24C-157 ikp irt:,i nt ui Industrial Accidents
Office of ll3 ►vests atif?s
pit na1 werrInx
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name altisiness/O oani7atinn/fr ivichnlr' i U t' t) ( 17-4- .._I i'-r1 C7 <7. >r --1.10r4
A .7.1_,...,.. 1 } ►= -_rte �7 n..," \ % :
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( ty/Sta!elLip i�-t"`5 \ kt'e -t e i� ..i "tN . 4 " :,ol> _ h -r e ff .:.I. 5'217; �J`�4� i
A you an employer? Check the appropriate box: ' 11 Type of project (regi red)-
1. V] I alp a employer with �— 4 - u 1 am a genial ea`etrazto' and i ` 6' New constriction
employees (full and/or part-time).* have hired the su -coatru;tors
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7 Remodeling
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' I D Building addition
[No workers' comp_ insurance carr.p. i 'ail.
required.) 5. D We are a corporation and its 1 ti. [ Electricai repairs or additions
3.0 I ain a homeowner doing all work officers have exercised their 1 L[] Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. Roof repairs
insurarre required.) 'i c. 152, §1(4), and we have :lo
employees [No werktrs' I3..Q Other
comp. insurance required, j
*Any applicant that checks box €tl most also fill out the section below showing their workers' compvacation policy information.
t
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
teontractors 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 errrpicyees. Belcnv is the policy and job site
information. n
Insurance Company Nance: l itil (2 t '1�2 A S 111 --S \- 0 l2 -s^4L A tr�l C� t` — `
Policy # or Self -ins. Lic_ #: 0 - 7H 2 w 5 2_ r.- Expiration Date: `� l -7 t hi
Job Site Address: 3 t AQ- tw ^lh m City /State/Zip: tr.ca -ri qe\ P n4 �
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.
Ar
I do hereby certify wide e and penalties of perjury that the information provided above is true and correct
Signature: Date : .__ 2 - it2 -1 —
Phone #: S 5 /el G � i t �f
Official use only. Do not write in this area, to he completed by city or ton, official
City or Town: PermitRuicense #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cleric -t. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
4.,
-
-67,24...id
Office of Consumer Affairs and business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Horne improvement Contractor Registration
Registration: 131279
Type: Individual
Expiration: 6/29/2012 Tr # 297765
SEAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW
EASTHAMPTON, MA 01027 __ ____. • _
()011ie Address and return card. Niarli reason for change.
Address .....-, Renewal ' Employment Lost Curd
DPS•CA1 l'} SototwN.G101216
r!' 0 fi1cA Liss itedrf/d License or registration valid for individul use only
..:,•--‘
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: .,
,-,
q...? Registration: 131279
Type; Office of Consumer Affairs anti .-Rii5inesS Regulation
Expiration: 6/29/2012 Individual 10 1 N P I II , I t z 0 a 2 - 1 S i u 6 ite 5170
,
StAN JEFFORDS
SEAN JEFFORDS
13 TERRACE VIEW
EASTHAMPTON, MA 01027 Utiderseerrttlo Not valid without signature
SECTIom 8 - CONSTRUCTION SERVICES 1
8.1 Licensed Construction Supervisor: Not Applicable 0
game of f}totaer : Se P �� t=er--Aarz.IP S. 145
License Number
t a. -.� VC "Efcrt +r » OWL-1 /I SI 24aZ
Address Expiration Date
4 2 5 Z`1 -o
Signature Telephone
fil+d l`orOd11 ett s i€' _ `.. NotAppfcable ❑
S 5 r s - *-�c'�, Q Csyu.,„ C r■ a_LA. ,.�r.t /31 a7
Company Name Registration Number
t 3 �K-vL \/ c t s Tug, r , O t o Z 7 (J2?J 2v / .r
Address Expiration Date
Slei
Telephone `{ l3 5
SECTION 10- WORKERS COMPENSATION INSURANCE AFFIDAVIT (llk�_..l C.152, § 25gem 1
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 budding permit
Signed Affidavit Attached Yes fit No ❑
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)
I
New House D Addition Replacement Windows Atteration(s) ® Roofing El
r—� Or Doors
Accessory Bldg. D Demolition a New Signs [D] Decks ID Siding [DJ Other [Dj
Brief Description of Proposed
Work: AS i.L Ceu- -c I1-1Sut.J4 - O r.[ i A:0-
Alteration of existing bedroom Yes no No Adding new bedroom Yes rice No
Attached Narrative Renovating unfinished basement Yes no No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing ] housina. complete the fallowing:
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. floociplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Wifl 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
1, 1)n;,40, A AM S , as Owner of the subject
property
hereby authorize th > � to J C:-‘(1-€1.-.1\-4 CC) . .. 2"(X- TI d
to act on my be I - If, in all matters relative to work authorized by this building permit application.
re of Owner `�"
M-
T � ) r
1 , S` EA �I :1c i r✓(' i>S - - •(eryl� `�`Y�c ..+� Cbiq , 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
Print Name
Signature of Owner /A ent Date
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 %
Open Space Footage cQ
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location)
-
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 Q DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO ) DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
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
0h ; . rthampton Storm Water Management Permit from the DPW is required.
Department use on(y
City' of Northampton S r i ' L i s a f Per P
Budding Department Curl t tft reuray Perm
20�� 212 Main Street _
Se eptic Av ability
Room 100 Water/Weil Availabslity
,oµs Northampton, MA 01060 Two -Sets ct.�tt l Pia's
° ,�' - 13 -587 -1240 Fax 413- 587 -1272 P at1S Pla
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORIVIATION
1.1 Property Address: This section to be t:arnpleted by office
3 ate, A a t-i, Si . .tap Lot Unit
Zone Overlay District
errs St. DDstrict Cs Minot
'
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
f\' AfA 3 b =. \a "- ,Prnri no\k
Name (Print Current Mailing Address:
Telephone
'' ure
2.2 Authorized Agent:
13e\ y @ c t �c r 2 T - c Tt e v 3 T r_au\ - �, /l , w' EAtT+t 14 MA tto 21
Name (• tint � 9 Current Mailing Address:
1-11 3 52c1- 0 54
Signature r Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building S0 D (a) Building Permit Fee
2. Electrical (b) Estirrrated Totot ' Cost of
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total= (1 +2 +3 +4 +5) 5 D0 Check Number ia• / l�?
This Section For Official Use Onl
Building Permit Number: ate
Issued:
Signature:
Building Commissioner /inspector of Buildings Date
File # BP- 2011 -0686 •
APPLICANT /CONTACT PERSON SEAN JEFFORDS
ADDRESS/PHONE 13 TERRACE VIEW EASTHAMPTON (416) 529 -0544
PROPERTY LOCATION 36 ARLINGTON ST
MAP 24C PARCEL 157 001 ZONE URB(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 (' �l
Tvpeof Construction: INSTALL CELLULOSE INSULATION AIR SEALING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 074539
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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
Deny, Dela
-- " .1 • 0 7/
S e of B. ild g Offi is 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.
36 ARLINGTON ST BP- 2011 -0686
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24C -157 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: INSULATION BUILDING PERMIT
Permit # BP- 2011 -0686
Project # JS- 2011- 001125
Est. Cost: $3500.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sq. ft.): 1 1804.76 Owner: ADAMS BRIAN & PHIPPEN EDITH M
Zoning: URB(100)/ Applicant: SEAN JEFFORDS
AT: 36 ARLINGTON ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (416) 529 -0544 WC
EASTHAM PTONMA01027 ISSUED ON:2/23/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL CELLULOSE INSULATION AIR
SEALING
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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 2/23/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner