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24D-164 ' ,\ The Commonwealth of Massachusetts Department of Industrial Accidents t Office of Investigations • -1=- 600 Washington Street Boston, MA 02111 51 . www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): `./ 4 lf'"'' /77/ 2__ Address: c- . d z C' (/., . - • City /State/Zip: /747 T,-7 —z. ,� `'-('` Phone . #: /3 /9 3/ 9 - , • i Are you an employer? Check the appropriate box: Type of project (required): /' 1.4z I am a employer with I am a general contractor and I 6. New construction 4. ❑ employees (full and/or part-time).* have hired the sub- contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodelin Q ship null have. no ploy ees These sub - contractors have. g. El Demolition working for me in any a employees and have workers' Y c a P ci t'' - - 9. 0 Building addition [No workers' comp. insurance co ,.nsuran, e.._. _- required:] 5. ❑ We are a corpo ration and its 10.0 Electrical repairs or additions 3.0 I am-a-homeowner- doing-all- work — o cexs ve'cxezcise_d their - -11 �- ©- 1?kunbing repairs or additions myself [No workers' comp. right of exemption 'per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no . employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section beiow.showing their workers' compensation policy information. t Homeowners who submit this affidavit, indicating they are doingall 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 state whether or not those entities have employees. If the sub - contactors have employees; they must provide their workers' comp. policy number. Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site informal(' m. C � r Insurance Company Name: 5 6' l< //-7?-4-1 vi � y 7 5 )• Policy # or Self -ins. Lic. #:emu S-60 6 e ie /2.. Cc? y Expiration Date: VV/ Job Site Address: / 7 � �. $ i . City/ State /Zip :'Gg `' ' 2 77 / dlefr 21 ' '‘r 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 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 aganst the violator. > e advised that a copy of filis statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. _ I do_hereby.certifjy under the pains and penalties of perjury that the information provided above i .true.and correct.____ - Signature: Date: Phone #: .7 Official use only. Do not write iti this area; to be compT ed by city or town offciaL City or Town: Permit/License # Issuing Authority (circle one): - I. 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 : � / r�� � / /sJ .5/6/ License Number ``% 0 c Address Expiration Date _ 2 / 3 / r r 0 Signatures, A ; Telephone 57/4- 9-Re Home Improvement Contractor :, , ;' ;; Not Applicable ❑ Company Name Registration Number Address Expiration Date 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 ❑ Omer EXempt on _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 farrn 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 port - amp on r•rnances; a e °and° . - •- • , ,. . -tts- Creaser -al - Laws - Annotated. Homeowner Signature • ,, SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition E Replacement Windows Alteration(s) ❑ Roofing ❑ C Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [ZI] Decks [I= Siding [O] Other [p] Brief Description of Proposed Work: /s' &'7'e/t6 7 / 5r --e. ._, x. ,.J.,.i ,r>L- S , t5/7.ac-- J7"Mr>E= en- »z -3e-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 housing, complete fol 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 ./"7d:Yr.�-- Y`h'i e y.' 4 z_3 , as Owner of the subject property , _ hereby authorize 7 ?, Y7-' f /7 _,/ -L---2,,,,,,t s"'ye/ ' to act on my behalf, in all matters relative to work authorized by this building permit application. ' fi2. //, , �i.- •e.- V ? // Signature of Owner Date I _/ ' -' /tw /-/ - / L -2/ 1 ✓si ,-/ , 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. -_7 , / 72,- /7/_ 2 ,- ,i ,,<_,3.s,- c / Print Name Z z.. Vi e' . 1 1 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:_ L : 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 0 DONT KNOW 0 YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 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 C , Date Issued. C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D:O € here any proposed changes to or addition inters ed for the property ? YES 0 NO 0 IF YES, describe size, type and location: tr µ 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 Storm Water Management Permit from the DPW is required. • Department ise:only City of Northampton Status of Permit Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Avatlability Northampton, MA 01060 Two ;Sets of Structural Plan phone 413 - 587 -1240 Fax 413 - 587 -1272 PIot'Site Plants 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 /`� Yf2 - r s s Lot unit Map v /2 77,--,-.7)-)--? v 7 �� Zone '` Overlay District f E Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT • 2.1 Owner of Record: �7 Name (Print) Current Mail Address: ..,, • J � `� �� -�- Telephone Signature 2.2 Authorized Agent: Name .dnt) Current Mailing Address: 7 Signatures Telephone SECTION 3 - ESTIMATED ONSTRUCTION C OSTS' Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building ) . . — (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) +3 vU " Check Number This Section ForOffiCial Use O.aty Date Building Permit Number- Issued: Signature: Building Commissioner /Inspector of Buildings Date 17 MYRTLE ST BP- 2010 -0326 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 164 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 -0326 Project # JS- 2010 - 000446 Est. Cost: $2900.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOHN ZIEMINSKI 017889 Lot Size(sq. ft.): 3049.20 Owner: BARNES MARY H & THOMAS M & MARGARET A & MARY ANN Zoning: URC(100)/ Applicant: JOHN ZIEMINSKI AT: 17 MYRTL ST Applicant Address: Phone: Insurance: 8 WOODRIDGE CIRC (413) 247 -9014 HATF ISSUED ON :9/29/2009 0 :00 :00 TO PERFORM THE FOLLOWING WORK :INSTALL REPLACEMENT WINDOWS 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. I to of Occupancy r �* �` Signature: ca p y nature: :± FeeType: Date Paid: Amount: Building 9/29/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo