_, , as Owner of the subject
property
hereby authorize - ,3 (.6.-i it 2 ,,,,,i, ,,, SlL/
to acton my behalf II matters ' lative to wo autho_rized by this building permit application.
Signature of Owner Date
I, (' d ` 2 4 - 4-.r5C( , as.Owef /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.
Print Nam-
Q(� 11. 2 (- / ,-3501 t , ;- 3 2 Z- l0
Signature of Own: Agent , Date
a §a n j1Se Orly
City of Northampton
Stags of "Pei it � T �
Building Department
g p x Ct�rkf �Ct�tlDt��eWal+Perrn� � �
212 Main Street Se�e�Seprvatlabi7 t�
Room 100 atflWe�I
Northampton, MA 01060 •fie c ra a z�
phone 413 - 587 -1240 Fax 413 - 587 -1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLIIi:t 0 O FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot Unit
j� Vit•D f P " ' Overlay District
" EIm St'District' CB District
SECTION . 2 - PROPERTY OWNERSHIP /AU.THORIZED AGENT
2.1 Owner of Record:
I (% / 4I S S �' — 7_e3 (P G em v)0 r) % 6'40.'L/7 s`);),,ii
Name (2rint) Current Mailing Address:
Cr 66
�— Telephone
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
v - ' Ce 4( 3 63)90 c 7 1
Signatur Telephone
SECTION 3. - ' C NSTRUCTIOPI!'CO
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building g 0.16 dZ -- (a) Building Fee •
2. Electrical (b) Estimated Total Cost of
• Construction from (6) •
3. Plumbing --- Building P Fee.
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 64) Check Number
This Section For Officialese Only'
Date
...Building Permit Number. Issued:
Signature:
BurTding Commissionertlnspector of Buildings-° Date
File # BP- 2010 -0830
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 /�( �j
Fee Paid %Jbd 0
Tvpeof Construction: INSTALL SIDE DOOR & SIDING TO GARAGE, REPAIR SILL PLATES
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
INFORMATION 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
At et 2-Si to
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 BP -2010 -0830
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24A - 030 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 -0830
Project # JS- 2010- 001227
Est. Cost: $8000.00
Fee: $60.00 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 ZIEM NSKi
AT: 78 RIDGEWOOD TER
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247 -9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON :3/25/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK :INSTALL SIDE DOOR & SIDING TO GARAGE,
REPAIR SILL PLATES
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:
G's: Fire Department Fireplace /Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: O '" [ 20 1 tO GO LA LS
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy ) za �� /A -4. ..4 Signature:
FeeType: Date Paid: Amount:
Building 3/25/2010 0:00:00 $60.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo