29-270 •
4
The Commonwealth of Massachusetts
r = Department of Industrial Accidents
:.; Office of Investigations
6 f
600 Washington Street
— _ R Boston, MA 02111
www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual):n
Address: r 3 EQSAn McAP-K. S
City /State /Zip: & � • Phone #:
Are y u an employer? Check the appropriate box: Type of project (required):
1. I am a employer with 4_ 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub - contractors 6. ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ 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. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12. oof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13. ❑ Other
comp. insurance required.]
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
' 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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: ,►O�l/
Policy # or Self -ins. Lic. #: QC) ( C= 5 6 d� Expiration Date: ' .� , 1
r
Job Site Address: ) 1..1) V) 0 \ t . Y 11 r'iI t 4C City /State /Zip: 0 1 0 (
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: Dutc. '
0-3- d 1
Phone #: 5 ' ) ( Cor3
Official use only. Do not write in this area, to be completed by city or town official
City 4r 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 #:
Versionl.7 Commercial Building Permit May 15, 2000
SECTION 10- STRUCTURAL, PEER REVIEW (780 CMR 110.11)
Independent Structural Engineering Structural Peer Review Required Yes 0 No Q
SECTION 11 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
c (.. ) thaL ki Z. .Q _ ) 1 as Owner of the subject property
hereby authorize C'')
act on my behalf, in all matters relative to work authorized by this building permit application.
C 111 . 4.12 < \ 14:4„Llyrifr).10 -3_
Signature of Owner Date
I ZJ. . _ �__..1,,,.�W.,..�..j..... _ e_._...__ , 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_
--- 711)) i'1'. o . .
Print Name
-3- .r. _
Signature of Owner /Agent Date
SECTION 12 - CONSTRUCTION SERVICES
10.1 Licensed Construction Supervisor: Not Applicable ❑
Q.3_9 . .
License Number
Address Expiration Date
Signature Telephone
SECTION 13 = WORKERS' COMPENSATION INSURANCE AFFIDAVIT ,I(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 ilding permit. - - - --
Signed Affidavit Attached Yes No 0
.. eio•
. ~
Version 1.7 Commercial Buildirig Permit May 15, 2000
SECTION 9- PROFESSIONAL DESIGN AND CONSTRUCTION SERVICES - FOR BUILDINGS AND STRUCTURES SUBJECT TO
CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 (CONTAINING MORE THAN 35,000 C.F. OF ENCLOSED SPACE)
9.1 Registered Ar hdact:
---- ---�-------'� Not Applicable []
Name _-'
Registration Number
Address
' �xp�aonnoo�
Signature Telephone
9.2 Registered Professional Engineer(s):
wamm Areavx Responsibility
� --� ----------------------------------'---� [---------------- ----- /
- - - -----'--------------------------- L___-__�____________�-__
Address Registration Number
Signature Telephone Expiration Date
mame Area mResponsibility
� ----_-' ~.~__-_--_____________
Address
Signature Telephone Expiration Date
'
_ ---------
Name Aeonxnespon Responsibility
Address Registration Number
Signature Telephone Expiration Date
Name xmoo,Revponomm�
-----
Address Registration Number
Signature Telephone Expiration Date
9.3 General Contractor
Not Applicable 0
Company Name:
Responsible Address
^-�
Signature Telephone
•
Versionl.7 Commercial Building Permit May 15, 2000
8. NORTHAMPTON ZONING
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L.. R..__..._.,. _ L:..,...._.. R:
Rear �r..,._ ......
Building Height
Bldg. Square Footage
Open Space Footage °
(Lot area minus bldg & paved
parking)
# of Parking Spaces
Fill:
(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:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and /or Document #
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 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
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:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a comMOYI pl8n
that will disturb over 1 acre? YES Q NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Version1.7 Commercial Building Permit May 15, 2000
SECTION 4- CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35,000
CUBIC FEET OF ENCLOSED SPACE
Interior Alterations ❑ Existing Wall Signs ❑ Demolition ❑ Repairs ❑ Additions ❑ Accessory Building ❑
Exterior Alteration 0 Existing Ground Sign ❑ New Signs ❑ Roofing Z Change of Use ❑ Other ❑
Brief Description Enter a brief description here. r(`no vg., )(i3 1%v�lR....0 4n 4 e ( . �
Of Proposed Work: `.‘ NON ' 1
SECTION 5 - USE GROUP AND CONSTRUCTION TYPE
USE GROUP (Check as applicable) CONSTRUCTION TYPE
A Assembly A -1 ❑ A -2 ❑ A -3 ❑ 1A 1 ❑
A -4 ❑ A -5 ❑ 1B ❑
B Business ❑ 2A ❑
E Educational ❑ 2B 1 ❑
F Factory ❑ F -1 0 F -2 ❑ 2C ❑
H High Hazard ❑ 3A ❑
1 Institutional ❑ 1 -1 ❑ 1 -2 ❑ 1 -3 ❑ 3B ❑
M Mercantile ❑ 4 0
R Residential ❑ R -1 ❑ R -2 ❑ R -3 ❑ 5A ❑
S Storage ❑ S -1 ❑ S -2 ❑ 5B I ❑
U Utility ❑ Specify:
M Mixed Use ❑ Specify:
S Special Use ❑ Specify:
COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND /OR CHANGE IN USE
Existing Use Group:
Existing Hazard Index 780 CMR 34): _ „ _. _ Proposed Hazard Index 780 CMR 34): ,
SECTION 6 BUILDING HEIGHT AND AREA
BUILDING AREA EXISTING PROPOSED NEW CONSTRUCTION OFFICE USE ONLY
Floor Area per Floor (sf)
1st 1st
2..d 2nd
3rd 3
4 th
Total Area (sf) Total Proposed New Construction (sf)
Total Height (ft).�...____,_ .
Total Height ft
7. Water Supply (M.G.L. c. 40, § 54) 7.1 Flood Zone Information: 7.3 Sewage Disposal System:
Public ❑ Private 0 Zone ., Outside Flood Zone❑ Municipal ❑ On site disposal system
Version1.7 Commercial Building Permit May 15, 2000
Department use only
City of Northampton Statusof t?em it
Building Department Curb Gut/Drive
_ ` 212 Main Street Sewer/Septic Avattabitty
, ;, Room 100 Water/1Nelf Avatlabttity
CC - F 4 -Uu-. Northampton, MA 01060 Two Sets of- Structural Ptans
p
hone 413-58-1240 Fax 413- 587 -1272 Piot/Ste Plans
Other Specify'
APPLICATION T - CONSTRUCT, REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING
---`" OTHER THAN A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
Map Lot Unit
5 Zone Overlay District
LOn V 1
. m St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Current Mailing Address:
5E4 qirt
Signature _ 111 iv., A Telephone
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature W 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
4. Mechanical (HVAC) ...,. _.
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) S® C) 0 Check Number /Off t��
This Section For Official Use Only
Building Permit Number Date
Issued
Signature-
Building Commissioner /Inspector of Buildings Date
574.ot s u , BP- 2010 -0374
GIS #: COMMONWEALTH OF MASSACHUSETTS
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- 2010 -0374
Project # JS- 2010 - 000496
Est. Cost: $5000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 065699
Lot Size(sq. ft.): 15333.12 Owner: KUZMESKI MICHAEL G & SUSAN J
Zoning: URA(100) //WSP Applicant: BOB THIBODO ROOFING & SIDING
AT: 57 LONGVIEW DR
Applicant Address: Phone: Insurance:
P 0 BOX 201 (413) 527 -7663 () WC
NORTHAMPTONMAO1061 ISSUED ON :10/6/2009 0 :00 :00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE ROOF
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 10/6/2009 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo