32C-123 NOTICE MAW- NOTICE
TO TO
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EMPLOYEES _ — / EMPLOYEES
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The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617 - 727 -4900 — http: / /www.mass.gov /dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
THE TRAVELERS INSURANCE COMPANIES
NAME OF INSURANCE COMPANY
P.O. BOX 1 450
MIDDLEBORO, MA 02344 -1450
ADDRESS OF INSURANCE COMPANY
(6KUB - 5031 P58 - 3 - 1 2) 02 TO 02 - 08 - 13
POLICY NUMBER EFFECTIVE DATES
ANDREW PADDOCK INS AGCY 20 GATEHOUSE ROAD
MININENIM "~— P 0 BOX 48
AMHERST MA 01004
o NAME OF INSURANCE AGENT ADDRESS PHONE #
°
° STARKOFF, JOSEPH DBA 80 HITCHCOCK STREET
UMBRELLA ROOFING
° HOLYOKE
o MA 01040
EMPLOYER ADDRESS
°
EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
• The above named insurer is required in cases of personal injuries arising out of and in the course of
0-- employment to furnish adequate and reasonable hospital and medical services in accordance with the
° provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
• connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
000062 W20P1G02
4 • t
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supe visor: / Not Applicable ❑
J
I Name of License Holder : 141 C I t6Jl n' t ' ,1 ,I 0,S O �
�� License Number
/3, s/ /1/C, rT - ho ,� /9T N S . �' y
Addres C 5 Expiration Date
.� 3 .s a ( A 3
/ Signature Telephone
0 Rectistereitilome . Opf+l vernent Contiactor: Not Applicable ,s-/
Compa Name Registration Number
S( �/'dr /r /JG ,M��'`o Si" , y 4/8 / 3
Address
/ Expiration Date
— !;/ D /y�J1 ' 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 No ❑
11. * Home 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
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding [0] Other [0]
Brief Description of Proposed -move- f AFL L� ' 7 S .� G Row----
Work: ��J ,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housin comple 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? ' -places or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ,. • wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basem: - or cellar floor below finished grade
k. Will b ' 'mg 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 , "6 2 �01iyL , as Owner of the subject
property
r
hereby authorize g! t•e_ L y Le- D`
2---YL�. .vG V /d'NG
to act on m . = h. lf, in all • - - -la ive to work authorized by this building permit application.
girl'-'Mm ��� /� z
Signature of Owner / Date
"Alijr
as Owner /Authorized
Agent hereby declare that the st. - ents 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.
/1/ 3 Art'
Print Nam/7/46.--
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i
Signature of Owner /Agent / 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:=
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 been issued for /on the site?
NO DON'T KNOW 0 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained l Obtained , Date Issued:
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES C NO e
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 (2)
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit
b+• Building Department Curb Cut/c riv +ay. Permit,
2012 212 Main Street Sewer/Septic Availability
P� t Room 100 Water/ ell vailabibty
0FgU11DMGINSPEC?I orthampton, MA 01060 Two Sets of Structural Plans
NORTHAMPTON MAO • • - 3- 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans:
Other Specify
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
2$ re U( r Map Lot Unit
Zone Overlay District
771 /9141 r )/t/
Elm St. District " CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
/t? /6 /4i9c2 / 2z /7Gu T 5 7 , PTd•J
Name (Pri CurrentiA5inAddress
Telephone
Signature
2.2 Authorized Agent:
13/u I- Vi-e /16 /t/od -r// ✓ SST /4
Name (Print) Current Mailing Address: O /O
V/3 s"33-Go /
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ( 0 D U (a) Building Permit Fee
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) / 1 va L, Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
s gnatureC / /1
Building Commissioner /Inspector of Buildings Date
28 FRUIT ST BP- 2012 -0892
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C - 123 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: ROOF BUILDING PERMIT
Permit # BP- 2012 -0892
Project # JS- 2012 - 001564
Est. Cost: $10000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: WILLIAM LYLE
Lot Size(sq. ft.): 5401.44 Owner: DOHERTY MICHAEL J
Zoning: URC(100)/ Applicant: WILLIAM LYLE
AT: 28 FRUIT ST
Applicant Address: Phone: Insurance:
1851 NORTHAMPTON ST (413) 533 -6012 WC
HOLYOKEMA01040 ISSUED ON:4/12/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 4/12/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner