48-017 The Commonwealth of Massachusetts
Department of Industrial Accidents
• = �1 E� /, Office of Investigations
?111
600 Washington Street
0
Boston, MA 02111
ow www.mass gov /dia
Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): 8 3 P C)4,/ X> (r Ore, .. /)
Address: &e
City /State /Zip: 4 m, 70 k) 171/ (1-) Ph one. #: sy6 - �'j 14% ✓
Are u an employer? Check the appropriate box: Type of project (required):
1. I am a employer with 4. 0 I am a general contractor and I
employees (full and/or part- time).* have hired the sub - contractors 6. ❑ New construction
listed on the attached sheet. 7. 0 Remodeling
2. ❑ I am a sole proprietor or partner-
ship and have no employees These sub - contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
g Y P h'• $ 9. 0 Building addition
[No workers' comp. insurance comp. insurance.
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 12.0 Roof repairs
insurance required.) t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homd'owners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. J
Insurance Company Name: l.� / E , r� M i _ , i /
1iv � / " /'" 01
i
Policy # or Self -ins. Lic. #: � � 3 �j c7C� 9 Expiration Date: 0 $ - 7 1 6 - - 3..4
j . 0 al
Job Site Address: .Ig pie 0 2i 2' City /State /Zip: 6590 ,q rry l - It �� / ✓Q-?
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 under the pains and penalties of perjury that the information provided above is true and correct.
Signature - -' igA-d Date: J d / �9 117' c 6 f'v'
•
Phone #: S - 4 i' /6
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 #:
�0p ? CITY OF EASTHAMPTON
`` 41ig , BUILDING INSPECTOR
50 Payson Avenue
Easthampton, MA 01027
, ‘TED 3‘14' (413) 529 -1402 Tel
(413) 529 -1433 Fax
Joseph Fydenkevez,Jr
Inspector of Buildings
Construction Debris Affidavit
(for all demolition and renovation work)
In accordance with the provisions of MGL c40, S 54, a condition of Building Permit
Number is that the debris resulting from this work shall be disposed of in a
property licensed waste disposal facility as defined by MGL c 111, $150A.
The debris will be disposed of in:
ua to ;d >J ti
LOCATION OF FACILITY
The debris will be transported by:
4440- yr � � Ai - 6
NAME OF HAULER
SIGNATURE OF APPLICANT
DATE
sI1; TIUN 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) .)
r, -- _k,.(), ,, 1 4, - 6k, A o V
/ License Number Expiration Date
Name of CSL- older ' W
0) 4 t List CSL Type (see below)
Add T Description
�, -ti A w, Q 13 r Unrest ricted (up to 35,000 Cu. Ft.)
Si re R Restricted 1 &2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
elephone WS Residential Window and Siding
',/ SF Residential Solid Fuel Burning Appliance Installation
�� i r' f D Residential Demolition . -
5.2 Registered Home Imprp.vement C tractor (HIC)
X30 R Sje,iO4. " c_, /d0yZ
HIC Com p N e ,x g istrant Name Registration Number
� t ,Jet" Q6 _e g a NY
A dress) k 1 / >n *M , + 1 � (3j j „- 9a Expiration Date •
Signatures _ N /r� Telephone
SECTION 6: WORKS/6' 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 Issuan of the building permit.
Signed Affidavit Attached? Yes No 0
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 1 /I /24 i 4Az G /,/ , as Owner of the subject property hereby
authorize ,to: N L i r to act on my behalf, in all matters
relative to work authorized by this building perrrAt application. .
it 1/140A gwut ) - 3i MA .7 0 ) 2
AO
Signature of Ow Date l
SECTION 7b: OWNER' WNER' OR AUTHORIZED AGENT DECLARATION
I, Ei''C L
. o : ? RA/0 • as.Uwa.r- erAuthorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
e4O/• z_ /J 12,/,' ,,
Print Name
A- --- -- �=`' ` / 31 114,47 L961.--, _
Signature odor Authorized Agent Date
(Signed under the pains and penalties of p
NOTES:
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 M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 C.MR Regulations 110.R6 and 110.15, respectively.
2. When substantial work is planned, provide the information below:
Total floors 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"
g� The Commonwealth of Massachusetts
h._ Board of Building Regulations and Standards FOR
or Massachusetts State Building Code, 780 CMR, 7 edition MUNICIPALITY
z_ USE
ev IF g Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised January
i CZ T ' One- or Two - Family Dwelling 1, 2008
N ;z�
, - This Section For Official Use Only
0 , :1 ilding Permit Number:
s I Date Applied:
0]
LLg
• :nature:
f a z Building Commissioner/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
>! .1 Property Ad4ress: C1 a 1.2 Assessors Map & Parcel Numbers
Vii? b �/1tt ' 4— .
1.1a Is this an accepted street? yes no Map Number Parcel Number
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
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: I 7 *f rrD rz» & i. vt -
�,6 6 IT R�1 24: :,715 Jiz v it)
1 rY,1A A¢
N (Print) Address for Service:
-k� '�l — l 4 / ,7 - 4 '
Signature y 8a4kt Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner- Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑
Demolition • ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work
.:. — 'mi% /1. f I 37 d i. &
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials)
1. Building $ 7 806 01 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard CityiTown Application Fee
❑ Total Project Cost (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees:
4. Mechanical (HVAC) $ r List
5. Mechanical (Fire $ ✓
Suppression) Total All Fee $ ./
Check 4 dG O heck Amount: Rash Amount:
6. Total Project Cost: $ i700 ❑ Paid in Full ❑ Outstanding Balance Due:
218 DRURY LN BP- 2012 -1061
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 48 - 017 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: vinyl siding BUILDING PERMIT
Permit # BP- 2012 -1061
Project # JS- 2012 - 001831
Est. Cost: $7800.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R SIDING 026846
Lot Size(sq. ft.): 21997.80 Owner: BARRETT MARGARET L
Zoning: Applicant: B & R SIDING
AT: 218 DRURY LN
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586 -4167 Workers Compensation
NORTHAM PTONMA01060 ISSUED ON:5/31/2012 0:00:00
TO PERFORM THE FOLLOWING WORK: install vinyl siding
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 5/31/2012 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner