24A-030 (3) The Commonwealth of Massathusetts
Department of Industrial Accidents
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1 :,--"=.. ,I.W,-... E. Office of Investig,ations •
600 Washington Street
a INE11,11 • /OWE Boston, MA 02111
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www.mass.gov/dia
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-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): t:::- 0 // /--/ - ...2_,-&-
Address: g e . . . i z c2 b / 2 „ / pes i.-7 cl,•• .,._
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City/State/Zip: / . / 7-- " - 7 - ' - ' 2 t 2- . ' 3 ' /(7' ' ( Phone #:
Are you an employer? Check the appropriate box: Type of project (required): /
1. [RI am a emplo ,..- - with ( 4. 0 I am a general contractor and I
6. Ej New construction
employer - tiA . cVor part-time).* have hired the sub-contractors
listed on the attached sheet. 7. 0 Remodeling
2. 111 I am a sole proprietor or partner-
These sub-contractors have
ship and have no e...loyees 8. 0 Deraolition
employees and have workers'
working for me in any cap_acity. 9 Ei l3uilaing addition
[No workers' comp. insurance _ comp:rinsmance -t - --
requirecL] 5. 0 We are a corporation and its 10 .1] Electrical repairs or additions
3. El I am a-homeowner-doing,-all-work ---- ILO 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 •
13.n Other
employees. [No workers'
comp. insurance required.j
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infonaiation.
t Homeowners who submit this affidavit 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 narne 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
information.
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k.; 4) •
insurance Company Naine: /7- 5 I-' c e "1.--/- l-- " 6' 7 - -- ,6-3,s
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Policy # or Se]f-Ms. Lic. #: 431 t_."-(_._ j 06 0 V 0 7 c -,
Expiration Date: - ./ ”-
Job Site Address: 2 i 47 f 7. City/State/Zip: /1 (2);- ' ''.
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 pe alties 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 fne
of up to $250.00 a day against the violator. le 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 certin, under the pains arm I penalties of perjury that the inforntation provided :above.is_true aruLcorrect.____
Signature: , • Date:
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Phone #: • ' -
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Official use crib,. Di) - 1151w in this ezi-erz, to completed by city or town
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_ City or Town: Permit/License # —
Issuing Authority (circle one):
_ 1:.- Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbina Inspector.
6. Other .,.--
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : l a7 /( f 2-! e '-
License Number
Address Expiration Date
2/2 f/, 2_ z"--44A---
Signature Telephone
9 :'Registered Home" Improvement Cortractor:: � Not Applicable ❑
Company Name Registration Number
L.-pi/ 2—
Address Expiration Date
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 j ., No ❑
11 Home Owner Exemption;
The_current_exemption for 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 1083.5.1.
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
- orf amp on r tna ee � a e an' tom . ' W - .: > , , , w - s- Ereneral Laws- Annotated.
Homeowner Signature
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SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) El Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding [0] Other [0]
Brief Desc(ption of Proposed
Work: /�"G /G j) 4) i' Gr /5 RU 770 ( ( ? 2 at- /t12t7i Oat &PO
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
sa, if. tsiew house and oraddition to'existing housing, eoniplete the fallouving:
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 Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
! G !E ��ti .; /c j , as Owner of the subject
property
hereby authorize f� /■
/7 . 2 / &- -' 1 5 /C/
to act on my behalf, in all matters re .tive to work authorized by this building permit application.
C /C-6(.,j , ..AB/ (.‘,/7//0
Signature of Owner Date
1, ' /,-r0 l _ l r`r_ r / .✓ /6/ -r_= 'uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the .es of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner /Agent Date
City of Northampton Status ofPermit
Building Department
\212 Main Street Swer/SepticAvaWabhty -.
,/ Room 100
)47
orthampton, MA 01060 Two SetsbStruQtua1 Plans
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
.SECTION -SITE INFORMATION
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This section to be completed by office
1.1 Property Address:
74 6 E Jo b Ma Lot Unit
A/cc' /2._ P7?-f ! • Overlay District
EliifSt:-.District GB District
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SECTION 2:- PROPERTY OWNERSHIP/AUTHORIZED AGENT
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2.1 Owner of Record:
z")-7 Z-1—)/
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Name (Print) Current Mailing Address:
t--/ 6-0 K_ 1 Telephone - 3 — a" y 5 4-
Signature
2.2 Authorized Apent:
1/ #--jS 7 e.) /0
Name (Pri• Current Mailing Address:
1 7 / (9 96)
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Signature Telephone
SECTION 3 . . .
TIMATED CONSTRUCTION'.COSTS::::
Item Estimated Cost (Dollars) to be ... Official Use Only
completed by perrnit applicant
1. Building (a)..13culding. Permit Fee
2. Electrical (b) Cost of
, :Construction from (6)
3. Plumbing . .Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 7 d ...Check Number
' r )t,
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... . This.Section ForOthcial
Date
....Building Permit Number : Issued:
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Signature:
•Boilding:Commissiorier/Inspettor.ofBuiliiings Date
78 RIDGEWOOD TER BP- 2010 -1125
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 -1125
Project # JS- 2010 - 001649
Est. Cost: $7000.00
Fee: $25.00 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: uKA(iuu)/ Applicant: t: JOHN 7IFMINSKI
AT: 78 RIDGEWOOD TER
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247 -9014 Workers
Compensation
HATFIELDMAO1038 ISSUED ON :6/10/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK: REBUILD 2 CHIMNEYS FROM ROOFLINE
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: 6/_ I, /Q
C//A
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGU - 4
,e4 1 °444 Ala Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 6/10/2010 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo