24D-286 w ° The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
4, Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): fit) 6 ( z . E L - - + G . r6.. ( - 1 1 2 - 4 - . )
Address: '?. 1
City /State /Zip: F-P-s })- ' 1t lr6N. r visa c iot1 Phone #: 4, } 152c1 �5 �
Are you an employer? Cheek the appropriate box:
Z 4. of project (required):
1. � I am a employer with ❑ 1 am a g eneral contractor and I
employees (full and/or part- time).* have hived the sib- contractors 6 El N construction
2. Q I am a sole proprietor or partner- listed on the attached sheet. 7. 1E1 Remodeling
ship and have no employees These sub - contractors have 8. Q Demolition
working for me in any capacity. employees and have workers'
[No workers' comp. insurance comp_ insurance_ $ 9. [] Building addition
required.] 5. Q We are a corporation and its 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. o workers' comp. right of exemption per MGL
insurance requited.] t c. 152, § 1(4), and we have no 12.0 Roof repairs
employees. [No workers' 13.0 Other
comp. insurance required.]
* Any applicant that checks box #I 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. If the sub - contractors have employees, they must provide their workers' comp. policy number.
1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: V1 NC I< PEi(<s(2- A-S hlS■) 12 -Ar•kt A at-t-L c--4 — L I f ( 1 S
Policy # or Self-ins. Lic. #: t 0 Z (v 5 Expiration Date: 4 1 2 t 1 . l
Job Site Address: t \0+t.— *a(Npreil City/State/Zip: 14) P�i / L i d
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.
1 do hereby certify unde e .r,;' and penalties of perjury that the information provided above is true and correct
Signature: Date: 3- ' t 1
Phone #: t S 5'lei - 09-1-9
Official use only. Do not write in this area, to be completed by city or tow 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 #:
,
4
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to:7 624n/i` weitzza e.. "& f✓iar 2s'.€oP..11
. t.-. ' ' Off ice of Consumer Affairs and business Regulation
�, 1 0 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Horne Improvement Contractor Registration
Rerlistration: 131279
Type: Individual
Expiration: 6/29/2012 Tr# 297765
SEAN JEFFORDS
SEAN JEFFORDS _ __ .. __
13 TERRACE VIEW ___... _ ____ __-
EASTHAMPTON, MA 01027 -- _ ___
update Address and return curd. Mnrk reason for ch ange,
Address Renewal Employment Lost Curd
1PS.CA1 Ci 50trt.0.44•C1101216
Ufticec "'rtaaiiifjct `k if4fif�i `it"sint license or registration valid for indiridul use only
HOME IMPROVEMENT CONTRACTOR before the ex piration date. If found return to:
�� c Registration: 131279 Type; Office o € Consumer Affairs and Business Regulation it it
. ' , .+ Expiration: 8/29/2012 Individual 10 Park Plaza - Suite 5170
r ' ; Boston, NIA 02116
• SEAN JEFFORDS
SEAN JEFFORDS
11 TERRACE VIEW : ;,.�r -.
r;7s li '''MPTON, MA 01027 lVndersecretnry Not valid without signat
_ . - 74539
SEAN R JEFFORDS ; �
13 TERRACE VIEW
EASTHAMPTON, MA 01027
_ 11/28/2012
5544
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : ' i= tk n.t — 145 c 7
License Number
-
tYL a nL i= : \t a� nl (V! t' 7c'tn t'� gE- O t GI., t I ' "
,
Address Expiration Date
4 t 2 > 52'1 c)
Signature Telephone
9, Reoistered:Home itnprovemect Contractor: Not Applicable 0
( 2_ -- / v 9 ec ,, NS; t f �v+ :f� c; / /r9 -7 C J
Company Name Registration Number
\1 t Oiki v k � ,.; ( L G t c, Z 7 W/2 J 2-c> / d-
Address Expiration Date
Ski V
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (411.G.L c. 152, § 25C(6)) 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 buil ding permit.
Signed Affidavit Attached Yes EY No 0
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 am licable)
New House Q Addition Replacement j (indoors Alteration(s) EJ Roofing Q
Or Doors °�
Accessory Bldg. 0 9omolition 0 New Signs [CO Decks [D Siding [D] Other [MI
Brief Description of Proposed
Work: 4-e.X tk.. 5 v
Alteration of existing bedroom Yes no No Adding new bedroom Yes no No
Attached Narrative Renovating unfinished basement Yes no No
Plans Attached Roll - Sheet
6a. If New house and or addition to existing housing, compete 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? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. tloodplain Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No
1. 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?c ( Elk I 1 , as Owner of the subject
property
hereby authorize V� C f LL-� (
.E N S T 62 t�C . t 5 t.
to act on my behalf, in all matters relative to work authorized by this building permit application_
/ .w.�'4 // / /g ///
Signature of Owner Date
—� 3
1, S`E r•-1 cl= ForL >S (�r�� s``� -tit. CD Slit() L rt , 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.
SE 1 c> (L IDS
Print Name
Signature of Owner /A ent Date
Section 4. ZONING Att Information Must Be Completed. Permit Can Be Denied Due To I omptetnft , { r,
Existing Proposed Requi d by Zoning
This CO mn to AO in b
Buildi Depart
Lot Size 10'
a.
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage °c
Open Space Footage i ii
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(volume & Location) __ t
A. Has a Special Permit /Variance /Finding ever been issued for /ort 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 DON'T KNOW 0 YES 0
tF YES: enter Book Page andfor 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 Obtained , Date Issued:
C. Do any signs exist on the property? YES 0 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 0 NO 0
IF YES. describe size, type and location:
E. tail the construction activity disturb (clearing, grading, excavation, or Ming) over 1 acre or is it part of a common Oar:
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required
_ __Department use enty-
1 , of Northampton Status of Permit:
13 ping Department Curb Gut/Drivemay Perl^:tit
12 Main Street Sewer#Septic AvailabiritY
t Room 100 WatssiWeA ilability
i '' • : mpton, MA 01060 Tyro Sets of Structural Plan s
' '` - .-7i, - .7*:::;' -- -5 ' -1240 Fax 413- 587 -1272
. Pu J to Plans
— aver
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEILMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE 1NFORMATION 1
Zone Overlay District
1.1 Property Address: Thies in to comp try office
{ Iv UR CSC F c�1`r S�t map Lc Unit
0 o � -r1,11 � / - P -- o t Zone
St District C8 District leaed
SECTION 2.. PROPERTY OWNERSNrP /AUTHORSZED AGENT
2.1 Owner of Record:
C0-0 ',..)1..-i-- iris Moi. -LY M i 46 Cat -e s - e:a -- . Ao,n..r'ik "-Ptoti n,4
Name print) Current Mailing Address:
s / q • 1-21- • p"
ti L ..� Telephone
Signature
2,2 Authorized Agent:
13e Y1 e - - -1 C 7.0..,_7 c ► e 13 TE ., � vj, ,./ i EA Ti > non 1 ( A bto 21
Name ('ri �/ C urrent Mailing Address:
Lt 3 5 - -054y
Signature t Telephone
SECTION S ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use OnIy
completed by permit applicant
1 Building A 1 S e J 2 (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 S S 2 Check Number
This Section For Official Use Only__
Building Perm Number it Numbe Date
3 z,77,..._././ iioor'
/
Si 0
I Building Commissioner/Inspector of Buildings Date
hi K� //
/11 e' A'7 _
6Yc cj(- / ie - l/ee z ` . ES-
176 CRESCENT ST BP-2011-0755
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D - 286 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: windows replaced BUILDING PERMIT
Permit# BP- 2011 -0755
Project # JS- 2011- 001248
Est. Cost: $3552.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SEAN JEFFORDS 074539
Lot Size(sq. ft.): 6316.20 Owner: BULL CAROLE & MARGARET MEAD
Zoning: URB(100)/ Applicant: SEAN JEFFORDS
AT: 176 CRESCENT ST
Applicant Address: Phone: Insurance:
13 TERRACE VIEW (416) 529 -0544 WC
EAST HAM PTO NMA01027 ISSUED ON:3/24/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 8 REPLACEMENT WINDOWS - U
VALUE MUST MEET STRETCH CODE REQUIREMENTS
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 3/24/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner