24B-002 The Commonwealth of Massachusetts
Department of Industrial Accidents
=� Office of Investigations
= °° = 6600 Washington Street
Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians /Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): Kohl Construction, Inc.
Address: 31 Campus Plaza Road, Suite 3
City /State /Zip: Hadley, MA 01035 Phone #: 256 -0321
Are you an employer? Check the appropriate box: Type of project (required):
1. Si I am a employer with 14 4. ❑ I am a general contractor and I 6. ❑ New construction
employees (full and/or part- time).* have hired the sub - contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ' • ❑ Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 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 11.0 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'
comp. insurance required.] 13.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affidavit 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 their workers' comp. policy information.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: AIM Mutual Insurance Company
Policy # or Self -ins. Lic. #: WMZ 800287201 2011 Expiration Date: 02/10/11
Job Site Address: 95 Barrett St City /State /Zip: Northampton, MA 01060
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. Be 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 certif under the p its and penalties of perjury that the information provided above is true and correct.
Si nature: 1/71.,( 'c' Date: August 4, 2011
Phone #: 256 -0321
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 #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :'N pC ibf p Q 2� � . C ' I Sri 7
License Number
Address Expiration Date
X56 - 0.? I
Signature Telephone
9.' Registered Home Improvement Contractor Not Applicable ❑
KOHL- CO )JS;I I IOk) /OR.,7 sZ
Company Name Registration Number
Address Expiration Date
Telephone L L-
?
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 ❑
it .- Ho me owner Exemption
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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing I I
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [D Siding [0] Other [0]
Brief Description of Proposed Proposed 1 nec.. I re ti`D6 w' 30 yr 65{;16 c �:h tn1It' is iinlir ttr)J 9 Sfi
vt
Alteration of existing bedroom Yes No Adding new bedroom Yes K No
Attached Narrative � j Renovating unfinished basement Yes No
Plans Attached Roll - Sheet t
6a. If. New house end'or` addition to existing housing* complete the following:
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, I H 1=oORt c pAZ`KI ' P `. 1 A "tom' T l v AC � C)C i 1 , as Owner of the subject
property
r
` (("N , S-T [ &)Cr 1 C)' 1
L)
hereby authorize krt ►.k) C..-
to act on my beha II atters relative to work authorized by this building permit application.
17)b
Signature of Owner Date
I, / //co J o its. PA 12 K E , 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.
Print Name
I P
MAIM L....... 8 - I I' //
Signature of Owned' gent Date
ection 4. ZONING All Information Must Be Completed. Permit Can Be Deified Due To Incomplete Information
Existing Proposed Doguind6yZoning
A,
mi,mm�w�uma��
/\
Building Department
Lot Size
Frontage
Setbacks Front
Side L: D: [---]
Rear
� �-- [--
Building Height �--- [---
Bldg. Square Footage
Open Space Footage '
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit/Variance/Finding ever bten issued for/on the site?
IF YES, date issued:
IF YES: Was the permit recorded at the'Registry of Deeds?
IF YES: enter Book Page and/or Document #
-_�
B. Does the site contain a broo ---, of water or wetlands? NO 0 DON'T .-.... 0 YES 0
IF YES, has i
Needs to be obtai d 0 Obtained
C. Do any signs exi on the rty? YES 0 NO K ]
IF YES, des ibe size, type and location:
D. Are there ny proposed changes to o additions of signs intended for the property . .
IF YES, describe size, type and location:
E. VWU the construction activity disturb ( ring, gradingexcavation, or filling) over 1 acre or is it part of a Ctrmon plan
that will disturb over 1 acre? YESK ) NO K )
�� ��
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
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4
4
Department use only
a w r
R CEtvE D City of Northampton Status of Pel-mity 4
Building Department Curb Cut/Driveway Permit°
5r� 212 Main Street Sewer /Sep#lo�tabtirtyr
.1% Room 100 Water/Well Availability 0. X04
am MA MA 01060 Two Sets of St ��
u o
----" of :,1,,,_ .t . -- - 3- 587 -1240 Fax 413- 587 -1272 Pr ot/Site Plans ��
tither Spedfy 4 f,4 x
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
J T Map Lot Unit
r`3 IJ�i22�'� �
Zone Overlay District
No i 1,r-\ v ow M A
Elm Si D istrict CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
I�% llvo A S S N. /A - T Q AO , h JEt t * 5l CAP.1INU Pi- u2,A /6, /94/)1.7 /VA
Name (Print) ` Current Mailing Address:
3 �_ L'/ a56 0 .?/
Telephone
Signature
2.2 Authorized Agent: f�
*OHS CO 4
T2- (- )%710ro A)C, '51 Ct oS P)-AzA F^ -6 4hbi_Ly i1 II
Name (Print)Current Mailing Address:
J6---FCti---- X1 /3 - 256 o 3e /
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building _. (a) Building Permit Fee
L, ow
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) Check Number . 10,91 tr.., 35"`
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
95 BARRETT ST BP-2012-0147
GIS #: IMONWEALTH OF MASSACHUSETTS
Map:Block: 24B - 002 CITY OF NORTHAMPTON
Lot: -001 ,TRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NO ESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0147
Project # JS- 2012- 000213
Est. Cost: $2000.00
Fee: $35.00 'ON IS HEREBY GRANTED TO:
Const. Class: License:
Use Group: l 'TRUCTION 064539
Lot Size(sq. ft.): 92695.68 1 \'O ASSOCIATES INC C/O HAMPSHIRE PROP MANAGEMENT
Zoning: URB(100)/ HL CONSTRUCTION
:ETT ST
Applicant Address: Phone: Insurance:
31 Campus Plaza Rd (413) 256 -0321 Workers Compensation
HADLEYMA01035 N'/5/2011 0:00:00
TO PERFORM THE FOL "ORK:STRIP, PLY & SHINGLE ROOF
POST THIS CARD SO 11' I S VI THE STREET
Inspector of Plumbing Inspector D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: (louse # Foundation:
Driveway Final:
Final:
Rough Frame:
Gas: Fire Dep.1 Fireplace /Chimney:
Rough: Oil: Insulation:
Final: `' ;1..,: Final:
THIS PERMIT 1\1:`.V BI: : :1' ' ; CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RUi. :;S AND 1
Certificate of Occ'!y,nncv Signature:
FeeType: - 1' Mount:
Building 5; :)i2.v1 i ii
.71 , (413) 587 -1240, Fax: (413) 587 -1272
kick — Building Commissioner