24B-020 . •
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ce of Investigations
'. 600 Washington Street
bx Boston, M4 02111
` : x www ^narss.gov /dia
Workers' Compensation Insurance Affidavit Builders/ Contractors/Electricians /Plumbers
Applicant Information Please Print Le
Name (Bu sttness/organiza iontlndiividual) f P4R k'& Cr bM /�� y 4EsZeAJ5
C i t y / S t a t e / Z i p : L t c . 'i j' _ Phone ##: 1317.3'. ®pr°
Are you an employer? Check the appropriate box: Type off project (required):
1. IA I am a employer with 11" 4. Q 1 am a general contractor and 1 New construction
employees (full and/or part- time).* have hired the sub - contractors 6.
2.0 I am a sole proprietor or partner- listed on the attu he4 sheet. 7. 0 Remodeling
ship and have no employees These sub - contractors have a. ❑ Demolition
working for me in act employees and have workers'
l; any capacity. t 9. 0 Blinding addition
[No workers' comp. insurance comp. insurance.
required.] 5. 0 We are a corporation and its 10 -0 Electrical repairs or additions
3.0 1 am a homeowner doing all work officers have exercised their 11.0 Pl repairs or additions
myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance requires) t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
* Ant 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 that him outside contractors must submit a new affidavit indicating such.
=Contractors that check this box mast attached an additional sheet showing the name of the sub - contractors and state whether or not those eatiti es have
employees. If the sub - contractors have employees, they must provide their workers' comp. policy number.
1 am an employer fleet tr providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: e .S ti. .-E ,/ WOR a
Policy # or Self -ins. Lic. #: : Aht. M 9,,T 4'6 Z. Expiration Date: al /r�, &/7/o9
Job Site Address: City/State/Zip:
Attach a copy off the workers' compensation polio 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
frae up to $1,50000 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 vitas statement may be forwarded to the Office of
Investigatitms of the DIA for insurance coverage verification.
1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
: a �' Date:
Phone #: :3 `
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 ofElealth 2. Building Department 3. CityfTowa Clerk 4. Electrical Inspector 5. Plumbing Inspector -
6. Other
Contact Person: _ Phone #:
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations in ion process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill),
sonotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final building inspection. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
— - - - - - -- permits -i conjuncti
n on_to the buitding.permityssued,_ they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
1/' f understand the above.
(Home ner / is signature requesting exemption)
g q g P )
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Address of work
location
The Commonwealth of Massachusetts
,;,, -__ Department of Industrial Accidents
- -- Office of lnvestia ations
C. r° ' 600 Washington Street
r
tr.:: = z Boston, MA 02111
' www.mass.gov/dia •
-Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumb.ers
Applicant Information Please Print Legibly
Name (Business/Or 'on/Individual):
Address:
City /State/Zip: Phone. #:
Are you an employer? Ch • . the appropriate box: Type of project (required): i'
1. ❑ I am a employer with 4. ❑ I am a general c..otractor and I 6. ❑New construction
employees (full and/or p • time).* have hired the • b- contractors
2. ❑ I am a sole proprietor or p • •. er- listed on th - ttached sheet. 7. ❑ Remodeling
ship and have. na eloy ees These sub =tractors have. 8. ❑ Demolition
working for me in any capaci , . employ- s andhave workers'
Y ca P 9. ❑ Buddi g addition
[No workers' comp. insurance imp.. •• � rranr P
required:] 5. ❑ We . a corporation and its 10.0 Electrical repairs or additions
3.0 I -am a -home _ x- _ -__ o is • ,.._11ave excised their__ —1—L -- PInrnbingrepairs or additions
myself. No workers' comp. right of exemption per MGL 12. ❑Roof repairs
insurance required] t c. § 1(4), and we have no
' e •.w.loyees. [No workers' 13.C Other
• omp. insurance requited.]
Any applicant that checks box #1 must also fill out the sectionb low showing their workers' cornpensation policy information. .
t Homeowners who submit this affidavit: indicating they are do all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional she_ bowing the name of the sub - contractors and state whether or not those entities have
employees. If the sub - contractors have employees, they must . ' their workers' comp. policy number. .
I am an employer that is providing workers' com Fens n insurance for my employees Below is the policy and job site
ormation
Insurance Company Name: -
Policy # or Self -ins. Lic. #: \ Expiration Date:
Job Site Address: / City /State/Zip
Attach a copy of the workers' compensatio policy declaration p • ge (showing the policy number and expiration date).
Failure to secure coverage as required under ection'25A of MGL c. 1.2 can lead to the imposition of criminal penalties of a
fine up to Si • .500.00 and/or one :year impris • nment, as well as civil pe . ties in the form of a STOP WORK ORDER and a �e
of up to $250.00 a day against the violator: Ile advised that a copy of o t. statement may be forwarded to the Office of
Investigations of the DIA for insurance c • eraze verification
y fy p fP rl ry f provided
I do hereby certi under the pains enalizes o - . e 'u that the info matiorz _above is trrce- arrdcarrec;♦ _-
ignature: ate:
X • .
Phone #:
Ofcial use only. if lrot write in this area, to be compteied by city or town official
City or Town: Permit/License #__
Issuing Authority (circle one):
I. Board of Health 2. Buil ding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector __ _
6.Other y -
Contact Person: Phone #:
,
a ,-
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9-. Registered HOme:.lmproverrient°Con C` S r _ v 'i .. .,,; ,.�...._ . .,.� _ , . , Not Applicable ❑
f l :d f %� /5M I ifts
Company Name Regis ra ion Number
j - 7&' 6 1 f v e .6 q l e- S.. -- Si- / , 3 --20 /O i
Address Exp�tion Date
3 n6, 1 L} Telephone ��' --° 1 V
_ SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152 § 25C(6)) J
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 ❑
The_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, 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
- - - - - - . - . eneral- -Laws-Annotated.
j -
V O ampt Ore iriances,. a e . � � �� � , - .. _ � � -.
H omeowner Signature 4';
f l
t
or t. ..
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing i l
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [0] Other [0]
rief Description of Proposed /
Work: 1 O1 $ +u (( WOoc S c'fi _
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No
Attached Narrative . Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
(4.1f New :house`and.oir.addition to: 'existinu- tiatasinq,:coinplete thelotioiNiriq:
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, , as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I 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.
L i P el r✓ " et, ( ri
P 'nt Name
Signature of Swn- /Agent Date
4
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.:.....__.__ L: R:____ _
Rear _ _ _____
Building Height
Bldg. Square Footage r--- r ' % r € '
Open Space Footage _ _
(Lot area minus bldg & paved
parking)
# of Parking Spaces
(volute & Location) _M .- ......,_..............,._,
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO (3 DONT KNOW 0 YES 0
IF YES: enter Book Pagel € 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 Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D.' - Arere tthere a y popose cfianges to or a ` rtlons o signs inten`dedf the property ? YES 0 NO 0
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 0
IF YES, then a Northampton Stour Water Management Permit from the DPW is required.
•
:ittnitae oFtl
City of Northampton 5tas of1?errtr
Building Department Cuutwaye s
212 Main Street �r
a7.w
Room 100 3�a am, .44 ; t
Northampton, MA 01060 , t-,e " cal 744
phone 413 - 587 -1240 Fax 413 - 587 -1272 at: e
p.�
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
p � 4G _ G LG9
SECTION 1 - SITE INFORMATION ;
L ,1.1 Property Address:
This section to becoriipleted by office
l �
Pik / S e Map r. Lot Unit
r � 1 yi /f- 0/ U 61 U Zone Overlay District
Elrn St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
— ,tNi— — - - - - - -- -
Name (Print) Current Mailing Address:
/ Telephone
/ Signatu
lll��� 2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
fl. Building / /9 0 0 (a) Building Permit Fee
r
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
3 (or d
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
39 DENISE CT BP- 2010 -0152
GIS #: ,.- COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24B - 020 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 -0152
Project # JS- 2010- 000182
Est. Cost: $1899.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: FIRESIDE DESIGNS 158891
Lot Size(sq. ft.): 9626.76 Owner: CORWIN LINNE V & MELODY A FOTI
Zoning: URB(1001/ Applicant: CORWIN LINNEV & MELODY A FOTI
AT: 39 DEINii t L ,
Applicant Address: Phone: Insurance:
39 DENISE CT WC
N O RTHAM PTO N MA01060 ISSUED ON :8/7/2009 0:00:00
TO PERFORM THE FOLLOWING WORK :INSTALL WOODSTOVE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET W (3i'‘ C/0)
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector �- b `
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:0 K q —/ 7 1,0q
THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL,. 7i1)NS. /
4
t of Occu • anc nature: / Si
Certificate 1:
FeeType: Date Paid: Amount:
•
Building 8/7/2009 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo