24A-030 (4) •;., C = °° (/Bice of invesngwwwilJ;
r - 0 01 1. - .. 600 Wash Street
w i u i w
it +F� Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /ElectriciansLPlumbers -
Applicant Information l Please Print Legibly
Name (Business/ Organization /Individual): J�(/W /�{- 2 /6 = i ....•5/,- (
Address: g (---!-t) 4. >, '1Z - / aces- 4 c° l'e '
City /State/Zip: /7 n/ 3' - Phone #: -)/"' 3 (9
Are you an employer? Check the appropriate box: Type of project (required):
1. 12 I I am a Y to cr with / - 4. ❑ I am a general contractor and I
* have hired the sub - contractors 6. ❑ New construction
employees (full and/or part -time). 7. R
2_ ❑ I am a sole proprietor or partner - "listed on the attached sheet. 1 g
ship and have no employees These sub - contractors have 8. [] Demolition
workin for me in any act workers' comp- insurance-
g Y �P tY� k' 9_ ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its -
required.] officers have exercised their 10_❑ Electrical repairs or additions
3_ ❑ I am a homeowner doing all work right of exemption per MGL 111A Plumbing repairs or additions
myself [No workers' comp. c. 152, §1(4), and we have no . 12_[] Roof repairs
insurance required] t - employees. [No workers' 13.0 Other
comp. insurance required_]
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy inku atioa:
r Homeowners who subunit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such
Contractors that chock this box must attached an additional sheet showing the name of the sub-contractors and their workers' comp_ policy information_
r am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
nformation_
nsurance Company Name_ / ' ,5 '7 -- "e"e C} yc �2S ''s C--...).
' olicy # or Self -ins. Lic_ #: 1-,2 C-c r Q `' 6 e `' e-f0(2 O"f• `' Expiration Date: 9 /��i
ob Site Address: 7f. At DG c' - 7 , .- City /State/Zip: A[ � 9 , --,'°-f .
►.ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
'allure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
ine 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
f up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
ivestigations of the DIA for insurance coverage verification_
do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
it;nature: ` '` "L-' L Date: g'2 I/ c'
bone #: / 3 3i 9 e
Official use only. Do not write in this area, to be completed by city or 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 #: .
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SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) •
2 z� rz—
1?/7 8�'y
. / 6 (fy" (-7 -2/�= r7 ,-Y 6�- License Number Exp 'on Date
Name of CSL- Holder
c5 t�/C7D 2,2 (bye C / %�r X& z,' CSL Type (see below) �(s�
Address Chi G: Type Description .
1 U Unrestricted (up to 35,000 Cu. Ft) •
R Restricted 1 &2 Family Dwelling
Si M Masonry Only
1' ^ ,. (G'° - • RC Residential Roofing Covering '
Telephone - WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
• 5.2 Registered Home Improvement Contractor (HIC)
. 1,0 r h-} /7 2 j L -'�i-, --S /c/ / G v 3.3
HIC Company Name or HIC Registrant Name Registration Number .
Address GA/ .
. - ,9 .2/9 /7.0 Expiration Date
Si _• 4 • - - Telephone •
SECTION'6: 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 • O • •
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN .
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT -
C i= n. � ,. ,' - , as Owner of the subject property hereby -
authorize .,f D f•,.,, • /I .. - , ,rt;^ - --57C - to act on my behalf in all matters
relative to work authorized by this building permit application.
Signature of Owner - C .( (_ `�1y1� Date 1
. SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION
I, .7‘.. //_ 2 i L e e S. •/ ; , as-Q or Authorized Agent hereby declare •
that the statements and information on the foregoing application are true and accurate,.to the best of my knowledge and
behalf.
J ( J / ( 7 - , ' /./, <<= t zz 5/6 j •
Print Name .
• • /o.
Signature of • er , Authorized Agea Date
(Signed under th - , s and penalties o' perjury) .
NOTES:
1. An Owner who obtains a building permit to do his/her own work, or an owner who bires an unregistered contractor
(not registered in the Horne Improvement. Contractor (HIC) Program), will got have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations 110.R6 and 110.85, respectively.
2. When substantial work is planned, provide the information below:
Total floors area (Sq. Ft.) (including garage, finishhed.basement/attics, decks or porch) ,
Gross living area (Sq: Ft.) • • Habitable room count
• Number of fireplaces . Number of bedrooms _ •
Number of bathrooms Number of half/baths •
Type of heating system • Number of decks/ porches
Type of cooling system - Enclosed Open _ •
. 3. `Total Project Square Footage" may be substituted for "Total Project Cost" -
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f 73 0/ / - t77P7►
The Commonwealth of Massachusetts
Bo o uilding Regulations and Standards FOR
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Massachusetts a Building Code, 780 CMR, 7 edition MUNICIPALITY
• . wilding Pernik 'Application To Construct, Repair, Renovate Or Demolish a . Revised January
One- or Two-Family Dwelling 1, 2008
•
• : • • • This Section For Official Use Only
Building Permit Number: I Date Applied: •
. Signature: •
Building Commissioner/ Inspector of Buildings Date •
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
7 f /44 -k-h al
. 1.1a Is this an accepted street? yes v no Map Number Parcel Number •
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13 Zoning Information: 1.4 Property Dimensions: • •
.Zoning District Proposed Use Lot Area (sq ft) • Frontage (ft) •
1.5 Building Setbacks (ft) .
. Front Yard Side Yards • Rear Yard •
Required • • Provided Required Provided • Required Provided
•
14 Water Supply: (MG L c. 40, § 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal Systenii •
Public ❑ Private ❑ Zones . Outside Flood Zone? M un i c i pal ❑ On s ite disposal sys ❑ •
Check if yes❑
• SECTION 2: PROPERTY OWNERSHIP
• 2.1 Owneri of Record: / •
•
SK; 7 S • £ 6 t
. Name (Print) Address for Service:
• r y • S •
Signatre 11,01; 4fr7A Telephone •
• SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ [ Repairs(s) 4it I Alteiation(s) ❑ I. Addition 0
Demolition ❑ Accessory Bldg..❑ Number ofUnits • I Other ❑ Specify:
Brief Description of Proposed Work2:
/7/ 62- -J /7 01)/L- Pj/EX GENE EE ( Stirs( cf
• SECTION 4: ESTIMATED CONSTRUCTION COSTS • •
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Item Estimated Costs: Official Use Only.
(Labor and Materials) . • .
1. Bu ilding • $ g Uz 1. Building Permit Fee: $ • Indicate how fee is determined:
2. Electrical $ . ❑ Standard City/Town Application Fee
❑ Total Project Cost (Item 6) x multiplier. x
3. Phunbing $ . • 2. Other Fees: $
4. Mechanical (HVAC) $ • • _ List: • : . .
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S. Mechanical (Fire $ •
Suppression) Total All Fees: $
Check No. Check Amount Cash Amount:. •
6. Total Project Cost: $ • ❑ Paid in Full 0 Outstanding Balance Due:.
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78 RIDGEWOOD TER BP- 2011 -0153
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- 2011 -0153
Project # JS- 2011- 000250
Est. Cost: $8000.00
Fee: $35.00 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)i Applicant: JOHN ZIEMINSKI
AT: 78 RiDGEWOOD TER
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247 -9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON :8/23/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK :SHINGLE ROOF OVER 1 LAYER
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:
Anngh: Oil: Insulation:
Final: Smoke: Final: 5 7-/d c//it,
THIS PERMIT MAY BE REVOKED BY THE CITY OF N RTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGU 1 • >
1 440.4 AMA.
Certificate of Occupanc gnature:
FeeType: Date Paid: Amount:
Building 8/23/2010 0:00:00 $35.00
212 Main Street; Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck -- Building Commissioner