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1
INSURER'S AFFIDAVIT AS TO WORKERS' COMPENSATION INSURANCE
O
1. Vim `1 � Q `A- ?S VC [Name. Address] am:
❑ an authorized representative of insurance Company
ICbnrpany Nantel
(a producer' in the voluntary market)
X an authorized agent of S"t" G.34-1_,:rt;11 Insurance Company (an agent
(Company Namel
in the voluntary market. authorized to sign on behalf of a producer)
❑ an authorized signatory of the , the Prime Contractor
(Company Namel
(an insured of a producer in the involuntary market pool)`
n an authorized signatory of , the Sub - Contractor (an insured of
!Company Name(
a producer in the involuntary market pool, group, or otherwise insured)'
and do hereby aver that effective -1 .4- \ \ 10 [Date]. W% i!1 e Qo ►ni- Wkhw rc
he-- _ the Prime or Sub - Contractor, is insured for Workers' Compensation insurance with
OCk C (LC A _ insurance Company under Policy No[s]. ■ -1-,- �j
pursuant to the attached Certificate of Insurance. and in accordance with Massachusetts General Laws.
',ow Chapter 152 and Subsection 7.OSA of the Standard Specifications for Highways and Bridges of the
Highway Division of the Massachusetts Department of Transportation.
Sin ' * 9---:1-1.1.----
t2 Ir..
,t -- C1` k" A
Title
COMMONWEALTH OF fvIASSACiIUSEi
On this 12th day of July 2010 before me, the undersigned notary public. personally
appeared Kimberly Balthazar [document signer), proved to me through satisfactory evidence of
identification, which was /were MA Driver's License , to be the person who signed the preceding or
attached document in my presence, and who swore or affirmed to me that tic ntents of the document
are truthful and accurate to the best of their knowledge and belief.
A EILEEN M. RYAN fi
Not ary Pu ^� .71,,<;; lam" . Notary
l it U commoNwEA r Or MASSACHUSETTS Eileen M. Ryan/ [Printed Name]
Nay Commission Expires
September 7, 2012
A producer is an insurance company that provides insurance policies directly, not an insurance agent.
4. For Prime or Sub - Contractor companies insured through the voluntary market. this Affidavit must be completed by the insurer
or an authorized agent of the insurer.
If the Prime or Sub - Contractor is insured through the involuntary insurance market, a pool, such as the Worker's Compensation
OW Inspection and Rating Bureau. or is otherwise insured they may provide a Certificate of Insurance and this Affidavit which may
be signed by an authorized signatory (company officer) of the Prime or the Sub - Contractor.
Effective lO-May- 10
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: n Not Applicable ❑
Name of License Holder: 55
License Number
acko. - ma y 7-t) M
Address Expiration Date
LS o(t93
Signature Telephone
S Regsteiecf`Hbiri fnat5iovrtent. ` Not Applicable ❑
I4 WE PowMTS (e -1NCs LAC
Company Name Registration Number
(Oo "T3dMTE1L ST•
Address Expiration Date
-Q- L 0161 Telephone SSA 752 735(0
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 .i No ❑
4, it o vrie on
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
res ' onsible for all such work l erformed under the buildin ' s emit.
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
. 4
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition 0 Replacement Windows Alteration(s) 0 Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [O] Other
Brief Description of Proposed % _
Work: S'1gI�TUtPN- .RIBS '- R.V 4 t3r�cxt. 1-k- Of {
Alteration of existing bedroom Yes u No Adding new bedroom Yes K No
Attached Narrative Renovating unfinished basement Yes X. No
Plans Attached Roll - Sheet
6a, it'ilaww: house "and or:additir n to', a tlstinq boos :inch co iplete the follow nq:
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. 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
I `/ 0/&t W� 7a or l, j ect
property
x �` C , as Owner of the subject
hereby authorize 71>k_€1 7 /io
Al l (NE 1�lt4TS 1, eD U.k3'JZ1 -(M - (l(
to act o y behalf, in all matters elativ work uthorized by this building permit application. 7.....,,,,,
---- ,ejtp 2-r ) K.,--
Signat re of Owner Date
• • ■� 1 �,., . _ , as Owner /Authorized
Agen 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.
E■)eic'i'r - N- r49ZE i 5
Oft Print Name ''``
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
'l This column to be filled in by
Building Department
Lot Size ....,..i ..._. __.
Frontage :7 _. - .__ _? E.,,z.27 .,__,,.._,.k_, :.,._..,1.~. ,....v _.._. ~,__,
Setbacks Front _ £ °
Side L L _il R:1::: L: I R:5 �_'_
Rear i2.-12_, 12.-1 Z . _.....F
•
Building Height , _ . ; �
Li 6',,,1 IJA- _i
Bldg. Square Footage I ° N 1 % I , µ ,I
Open Space Footage _ % _ _ E
(Lot area minus bldg & paved _ ~
parking)
# of Parking Spaces .
Fill:
(volume & Location) t i
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 DON'T KNOW 0 YES
IF YES: enter Book. Page ,.. and /or Document #'
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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 ,Date Issued: ! .
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO se
IF YES, describe size, type and location: 1 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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
tomatt
r City of Northampton f it €
�� a Building Department Ct ?, q +
} 2 Main Street WeC ®ttrA'�a
Room 100 Waf 1 attar
Northampton, MA 01060 T��s Otis
phone 413 - 587 -1240 Fax 413 - 587 -1272 loyptte r -r. -. :
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 conuaieted by office
2'7 -1- 4tLLSt DE 1 & T Map Lot Unit
oR Tt,`Mr1,TaT1
Zone F " � �� Overlay District
Eh'n ; St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
P�+JUP EC1 - 2�' 13'cSK` 2 +1 ILLS1be' , v`•
Nam / int) Current Mailing Address:
1 3•.5810 . 7 18
X / FdO � 4 1 Telep
Signature f
2.2 Authorized Agent: ICC - r>`}•1 MTE'R- ST, �� «'-, O (4 o
EUEVE -Pttl,P 1 k3 t /MtPI ct l`C'5 I•lc.
Name (Print) Current Mailing Address:
SoS 752 35
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building y/ � 2 7 g ( a) Buildi Permit Fee
2. Electrical ,9C O (b) Estimated Total Cost of
Construction from (6)
3. Plumbing Buildin Permit Fee
9
4. Mechanical (HVAC) O
5. Fire Protection $ - _ -
This 6. Total =(1 +2 +3 +4 +5) `ll Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /inspector of Buildings Date
File # BP- 2011 -0043
APPLICANT /CONTACT PERSON EVERETT ANDREWS
ADDRESS/PHONE 100 TAINTER ST WORCESTER (508) 328 -0693
PROPERTY LOCATION 27 HILLSIDE RD
MAP 24D PARCEL 300 001 ZONE URA(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 MO 00 Y/ az)
Tvpeof Construction:_REMOVE & REPLACE BACKWALL OF FOUNDATION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 55809
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
VApproved Additional permits required (see below)
PLANNING BOARD PERMTT 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
7/a0 fiC)
Signature of Building Official 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.
. s
127 HILLSIDE iw BP- 2011 -0043
is #: COMMONWEALTH OF MASSACHUSETTS
Vtap :Block: 24D - 300 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- 2011 -0043
Project # JS- 2011- 000087
Est. Cost: $41278.00
Fee: $247.20 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EVERETT ANDREWS 55809
Lot Size(sq. ft.): 8973.36 Owner: ZALESKI PHILIP T & CAROL G
Zoning: URA(100)/ Applicant: EVERETT ANDREWS
AT: 27 HILLSIDE RD
Applicant Address: Phone: Insurance:
100 TAINTER ST (508) 328 -0693 WC
WORCESTERMA01610 ISSUED ON: 7/20/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: REMOVE & REPLACE BACKWALL OF
FOUNDATION
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 7/20/2010 0:00:00 $247.20
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo