29-109 (5) •
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
Suggested Affidavit For Home Improvement Contractor Permit Application
Name of City / Town
For Office Use Only
Permit No.:
Date:
Note 142 A, requires that the Areconstruction, alteration, renovation, repair, modernization, conversion,
improvement, removal or demolition or the constructional of an addition to any pre - existing owner occupied
building containing at least one but no more than four dwelling unit, or to structures which are adjacent to such
residence or building® be done by registered contractors, with certain exceptions, along with other requirements.
Type of Work: ' U5t) '!,?-! A Est. Cost: 0708 /' 09'
Address of Work: 57q APIA- rr
Owners Name: - To At1A3 N i k t d5 41
Date of Permit / Application:
I hereby certify that:
Registration is not required for the following reason (s):
Work excluded by law
Job under $ 500.00
Building not owner occupied
Owner pulling own permit
Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS
FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE
ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL C. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
Date: / I/O Contractor: tb 1 J d i Reg. # : / I 9
OR:
Not withstanding the above notice, I hereby apply for a permit as the owner of the property.
Date: Owner: Tel. # :
The Commonwealth of Massachusetts
Department of Industrial Accidents
1= Office of Investigations
I 1 , 600 Washington Street
,� w ww mass. g Boston, MA 02111
f y � ov / dia
�
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information p� / Please Print Legibly
Name ( Business /Organization/Individual): ]o #Jft /d I , //e 1 ii,✓
Address: /J7 N . A) St
City /State /Zip: go t a K ' 4, ON* Phone #: L i / 3— 53/- 6 Q b-
Are you an employer? Check the appropriate box: Type of project (required):
1. A I am a employer with 4 ❑ I am a general contractor and I
6. ❑ New construction
employees (full and/or part-time).* have hired the sub - contractors
listed on the attached sheet,. 7. ❑ Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers' 9. El 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 A�
insurance required.] t c. 152, §1(4), and we have no 13.Jbther c)5 li PA
employees. [No workers'
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.
tContractors 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. /
Insurance Company Name: nee
f l C : V , j i
Policy # or Self -ins. Lic. #: c 71 3 R7 3 7 , Expiration Date: 1 /aS/ 11
Job Site Address: 3 r / A-N R9 City/State /Zip: crJ6 -,,,, GeA.-
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 certify nder the pains and enalties of pedury that the information provided above is true and correct
Signature: /4 "/ i d' /' Date: ;t 1 /l ji /1
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: - Permit/License #
Issuing Authority: Building Department
Contact Person: Phone #: (413) 499 -9440
•
Licensed Construction $ugervispr. 111 Not Applicable ❑
Nineof Hauer — Ov∎c,. et' \t \
License Number
\ \ CY V Nr ,„, alo<k) \D
Expiration Date
Signature Telephone
n . ... .... Not Applicable 0
Company Name Registration Number
k \d 1NnO■ \e- S-t • Hat YOKe rV` t d v r‘ c °off
Address � ®� Expiration Date
10' UYtc- d JL � I?1 , i Telephonk 1�..C3g )
Sl t f+l 1$*ViCOM tOtM VION Nt ArPi vr > . c 104 §
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 ❑
The current exemption for "homeowners" was extended to include Owner- occupied Dwellinns 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
at 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, von may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned `fhomeowner" 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
•
oi
New House E] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks (0 Siding [O] Other [ }Sj f Z
Brief Description of Proposed
work: Op/It ( /l �� i ac Wj -^ j . / 41�h� -••.�
Alteration of existing bedroom Yes No Adding new bedroom _ Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
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
44 41411AGt t:OR t 001TOR P E$ 4*
1, V A /1)4 J f, c, Jk , as Owner of the subject
party Pell hereby authorize TOA.h7+�L /4 } / L 1d7�
to act on my behalf, in a I matters relative to work authorized by this building permit application.
/ / 1719
Sig owner Date
1 , 1 M " r oi ii PJt - , 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.
T7o J o 1d IA) 11/ rz-fi ��-
Print Name
11), / 116-- )//611/
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 I - - - - . . . . : _ _ _ _ . . 1 L _. _ .. __ I I I
Frontage I I I — I
Setbacks Front L E r`1
Side L:L - --- R:E_.i L:I - -µ I R: —1 1-1 =I
Rear F-
Building Height - 1
I L___._
Bldg. Square Footage I L i % ' - -°i L i ; 1
Open Space Footage �° % r _ -
ET (Lot area minus bldg & paved 1 i i 3 ,..11
parking)
# of Parking Spaces = . = s
Fill: .
(volume & Location) -- - �-
A. Has a Special Permit /Variance /Finding ever been issued for /on the site? -
NO 0 DON'T KNOW 0 YES 0
.
IF YES, date issued t
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW O YES Q
IF YES: enter Book # I Pagel M and /or Document # r
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW ® YES
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 ® NO
IF YES, describe size, type and location: I
J
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
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 O NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
,
City of Northampton
,,,,,,,',\, Building Department
,
212 Main Street
- ' Room 100 •
Northampton, MA 01060
phone 413 -587 -1240 Fax 413- 587 -1272
APPLICATIO TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
xr ., ..
�,„a..,t+re0.5.- �" tie 1 r..�a ,, a
1.1 Proaerty Address: �t4 - 4 X - ; %,' Y 'n i a . ; . - `- - 1 -' ;
% i ce.` , - ..
/(.) v ` t�s� . . t r `hr , . ,, y ,--"
-;- s i 1 .
>
i
I 2.1 Owner of Record:
Zr t) ►tin n/ & k L V 4ri.ti
5 7 Y /et/ A,. t1�,, , ., �I9 rr,t , rl1 14-
Current Mailing
Name (Print) A r4ss:
t x �y1 7a7 eo�o
�� • Telephone
Signs
2.2 Authorized Aunt: /
J7,,iJ it� �z _ iif °7 � /rfb 6 J 5 `1 101 /b/< - e- /.4 O
Name (Print) Current ma Address
1t) �. J qi 3 57 $- co ate ,)-'
Signatpre Telephone
Item Estimated Cost (Dollars) to be _ "
com pleted by permit applicant
,. Building ()O , i �� 4a) It
2. Electrical {b) Estimated
3. Plumbing tt Fee
4. Mechanical (HVAC)
5. Fire Protection _
6 Total= (� + + + + 2- Q (.0./ l Ckhet s,
€ ii3d g t .Nu !
Sadatiaret; .,153, ,*
ots tie '
374 .RY A ' ` " BP-2011-0474
GIS #: COMMONWEALTH OF MASSACHUSETTS
:t - IUD 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 -0474
Project # JS- 2011 - 000777
Est. Cost: $2081.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DONALD PELLETIER 101876
Lot Size(sq. ft.): 21170.16 Owner: NAHLOVSKY JOANN
Zoning: URA(100) / /WSP II Applicant: DONALD PELLETIER
AT: 574 RYAN RD
Applicant Address: Phone: Insurance:
1107 MAIN ST (413) 538 -6002 WC
HOLYOKEMA01040 ISSUED ON:11/22/2010 0:00:00
TO PERFORM THE FOLLOWING WORK: INSTALL ATTIC INSULATION
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:
FeeTvpe: Date Paid: Amount:
Building 11/22/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner