36-108 The Commonwealth of Massachusetts
, ,,,.. xx Department of Industrial Accidents
r:' Office of Investigations
--
„' ` y ` 600 Washington Street
-' ' Boston, MA 02111
A O
k.�'sy www.inass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization /Individual): g 1 U ,,ev —d feiDT
Address: "2._0 /S L y. G
Ci / State/Zi .. �w . �� �.: • _ ! A Phone #: 11 i D
Are you an employer? Check the appropriate box Type of project (required):
1. ❑ I am a employer with 4. [DI am a general contractor and I
employees (full and/or part - time).
* have hired the sub - contractors 6. ❑ New construction
2.R am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling
ship and have no employees These sub- contractors have g. 0 Demolition
working for me in any capacity. employees and have workers' q Building addition
[No workers' comp. insurance comp. insurance .t
required.) 5. 0 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
Y � ' P 12.[] Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.(ther ,�
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. 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:
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.
v. _ ' 4
i' do hereby certify under the pains and ,':ti , erjury that the information provided above is true and correct
Signature: rNI 6 - 1, Date: ,<T 1/4 — ) ---.
Phone #: 1/ c5 J ‘ L
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 5 CONSTRUCTION SERVICES . - ,
5.1 Licensed Construction Supervisor (CSL):
g�t 6 — I`�.
1 GH � a_,p
SG O 1 T License Number Expiration Date
Name n- . jail!
D /3 L L ( /`7 y dLY . Type Description
Address Ai
/ U ,/ Unrestricted (up to 35,000 cu. Ft.)
!>f�� s3�
1 /73 � �
�--� � R Restricted 1 &2 Family Dwelling
Signature Telephone M Masonry Only
RC Residential Roofing Covering
WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
/1V.
5.2 Registered Home Improvement Contractor (HIC):
R/C /J hf ) Sin /i
Name Re Number
Address Expiration Date
Signature Telephone
SECTION 6 — WORKERS COMPENSATION INSURANCE AFFIDAVIT (MGL C152 SECT: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 Er No ❑
;SECTION 7a -- OWNER AUTHORIZATION — TO BE COMPLETED WHEN OWNERS AGENT OR CONTRAOR
'APPLIES FOR BUILDING PERMIT
I, , as Owner of the subject property hereby
authorize to act on my behalf,
in all matters relative to work authorized by this building permit.
Signature of Owner Date
- SECTION 7b =- OWNER'/AUTHORIZE D AGENT DECLARATION
I, 1 c.JC
1 A ,� � X1(1 z 4- Q w i c-- , 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.
M (4 hA.W C: . M
Print Nam
Signature of Owner /Agent Date
TOTES
1. An Owner who obtains a building permit to do his /her own work, or an owner who hires an unregistered contractor (not registered in
the Home Improvement Contractor (HIC) Program), will NOT have access to the arbitration program or guaranty fund under MGL
Chapter 142A. Other important information on the HIC Program and Construction Supervisor Licensing (CSL) can be found in 780
CMR Regulations 110.R6 and 110.R5, respectively.
2. When substantial work is planned, provide the information below:
Total floor area (sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area (sq. ft.) Habitable room count:
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half /baths
Type of heating system Number of decks /porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
0 1
4 is
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plosik sio,:., ;
7
I RECEIVED
The Common , eal.h of Mk_ssacht cEIU FOR
kkrtif i d oft - .in;, Re-'ulations and' Stan aru
i , ' MUNICIPALITY
Massa setts + Bu lding Code, 780 �diti USE
BuildiigP$ ° ;t.lr,�.1 1\'; on<truct,Repair, R ate lislt'a ! Revised January
NORTHAM PTO, 0 ,'..1, "` w o - Family Dwell 'ng 1, 2008
This Section For Offic s� PTON, MAO10ee
Building Permit Number: Date ' iiedl•• - i V E
Si atur : /4- 'Vet V S F1/ 2 RECEI ID
uilding Commissioner/ Inspector of Buildings Mffte 3 ni L
9
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.Z�A'ssl ir§ Ma '&TP rcel Numbe
/ - 7 R itoo t C Je . ( £C` N ORTHAM f
2 J 0 \' tv 01060 DEPT. OF BUILDING INSPBCTIoNS
NOBTHAMrTON, MA 0060
1.1a Is this an accepted street? yes / no Map Number Parcel Num
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area (sq ft) Frontage (ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
N l Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40, § 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' of Record:
ATT7+ g tv E , 1 C , IC I >r / c.- Y 13 (zvbesjb eJ c 1 k .
N ame rint) — .... Address for Service:
4: € • _.----e-.6 / T8?
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner- Occupied ❑ ' Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 04 S`f771J�
'Lk) / ,....5 7 l .1 -P? ed . 1 j t / ) 6
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials) �[''
1. Building $ 1. Building Permit Fee: $F✓' Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: •
5. Mechanical (Fire
Suppression)
$ Total All F s: $ 4W
Check No/ k Amount: Cash Amount:
6. Total Project Cost: $ . 3—_5--O � ❑ Paid in Ful ❑ Outstanding Balance Due:
247 BROOKSIDE CIR BP- 2012 -0954
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 108 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP -2012 -0954
Project # JS- 2012- 001671
Est. Cost: $2550.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: RICHARD SCOTT 83108
Lot Size(sq. ft.): 20647.44 Owner: MICKIEWICZ MATTHEW E & NOREEN
Zoning: Applicant: RICHARD SCOTT
AT: 247 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
20 BULLARD AVE (413) 533 -6340
HOLYOKEMA01040 ISSUED ON:5/9/2012 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE W /STANLESS STEEL
PIPING
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 5/9/2012 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner