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The Commonwealth of Massachusetts
Department of Industrial Accidents
i
Office of Investigations
41,
600 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): 6/
Address: Po:'' lam'
s:
City /State /Zip: Zeeck. /74 O/ Phone # :(/32 4:<S/c9
Are you an employer? Check the appropriate box: Type of project (required):
1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑ New construction
2,A I am a sole proprietor or partner- listed on the attached sheet. 7. a; Remodeling
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers' comp. insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing 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.]
*My 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 state whether or not those entities have
employees. lithe sub - contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address: City /State /Zip:
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 ce ' under the pains and penalties of perjury that the information provided a is true and correct.
Signature: ?IX Date: Phone #: `� /,f -S8 - 37
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 Supervispr: Not Applicable ❑
Nerve of License Molder : (?Q, / t'M 1 / 571 .
License Nu ber,
Coe IdFf z e4 / alo, % ' /i
Address Expiration Date
aj
Signature / Telephone
k.• P >ac .. ^ rb. a +�� . ar ct u ' Not Applicable ❑
J
Company Name Registrati� Nu ber
i I.Zef z'ec4 % 74 ec/sa
Address Expiration Date
Telephone 515 3 —
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 Exe n ►t0Qm
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 108.3.53.
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 buildine 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 [J Addition ❑ Replacement Windows Alteration(s) 42fr Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs (D] Decks ICJ Siding (D] Other ICI
e
Brief Des i tion 9� Pfop ��c k a Red. / �` - % S'✓ �'2L - e,- , 0 i‘ �'t�la ii • C �1 c �j ptv�, vn+ � � .vt � i` Work: ; tic;? .o. r / A..0,,, lnPr. L.11.,Zzn.do7 : � 7 Al8A/".1 .t; "d dime- e)su,L.-s Ac
Alteration of existing bedroom Yes No Adding new bedroom Yes No S.-42.474e,
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Rollee
Sa. f k e h. Id :.d ii.o. ..? : * x i.,ti , • ...n ! ! . _ 1 t. ! aj1 ! . IL L ' 1. *A .o .dl to ° :
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 Ta - OWNER AUTHORIZATION - TO SE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
K' I, cuts 1 e"1 f1al/A< L J , as Owner of the subject
property
hereby authorize C ` � HrA v n to to act on y be If, in all matters to work authorizedlby this building permit ap tion.
7ifo -.'.. q
/
Signature of ner Date
I, ACA 15 frA R.J A , as Owner/Authorized
Agent hereby decTare that the sments and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed der the pains and penalties of perjury.
RAJ
Print N. • e Y '
/ J • ...
Signat • of ! ner /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: 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 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 Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
W YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for 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 ® NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
t rtttie teseor'tiy
City of Northampton Status ofd.
' Building Department## Ferttr ti
212 Main Street StOSS
Room 100 W r/WeDA la ', ,
? - 1 Fin Northampton, MA 01060 Tuwa o S wctu l�r
phone 413 -587- 1,240 Fax 413- 587 -1272 PloVS .4,p0.4,,,,,... , ,,,,,.,..,,,,,,,, _ ,befill : - , ,, - L , , ,,,,,,,,,,,,,,,),..,,, t. ,,,,,, „.,‘,..„,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWOF WELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to to completed by office
Map Le Unit
d one OverfaY .Qistrkit �� -- ° , r :�
ma c' ( �w f'
El st Dtstrictt -`� } \ E _. 1. t D �.
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
SE? 1 2C°9
2.1 Owner of Record: a:•/'!oN � td5'� i ful 7Q�
Name (P 'nt� • rrent Mailing Address: t' Tele one
Signature
2.2 Au rized Aaent:
A ' tip,R.� r ✓ ' c eux laS7 2 e /1,4 ('/C ?
Name (Pri Current Mailing Address:
/7_9 6- 6' - 37&
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated ) to Official Use Only
completed Cost by permit (Dollars applican t
000. Co.
Building Permit Fee
1. Building J /S;
2. Electrical (b) Estimated al s of
Construction fro C n os
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) l /„$'off. Ct3 Check Number /3 —?- j
This Section For Official Use Only
Building Permit Number: Date
g Issued:
Signature:
•
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0244
APPLICANT /CONTACT PERSON CRAIG MARNEY
ADDRESS/PHONE P 0 Box 128 LEEDS (413) 586 -5512
PROPERTY LOCATION 242 PROSPECT ST
MAP 24D PARCEL 226 001 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
Fee Paid /36 05S
Typeof Construction: REBUILD PORCH DECK & SUPPORTS (SAME FOOTPRINT)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 057159
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF91MATION 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
Demolition Delay
..41i 1 _ "0 ,
Signature of Building 0 lf ial / 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.
242 PROSPECT ST BP -2010 -0244
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 226 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 -0244
Project # JS- 2010- 000305
Est. Cost: $15000.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: _ CRAIG MARNEY 057159
Lot Size(sq. ft.): 5706.36 Owner: SKOWRON JEFFREY J & SUSAN E MAYHEW
Zoning: URB(100)/ Applicant: CRAIG MARNEY
AT 24.2 PROSPECT ST
Applicant Address: Phone: Insurance:
P 0 Box 128 (413) 586 -5512
LEEDSMA01053 ISSUED ON:9/9/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: REBUILD PORCH DECK & SUPPORTS (SAME
FOOTPRINT)
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: O L c 6 J -6 '
Footings: TS
Rough: Rough:9� q a House # Foundation:
7� i t Driveway Final:
Final: Final: 1i) (( /0
Rough Frame:gik
Gas: Fire Department Fireplace /Chimney:
Ronah: Oil: Insulation:
Final: Smoke: Final: O /c- !/ ✓' 7 --tan
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. 1 -.
Certificate of Occupancy 7 signature:
FeeType: Date Paid: Amount:
Building 9/9/2009 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo