31B-316 workers comp affidavit
/ 7// 47
I, ,! d o hereby certify that:
I am not required to have workers' compensation insurance
under M.G.L. c. 152, Sec.25(c)(6)
We have no employees and all work is conducted by the owners
under shumway Roofing general partnership.
Alan R shumway
Deborah A shumway
Cory A shumway
Rick A Shumway
Page 1
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
home owner."
The building department for the City of Northampton wants person(s) who seek to use
the home owner exemption, to act as their own construction supervisor, to be aware that
by doing so you become responsible for compliance with state building codes and
regulations. The inspection process requires that the building department be called to
inspect work at various stages, which include foundation /footings (before backfill)
sonotube holes (before pour), a rough building inspection (before work is
• iding inspectiuit. The
building department requires these inspections before the work is concealed, failure to
secure these inspections can result in failure to obtain a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing & gas) the
homeowner will be responsible to make sure that the trades hired secure their proper
jermits in conjunction to the building permit issued, and that they get their required
inspections. Failure of the individual trades to secure the permits and inspections as
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
7
•
The Commonwealth ofMassachusetts
=-*=,,2----- Department of Industrial Accidents
Office of Investigations
600 Washington Street
t •= ft, Boston, MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organiza tion/Individnn1): -LT ( 71;, ‘ iff
Address: 625 7 ike5a-i 5-7 .. .
, i ,,,,
City/State/Zip: ,f ‘,."( 1 7 ‘/Zff g (12 z - - - Phone.#: 5- PI - Vef5
Are you an employer? Check the appropriate box: 'Type of project (required) /
1.0 I am a employer with 4.. D I am a general contactor and I
6. 0 New construction
havc: hired the sub-contractors
employees (full and/or part-time).*
listed on the attached sheet 7. 0 Remodeling
2.. I am a sole proprietor or partner-
ship and haven° e These sub-contractors have. 8• 0 Demolition
employees and have worke• rs'
working for me M any capacity. 9. 0 Building additiOn
-
[No workers' comp. insurance _ comp..insurance.f._
required.] 5. 0 We are a corporation and its 10.1:1 Electrical repairs or additions
3. 0 lama homeowner doing all work officers havexercised their
i 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
IIII •
. ii , 0 wo
comp. insurance required.] •
*Any applicant That checks box #1 must also fill out the section below showing their workers' compensation policy informstion.
• t Homeownera who submit this afErda;■it inclicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
I-Contract:as 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.
lam an employer that is providing workers' compensation insurance for my employee& Below is the policy and job site
information.
Insurance Company Name: ' •
Policy # or Self-ins. Lic. #: Expiration Date:
kb 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 51,500.00 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 coveraue iiiifiCition. 7 _ , ,, _
I do hereby certify the p ' an , allies ofperjury that the information provittedabov _androrrert _
Signature: risk: 7 , ,,, ,
--1
Phone #: 57 — ri‘sz, , - •
• 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 . E-
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 7 Not Applicable ❑
Name of License Holder : /i i �M `// /39i g
License Number
/ If 51 /1
6(0-
Address Expiration ate
II� —.etre - _
Sign -'re �' ' T: -phone
4 " s • , v
;. ..°ta Not Applicable ❑
company A R Number
j
Addre" ` Expire n ate
Telephoned Yc`W5
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 U No ❑ - —
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 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 ❑ Addition ❑ Replacement Windows Alteration(s) [3 Roofing
Or Doors E
Accessory Bldg. ❑ Demolition El New Signs [D] Decks [C] Siding [o] Other ED]
Brief Description of Proposed
Work: . e ,5 /t1 (f 1 l` I L iii e f '
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
I; fis ea Ck eiWai r fir.actaft t iit16 xts iiiwrr l ouitna,>corn tit Will i ta` kiiiina:
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 la - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, / - , as Owner of the subject
property �7
hereby authorize / /z! ��i '
to act on y behal in all matters relative to work aut b this building permit application.
Signature of Owner Date / / /
i
�6ful as utho oia 414--‘
hereby declare that the ate andirI1 rmation on th fregoing application are true and accurate, to the best o myk n ' owledge lief.
Signed under the pains and penalties of perjury.
At . 54 1
Print Name r
i ,, -.�_. "' , //
Signature of • ' e r Agent - Date
■
F
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by ' oning
This column t. filled in l ., * a
Building Dep. ent
8
' Lot Size i _ ` I ' E
Frontage 1 , I
Setbacks Front I I E
Side L: I R: L: I R: 7
Rear
E
Building Height
Bldg. Square Footage i "----1 % i i
Open Space Footage
(Lot area minus bldg & paved 77 I_ i I l I
parking)
# of Parking Spaces ` '—
Fill: „.,d ...,.a, ____. __.,„,_ _�.,�,.w ,..,�, � ,_�...�,.o_w
(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:I I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book l �
Page and /or Document ft:
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 ,Date Issued: ,
C. Do any signs exist on the property? YES Q NO Q
IF YES, describe size, type and location: 1
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: s'
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 (j NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
} .��
4 � �k �-� City of Northampton s e
Building Department - - .1
A
,
6 25■% 212 Main Street 4 a
,0\-- .. Room 100 € ' � -
�owi► N
N. hampton, MA 01060 ` � . s
o suttr , 3- 587 -1240 Fax 413- 587 -1272 ,
ku.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Pro a Addre s:
This section to be completed by office 4/
�� �( p
M Lot Un
Zone , ` Overlay District
Elm St District CB District_
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: ,
/ / : aA 6v E cog` /e/(/'
Nam nt) /D Current Mailing Address:
/ tZ,f4 - h Q / T elephone - ' 60,71e)
2.2 Auth7 Agent: ,i(ertsc scr ilx-/--/
Name (Print) Current Mailing Address:
9 — y6_r
Signa ure Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
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 f ad
4. Mechanical (HVAC) b
5. Fire Protection ei '-- n ' C
6. Total= (1 +2 +3 +4 +5) �� Check Number
This Section For Official Use Only v� 5 b O
Building Permit Number: 4Pid V a IIs
Signature: -,.. . /
y
Building Commissionerllnspector of Buildings Date
38 ROUND HILL RD BP- 2012 -0017
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 31B - 316 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit # BP- 2012 -0017
Project # JS- 2012- 000025
Est. Cost: $1700.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SHUMWAY ROOFING 013908
Lot Size(sq. ft.): 13372.92 Owner: GROSS NICHOLAS P & JANET S
Zoning: URC(100)/ Applicant: SHUMWAY ROOFING
AT: 38 ROUND HILL RD
Applicant Address: Phone: Insurance:
625 EAST PLEASANT ST (413) 549 -4658 ()
AM H E RSTMA01002 ISSUED ON: 7/14/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE GARAGE ROOF OVER 1 LAYER
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 7/14/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner